What We Know - And Don't Know - About Suboxone

May 4, 2016

Talk to people on the front lines of New Hampshire’s opioid crisis, and most of them will agree that addiction is a chronic disease. Yet there is still resistance to using medication to treat it.

Tym Rourke, who chairs the New Hampshire Governor’s Commission on Alcohol and Drug Abuse Prevention, Intervention and Treatment, says that some substance-abuse programs refuse to use methadone or Suboxone.

“I have friends and allies and partners in the recovery community who do feel it’s replacing one drug for another,” Rourke says, “and who define recovery as recovery from everything.”

Related story: As N.H.'s Opioid Crisis Grows, Primary-Care Doctors are Slow to Treat Addiction

But research dating back decades has consistently shown that programs that rely solely on behavioral therapy have a poor success rate when it comes to opioid addiction. For example, two studies that followed long-term addicts, one in 1943 and another 30 years later, found relapse rates as high as 80 percent within two years of discharge from intensive residential treatment.

Video: Hear the medical staff at one local community health center talk about their decision to start offering Suboxone to patients, and what they've learned along the way.

More recently, a 2009 review of 11 studies by the Cochrane Collaborative, an independent research network, found methadone "significantly more effective" than abstinence, or drug-free, models in keeping patients in treatment and preventing relapse.

The introduction of Suboxone in 2002 was considered a major advance in medication-assisted treatment, or MAT. The drug – buprenorphine, plus naloxone as an abuse deterrent – is safer than methadone, which can cause overdose. And because it has a longer half-life and stays in the system longer than methadone, patients don’t suffer withdrawal if they miss a dose.

Suboxone has been found to be as just effective as methadone at reducing opioid use, although the evidence suggests methadone might keep people in treatment longer.

Cindy Parks Thomas, with the Heller School for social Policy and Management at Brandeis University, conducted a review of studies on buprenorphine in 2014. She said the research, which involved an analysis of 16 clinical trials, was commissioned by the Substance Abuse and Mental Health Services Administration, or SAMHSA, the federal agency that oversees the Suboxone program.

“They wanted to get more information out there about the evidence to combat some of the preconceived notions that this was just another opioid that patients will get hooked on,” she said.

She said one “sticky” issue that hasn’t been resolved is if and when to discontinue Suboxone treatment. Neither SAMHSA or leading addiction experts have settled on when a patient is considered stable enough to begin reducing, or tapering, the daily dosage.

Research on tapering versus long-term use is limited. But one 2011 study looked at two Suboxone protocols, including counseling, for patients with prescription opioid addiction.

Phase one involved 12 weeks of treatment - two weeks on the drug, two weeks of dose reduction, followed by eight weeks of follow up. Only 43 of 653 patients – less than 7 percent – made it through the 12 weeks without using opioids.

A second group of 360 patients underwent longer treatment: 12 weeks on Suboxone, four weeks of taper and eight weeks of follow up. Nearly half that cohort  – 177 patients – made it through the treatment period successfully.

“It’s still an open question,” says Tym Rourke. “But ultimately it has to be in the best interests of the patient. There may be emerging science that tell us that there are some patients for whom a lifetime of [Suboxone] is required.”

Experts says more of these studies on duration of treatment are needed in the wake of the Affordable Care Act, which mandates that state Medicaid programs cover substance-abuse treatments,.

Robin Clark, an associate professor at the University of Massachusetts Medical School, and director of research and evaluation at UMass’s Center for Health Policy and Research, has studied state Medicaid policies on Suboxone, including lifetime limits on prescriptions imposed by nearly a dozen states.

He concludes there is no evidence that it reduces costs or cuts down on diversion of the drug onto the street.

“There are a lot of people around the country who think of this as an acute problem, when it’s really a chronic relapsing condition that for many people is a lifelong struggle,” Clark says. “If you think of it that way, people might need to stay on it a lot longer and there might be some people who need to stay on it indefinitely.

“What we do know is that people tend not to die when they are using it.”