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The promise of Suboxone depends on erasing stigma in opioid use disorder treatment

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December 1, 2023
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The promise of Suboxone depends on erasing stigma in opioid use disorder treatment

If a person with opioid use disorder overdoses and survives, that person can either seek help or continue using. When the person seeks help and a medical professional prescribes an opioid medication as part of treatment, that person's chances of dying from another overdose in the next year decrease by between 38% and 59%, according to one National Institutes of Health study.

But many people who could benefit from this type of help don't get it. The same study found that fewer than 1 in 3 patients who experienced an overdose were even provided the medication to treat their opioid use disorder. But it's not for lack of availability: Lifesaving opioid medications like buprenorphine and methadone, or combination drugs like Suboxone, are legal and widely available in the U.S.

Patients' lack of asking for help and physicians' reluctance to treat those who do ask with effective treatments is a result of a stigma against medication-assisted treatments for people with opioid use disorder, researchers say.

Ophelia analyzed data and studies by the National Institutes of Health to break down the stigmatization of medication-assisted treatment, as well as the functions and history of Suboxone, a leading medication for treating opioid use disorder.

A generic form of the drug Suboxone has been approved by the Food and Drug Administration to treat opioid use disorder since 2018. It's a combination of the drugs buprenorphine and naloxone.

Buprenorphine, often prescribed to relieve severe pain, is used in opioid use disorder treatment to activate opioid receptors in the patient's brain to reduce cravings. The addition of naloxone in Suboxone helps those taking the drug manage symptoms of withdrawal. Suboxone and similar combination opioid medications can come in the form of a pill or a film strip that dissolves under the tongue or against the cheek.

The number of Americans receiving buprenorphine products has increased since 2015, according to the National Institute on Drug Abuse. However, misuse of buprenorphine has actually declined from 2015 to 2019, leading the institute to recommend expanding access to the combination drug.

The FDA recognizes opioid use disorder as a chronic disease with long-term implications and has encouraged medical providers to expand the use of medication in combination with other forms of therapy. But while the stigma remains, people who could otherwise take advantage of life-saving treatments might not seek them out.

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'Swapping one addiction for another'

The use of drugs to combat addiction to drugs may sound counterintuitive. But that view, coupled with the widely held perspective that drug addiction is a moral failure, has created stigma about medication-assisted treatment for opioid use disorder.

It feels proper to bring a healthy dose of skepticism to new drugs. After all, the 1990s introduction of new opioids that were supposedly less addictive than earlier ones fueled the current opioid crisis America finds itself in. But experts increasingly view addiction as a chronic medical condition, and opioid use disorder is far more likely to be fatal with the spread of fentanyl, a synthetic opioid far more powerful than previous drugs in that category. These changes in circumstances and understanding have underscored calls in the medical community to dispose of dated views of addiction treatment.

Through careful study of humans and their relationships with drugs over time, researchers know today that a person's addiction stems not from personal failures, but from inherent genetic and socioeconomic factors that are often beyond the control of the individual who develops a substance use disorder. Once they've developed the disorder, the brain's chemical makeup can change, creating a dependence on the substance.

People with opioid use disorder who use medication therapy like Suboxone, "aren't swapping one addiction for another, as is sometimes unfortunately said," former FDA commissioner Scott Gottlieb said when the drug was approved for use. "They're able to regain control of their lives and end all of the destructive outcomes that come with being addicted to opioids."

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Preserving life above all

The 2010s saw a staggering acceleration of drug overdose deaths, from roughly 40,000 per year in 2011 to more than 106,000 by 2021. It resulted in the federal government declaring a public health emergency in 2017.

In the meantime, principles of "harm reduction" have also gained ground as death counts have soared. This approach focuses on decreasing the chances of the worst outcomes of opioid use disorder— infection, injury, and death. As a result, drug testing and sterile syringe services have proliferated nationwide. In addition, naloxone, a drug that can rapidly reverse the effects of an opioid overdose, has become much more widely available, including over-the-counter at many pharmacies around the country.

As another part of the effort to save lives, patients can take Suboxone—perhaps for the rest of their lives, according to Harvard Medical School instructor Peter Grinspoon. Health experts have yet to find evidence that full recovery from opioid use disorder is possible from taking the drug for a short period of time. Long-term use may be more appropriate, just as other drugs are used to treat lifelong disorders like diabetes or high blood pressure.

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Lowering the potential for misuse and overdose

The vast majority of people—three-quarters of them—who use buprenorphine do not misuse it, the authors of a 2021 NIDA study on misuse of buprenorphine found.

Technically speaking, buprenorphine is what's called a "partial opioid agonist," which means it activates opioid receptors and creates euphoria when ingested, but to a lesser degree than a drug like morphine. Naloxone is an "antagonist," which does the opposite—blocking activation of the receptors. In Suboxone and similar products, this combination has been credited with helping avoid misuse of the drug for those using it to treat opioid use disorder.

Still, FDA guidelines recommend medical providers see patients using these drugs "at frequent intervals" to monitor for relapse or other adverse outcomes.

Of the three drugs approved for the treatment of opioid use disorder, methadone and buprenorphine were determined to be associated with the fewest deaths after treatment. That's because the third commonly prescribed drug, naltrexone, does not activate opioid receptors, which causes the user's tolerance to drop. This makes it more difficult for the person with the disorder to properly judge dosage during a relapse, increasing the potential for a fatal overdose.

Story editing by Jeff Inglis. Copy editing by Tim Bruns.

This story originally appeared on Ophelia and was produced and distributed in partnership with Stacker Studio.

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