Detox(Suboxone) :

Detox Program

About SUBOXONE

SUBOXONE is the first opioid medication approved under DATA 2000 for the treatment of opioid dependence in an office-based setting. SUBOXONE also can be dispensed for take-home use, just as any other medicine for other medical conditions.

The primary active ingredient in SUBOXONE is buprenorphine.

Because buprenorphine is a partial opioid agonist, its opioid effects are limited compared with those produced by full opioid agonists, such as oxycodone or heroin. SUBOXONE also contains naloxone, an opioid antagonist.

The naloxone in SUBOXONE is there to discourage people from dissolving the tablet and injecting it. When SUBOXONE is placed under the tongue, as directed, very little naloxone reaches the bloodstream, so what the patient feels are the effects of the buprenorphine. However, if naloxone is injected, it can cause that person to quickly go into withdrawal.

SUBOXONE at the appropriate dose may be used to:

• Suppress symptoms of opioid withdrawal
• Decrease cravings for opioids
• Reduce illicit opioid use
• Block the effects of other opioids
• Help patients stay in treatment

Treatment Walk-through

SUBOXONE treatment can be broken down into 5 phases:

Intake
Induction
Stabilization
Maintenance
Medically Supervised Withdrawal

The following are general descriptions of each of these phases; the details of your treatment will depend on the procedures adopted by your doctor's office.

Intake

TBefore you begin treatment, the doctor or nurse will ask you questions about your medical health history, your mental health history, and your substance use history, including your current opioid use. There are no wrong answers to these questions—the goal is to be sure that your doctor has accurate information so she or he can create a treatment plan that meets your needs. All the information you give will be held strictly

confidential

During this visit, you and your doctor will go over the pros and cons of SUBOXONE treatment (if you haven't already). Your treatment expectations, as well as your doctor's expectations of you, will be discussed. You will most likely be asked to provide a urine sample so the doctor's office can confirm any use of opioids and possibly other drugs. You may also need to have blood drawn: blood analysis is important for detecting any health conditions (such as anemia or hepatitis) that might interfere with your SUBOXONE treatment if not addressed.

Induction

The goal of induction is to switch you from your current opioid (heroin, methadone or a prescription painkiller) on to SUBOXONE. You MUST arrive for your induction already experiencing mild-to-moderate opioid withdrawal symptoms. This point cannot be emphasized enough. If you take SUBOXONE before you are in withdrawal, the medication will make you feel worse because it can cause withdrawal symptoms.

Your doctor or nurse will assess your withdrawal symptoms and give you your first SUBOXONE dose in the office. Patients can begin to feel some relief within 20 minutes, although the full effects take about an hour, at which point your symptoms will be reassessed. Your doctor may suggest that you pass the time in the waiting area or by taking a short walk and returning to the office at a specific time. Depending on the extent to which the first SUBOXONE dose suppressed your symptoms, your doctor may decide to give you a second dose.

When you are ready to leave the office after your first induction visit:

• Your doctor will make arrangements for you to have SUBOXONE to take home. Typically, your doctor will give you a prescription for the amount of SUBOXONE that you will need until your next appointment, along with any special instructions related to your care
• Your doctor may also prescribe other medications to help control withdrawal symptoms

During induction, daily appointments are not uncommon. This allows your doctor to adjust for your withdrawal symptoms and cravings. Induction can last anywhere from 2 to 7 days. Urine drug screening at every visit is also fairly standard during induction. Patients whose SUBOXONE dose may be too low often use other drugs to try to suppress the withdrawal symptoms and cravings; doctors look for this when evaluating whether a patient is at the right dose.

Intake and induction may both occur at the first visit, depending on your needs and your doctor's procedures.

Stabilization

During stabilization, your SUBOXONE dose is "fine tuned" about once a week, as needed. The goal is to find a dose where your withdrawal symptoms and cravings are suppressed, and you experience minimal to no side effects. You and your doctor will discuss your treatment options going forward, specifically, maintenance versus medically supervised withdrawal.

Maintenance

Once your dose is stabilized, the maintenance phase of treatment begins. During maintenance, your treatment compliance and progress will continue to be monitored.

Participation in some form of behavioral counseling is strongly recommended to maximize the likelihood of your treatment success. You and your doctor will discuss counseling options that meet your needs.

Your doctor may request urine samples from time to time. Some doctors find urine testing a helpful part of treatment because by verifying the absence of opioids in your system they can evaluate the effectiveness of your SUBOXONE dose. Talk with your doctor if you have questions about the role of urine testing in treatment.

During your ongoing maintenance treatment, your doctor will want to know if you experience any cravings. If you do, your dose may need to be adjusted.

Appointments are usually scheduled on a weekly basis, however, if treatment progress is good and goals are met, monthly visits may eventually be considered sufficient. The maintenance phase can last anywhere from weeks to years—depending on what you, your doctor, and, possibly, your therapist or counselor determine is best for your individual needs.

Medically Supervised Withdrawal

Length of therapy is up to your doctor, you, and sometimes your therapist or counselor. In this phase of medically supervised withdrawal, your doctor will slowly taper your SUBOXONE dose, taking care to see that you experience minimal withdrawal symptoms or cravings. Your dose can always be changed if you experience uncomfortable symptoms or cravings at the reduced dose.

How to Take SUBOXONE

• Always take your SUBOXONE exactly as prescribed by your doctor
• Before taking SUBOXONE, it's a good idea to drink some water to moisten your mouth. This helps the SUBOXONE tablets dissolve more easily
• If your dose is 1 SUBOXONE tablet, place it under your tongue, lean your head slightly forward, and let the tablet dissolve completely. SUBOXONE is absorbed into the bloodstream through the veins under the tongue
• If your dose is 2 tablets, place both of them under your tongue, 1 on the left side and 1 on the right side (you can use a mirror to make sure the tablets are in the proper places). Lean your head slightly forward, and let the tablets dissolve completely
• If you have more than 2 tablets to take, put the next tablet(s) under your tongue after the first tablets have dissolved
• SUBOXONE takes a short time (about 5 to 10 minutes, but sometimes more) to dissolve completely. Don't chew or swallow the tablets, because less SUBOXONE will be absorbed into your bloodstream, it will not work as well, and your withdrawal symptoms could worsen
• Talking while the tablets are dissolving can interfere with how well SUBOXONE is absorbed
• You may want to do something that doesn't require talking, such as reading or watching television, while waiting for the tablets to dissolve
• Let family and friends know that you won't be able to answer them or talk on the phone during this time

Important SUBOXONE Safety Information

• If you miss a dose of SUBOXONE, take it as soon as possible. If it is almost time for your next dose, skip the missed dose and take the next dose at the regular time, unless your doctor instructs you otherwise
• Injecting SUBOXONE is dangerous and can cause severe withdrawal symptoms, painful or collapsed veins, blood clots, and increased risk of infection
• Your friends and family should be advised that an ambulance should be called right away in the event that you become extremely sleepy, the pupils of your eyes become like pinpoints, you feel faint or dizzy, or your breathing becomes much slower than normal
• It is important that you take your SUBOXONE or SUBUTEX® (buprenorphine HCl sublingual tablets) with your other medications exactly as directed by your physician. Abuse or misuse of your medications while on SUBOXONE or SUBUTEX can cause death.
• A number of deaths have occurred when dependent people have injected buprenorphine, usually together with benzodiazepines. While you are being treated with SUBOXONE or SUBUTEX, do not use benzodiazepines, tranquilizers, or sedatives unless they have been prescribed by your doctor. Do not drink alcohol while taking SUBOXONE or SUBUTEX.

Frequently Asked Questions

• How common is opioid dependence?
• How common is misuse of opioid pain relievers?
• How common is heroin use?
• Why are some people more likely to become opioid-dependent?
• How long has SUBOXONE been used to treat opioid dependence?
• Does SUBOXONE just substitute one dependence for another?
• Can I take too much SUBOXONE?
• Can I switch from methadone to SUBOXONE?
• Why do I need to be in withdrawal when I start SUBOXONE?
• How long will I stay on SUBOXONE?
• Where can I find a doctor who can prescribe SUBOXONE?
• What safety information should I know about SUBOXONE?

How common is opioid dependence?

Opioid dependence is more common than you may think. Opioid dependence is not predictable—it is a reaction that occurs in people who, for reasons that are not completely understood, are biologically and psychosocially vulnerable. Men and women of all ages, races, ethnic groups, and educational levels can become dependent on opioids.

How common is misuse of opioid pain relievers?

According to the 2003 National Survey on Drug Use and Health:

• 4.7 million people ages 12 and older misused pain relievers in 20031
• In 2001, almost 2.5 million people used pain relievers nonmedically (ie, for recreational purposes) for the first time. This is a 335% increase from 1990, when 573,000 reported using pain relievers nonmedically1

How common is heroin use?

As of 2003, roughly 3.7 million Americans ages 12 and older reported having tried heroin at least once in their lives. More than 400,000 people reported that they had used heroin within the last year.²

Over the last 2 decades, inexpensive, high-purity heroin has become more available.3,4 Rather than injecting, many new users are smoking or snorting heroin, with the misperception that these routes are less addictive.3 Also, use is growing among younger adults and in many suburban communities.^3-6

Why are some people more likely to become opioid-dependent?

Exactly why some people, and not others, become dependent on opioids (or any addictive substance) is not totally understood. Most people who take opioids do not become opioid-dependent. However, certain factors appear to increase the likelihood of dependence, including:

• Risk-taking or novelty-seeking personality7
• Psychiatric disorders (eg, depression, bipolar disorder)⁷
• Stress (high stress seems to increase the desire to use drugs)⁸
• Properties of the drug itself (eg, how quickly it creates a "high," how long the effects of the drug last) ⁷
• Genetic factors that influence drug metabolism⁷
• Genetic factors contributing to the risk of addiction (ie, a family history of alcoholism) ⁷
• Lastly, substance abuse, which can lead to dependence, is often highly influenced by societal norms and peer pressure.

How long has SUBOXONE been used to treat opioid dependence?

Buprenorphine has been available as SUBOXONE in the United States since 2003. In Europe, buprenorphine was introduced during the mid-90s. Today, more than 400,000 opioid-dependent patients worldwide have been treated with buprenorphine.

Does SUBOXONE just substitute one dependence for another?

All opioids can cause physical dependence. SUBOXONE belongs to a class of opioids called "partial opioid agonists." As a partial agonist, buprenorphine appears to produce less physical dependence, limited euphoria, and less potential for abuse compared with a full agonist, eg, heroin, oxycodone, and hydrocodone. SUBOXONE has potential for abuse and produces dependence of the opioid type with a milder withdrawal syndrome than full agonists.

When patients are ready to stop taking SUBOXONE, the dose is slowly and gradually tapered. The withdrawal symptoms of SUBOXONE are milder than those seen with a full opioid agonist and can be managed with your doctor's supervision.

Can I take too much SUBOXONE?

Taken on its own, SUBOXONE has lower potential for fatal overdose than a full opioid agonist because it has a limited effect on reducing breathing. Taking more SUBOXONE does not affect breathing as much as full opioid agonists can, so it is less likely to cause death in cases of accidental or deliberate overdose when taken in the absence of benzodiazepines, sedatives, tranquilizers, antidepressants, or alcohol. Intravenous misuse of buprenorphine, usually in combination with benzodiazepines or other central nervous system (CNS) depressants, has been associated with significant respiratory depression and death.

Can I switch from methadone to SUBOXONE?

It is possible to switch to SUBOXONE from methadone treatment, but because everyone's situation is different, switching should first be discussed with your doctor.

Why do I need to be in withdrawal when I start SUBOXONE?

It is important to be in mild-to-moderate withdrawal when you take your first dose of SUBOXONE. If you have high levels of another opioid in your system, SUBOXONE will compete with the other opioid molecules and knock them off the receptors. SUBOXONE then replaces those opioid molecules on the receptors, but because SUBOXONE has less opioid effects than full opioid agonists, you may go into withdrawal and feel sick. This is called precipitated withdrawal. If you are already in the first stages of withdrawal when you take your first dose, SUBOXONE will make you feel better, not worse. Once your doctor has assessed your withdrawal symptoms and decided that you are ready to start SUBOXONE, you will begin Induction.

How long will I stay on SUBOXONE?

The length of your SUBOXONE treatment depends on what your doctor, you, and, possibly, your counselor or therapist decide is best for your needs. Although short-term treatment may be an effective option for some, for others it may not allow enough time to address the psychological and behavioral aspects of their condition. The chance of relapsing can be higher with short-term treatment because patients have less time to learn the skills needed to maintain an opioid-free lifestyle.

In general, suppressing cravings with SUBOXONE (for as long as necessary), together with counseling, offers the best likelihood for treatment success.

Discontinuing SUBOXONE abruptly can cause withdrawal symptoms, so when you are ready, your doctor will gradually taper your SUBOXONE dose. You should be aware of signs of relapse or withdrawal symptoms. Discard any leftover pills to ensure that they aren't used by anyone else.

Where can I find a doctor who can prescribe SUBOXONE?

Doctors need to be certified to prescribe SUBOXONE. Doctors who are already specialists in addiction medicine or who complete specific training can become certified to treat opioid dependence with SUBOXONE in their offices. Ask your doctor if he or she is certified. If not, your doctor may elect to become certified so that he or she can treat you, or opt to refer you to a colleague who is certified. You may also be able to find a doctor who can treat you with SUBOXONE by calling your local hospital or mental health center and asking whether they have any doctors certified to use SUBOXONE for treatment of opioid dependence. Certified physicians can also be found through the Find a Doctor section of this website.

What safety information should I know about SUBOXONE?

Important directions about SUBOXONE use

Intravenous misuse of buprenorphine, usually in combination with benzodiazepines or other CNS depressants, has been associated with significant respiratory depression and death.

SUBOXONE combined with medications/drugs

It can be dangerous to mix SUBOXONE with drugs like benzodiazepines, alcohol, sleeping pills and other tranquilizers, certain antidepressants, or other opioid medications, especially when not under the care of a doctor or in doses different from those prescribed by your doctor. Mixing these drugs can lead to drowsiness, sedation, unconsciousness, and death, especially if injected. It is important to let your doctor know about all medications and substances you are taking. Your doctor can provide guidance if any of these medications are prescribed for the treatment of other medical conditions you may have.

Potential for dependence

SUBOXONE and SUBUTEX® CIII (buprenorphine HCl sublingual tablets) have potential for abuse and produce dependence of the opioid type with a milder withdrawal syndrome than that of full agonists.

Contact your doctor if

• You feel faint, dizzy, confused, or have any other unusual symptoms, or if your breathing becomes much slower than normal. These can be signs of taking too much SUBOXONE or of other serious problems.
• You experience an allergic reaction. Symptoms of a bad allergic reaction include difficulty breathing, hives, swelling of your face, asthma (wheezing), or shock (loss of blood pressure and consciousness)
• You suspect liver problems due to any of these symptoms:
• Your skin or the white part of your eyes turns yellow (jaundice)
• Your urine turns dark
• Your bowel movements (stools) turn light in color
• You don't feel like eating much food for several days or longer
• You feel sick to your stomach (nauseated)
• You have lower-stomach pain
• Cytolytic hepatitis and hepatitis with jaundice have been observed in the addicted population receiving buprenorphine.
• Your doctor may do blood tests while you are taking SUBOXONE to ensure that your liver is okay.
• You've recently experienced a head injury (SUBOXONE can alter pupil size and cause changes in the level of consciousness that may interfere with patient evaluation)

Pregnancy

There are no adequate and well-controlled studies of SUBOXONE (a Category C medication) in pregnancy. SUBOXONE should not be taken during pregnancy unless your doctor determines that the potential benefit to you justifies the potential risk to your unborn child. Contraception should be used while taking SUBOXONE. If you are considering becoming pregnant or do become pregnant while taking SUBOXONE, consult your doctor immediately.

Many women also have changes in menstruation when they use opioids. This may continue while you are taking SUBOXONE. It is important to remember that you can still become pregnant even with irregular periods.

Breast-feeding

Buprenorphine will pass through a mother's milk and may harm the baby, so SUBOXONE is not recommended if you are breast-feeding. Your doctor should know if you are breast-feeding before you start treatment for opioid dependence.

Driving and operating machinery

SUBOXONE can cause drowsiness and slow reaction times. This may occur more often in the first few weeks of treatment, when your dose is being changed, but can also occur if you drink alcohol or take other sedative drugs when you are taking SUBOXONE. Due caution should be exercised when driving cars or operating machinery.

Commonly reported side effects

Side effects of SUBOXONE are similar to those of other opioids. The most commonly reported adverse events with SUBOXONE include: headache (36%, placebo 22%), withdrawal syndrome (25%, placebo 37%), pain (22%, placebo 19%), nausea (15%, placebo 11%), insomnia (14%, placebo 16%), and sweating (14%, placebo 10%). You may already be experiencing some of these side effects because of your current use of opioids. If so, let your doctor know. Your doctor can effectively treat many of these symptoms.

SUBOXONE can cause blood pressure to drop. This can cause you to feel dizzy if you get up too fast from sitting or lying down.

Your doctor will determine if you need to stop taking SUBOXONE because of side effects.

SUBOXONE use in children

SUBOXONE can be used in people ages 16 and older. It hasn't been approved for use in children younger than 16. Accidental overdose in children is dangerous and can result in death.

Appropriate use of SUBOXONE

Do not use SUBOXONE or SUBUTEX for conditions for which they were not prescribed. Patients with a clinical need for analgesia should not be transferred to a SUBOXONE regimen. SUBOXONE is not indicated for pain management.

Do not give your medication to other people, even if they have the same symptoms that you have. Sharing is illegal and may cause severe medical problems.