Frequently Asked Questions

Some of the most common misunderstandings about buprenorphine

Is addiction really a disease? If so, prove it.

Addiction alters the biology of the brain in long-lasting ways.¹ This abnormal change to the biological structures of the brain has an effect on the functioning of the brain in negative ways.¹ When the biology of any organ is affected in a way which produces unhealthy results, we call that pathology diseased.^2,3 When the changes are long-lasting we call that chronic. This is why addiction is classified as a chronic brain disease.³ It has nothing to do with someone's initial choice to take drugs, nor is it an excuse which absolves patients from all responsibility. Instead, it refers to the unhealthy biology causing the abnormal persistent cravings. The action of seeking and taking drugs is not the disease, that's a choice, but it's a choice which is influenced by diseased brain structures. The fact that someone can choose to not take drugs for a short time does not prove addiction is not a disease because the cravings still remain and it's the unhealthy brain biology responsible for those cravings which is the disease.² - back to top -

What is it that buprenorphine treatment is supposed to do, exactly?

The purpose of buprenorphine treatment is to suppress the debilitating symptoms of cravings and withdrawal, enabling the patient to engage in therapy, counseling and support, so they can implement positive long-term changes in their lives which develops into the new healthy patterns of behavior necessary to achieve sustained addiction remission. Buprenorphine is only a small part of the treatment and by itself would only serve to temporarily suppress symptoms of addiction which would likely reemerge upon stopping the medication. Recovery is the process of reversing and/or coping with the abnormal brain adaptations responsible for the disruptive addictive behaviors. Buprenorphine merely helps make this effort possible by suppressing symptoms of addiction.² - back to top -

Isn't buprenorphine treatment just switching one addiction for another?

Not at all. Addiction is the uncontrollable cravings, use despite doing harm, and compulsive use, not the act of taking a medication as prescribed.^2,3 It is the loss of control amid constant cravings which bring about the misery of addiction and it's that which needs to be stopped. Taking a medication as one would a vitamin, even if withdrawal occurs in its absence, is not the problem and just a distraction to those who think it is. Once stable, buprenorphine patients regain control of their medication use, do not use compulsively, do not suffer persistent cravings, and do not use despite harm.⁴ All of the hallmarks of addiction vanish, that's not switching addictions, it's addiction remission. - back to top -

Wouldn't just quitting be better than some long drawn out treatment?

Of course it would be. Medication assisted treatment is not for people who can just quit and be done with it. Those people don't need medication. Just as someone who can control their diabetes with diet and exercise doesn't need insulin therapy, those who can just quit, and remain addiction-free, don't need addiction medication. Buprenorphine is only for those who would relapse without it. With each relapse lies the risk of overdose death. Minimizing relapse with treatment reduces risk and saves lives. Clearly ongoing treatment is better than relapse, even militant abstinence-only folks would agree with that, right? Once the patient can remain addiction-free without medication it can be tapered off of. Nobody is saying that those who could just quit and remain addiction-free should take medication instead. Medication is for those who have tried just stopping but are unable to do so without relapsing.² - back to top -

Am I clean while in buprenorphine treatment?

Clean is a term created and used by abstinence-only groups which, in this context, has no medical meaning. Although these groups covet the status of clean, it's meaningless now that there are medications to treat addiction. Being clean is irrelevant, being addiction-free is what matters and if it takes a medication to remain addiction-free so be it. Suffering constant cravings and consequences from repeated relapses so that you can someday be deemed "clean" is senseless. What matters is stopping the uncontrollable cravings which lead to all the negative aspects of addiction. Reaching the status of clean is a distraction from what really matters to you and your loved ones which is being free from the cravings and compulsive behavior of addiction, not whether or not you take a medication to achieve this. Don't waste another minute of your life wondering if you're clean while in buprenorphine treatment.² - back to top -

Someone said buprenorphine is harder to get off of than other opiates, is that true?

No, but thinking that it is, is an easy mistake to make. Addiction is a progressive disease, meaning it continues to get worse as time passes. Early on, in the addiction process, most opiate users could stop, have a few days of withdrawal and be fine afterwards. As the disease progresses, other symptoms linger long after the few days experienced early on. Eventually, the person is unable to stop, yet the disease continues to progress. So if they were to stop, they would find that after the acute withdrawal ended in 3-5 days, other symptoms would linger for weeks or even months, but few patents can quit long enough to find this out. It's not until they are in buprenorphine treatment and begin to taper that the extent of their addiction becomes evident. Where the mistake is made is in blaming the buprenorphine for the symptoms instead of the years of progressive addiction. They compare the current buprenorphine taper with the early experience of being able to stop and be fine after a few days and assume the difference is due to the buprenorphine. The fact is, when dosed correctly the buprenorphine doesn't make the situation any worse, instead it stops the addiction in its tracks and prevents the progression. However, it doesn't undo the damage already caused by years of addiction. So although a taper off buprenorphine may be harder than before the addiction took hold, it's not the buprenorphine which is making it harder, in fact the bupe makes it possible.^1,2,4
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Should I only stay on buprenorphine a couple weeks, so I don't get addicted to it?

No, and stopping too soon might be a tragic mistake.⁷ If two weeks of buprenorphine is all you need, you probably never needed it in the first place. Understanding the difference between physical dependence and addiction is key to understanding why.^2,3

First addiction; have you lost control of your buprenorphine use? Do you crave your buprenorphine constantly? Do you use your buprenorphine compulsively? If you answered "no" to these questions you are not addicted to buprenorphine.

Physical dependence; If you've been diagnosed with opioid addiction, you don't have to worry about becoming physically dependent to the buprenorphine because you already are. Your brain can't easily discern between which opioid it develops tolerance and physical dependence to. In other words, you don't end one dependency and start another, instead the physical dependence is continued while on any opioid, even while in buprenorphine treatment. This is not a problem because the addiction (the loss of control, inability to control use, and cravings) is successfully suppressed.

While symptoms of addiction are suppressed, it's important to address the brain adaptations responsible for the uncontrollable cravings of addiction, although the effects are suppressed the brain adaptations still remain. Making life changes and gaining experience living with those changes is what rewires the brain.⁶ This takes time, much longer than a couple weeks. Once that's done however, you'll be able to deal with the physical dependence with a slow taper. Without making the changes, after the taper the cravings will come back and you will have only paused the addiction temporarily. -what to do while in buprenorphine treatment-

The main point here is that addiction is bad and physical dependence is just an inconvenience, knowing the difference is critical to success. People generally don't lose control of their buprenorphine use (addiction) however, some of their existing physical dependence is intentionally maintained with the buprenorphine. So although you should watch for the development of addiction it is rare and should not be a reason to discontinue treatment early, unless in the rare event symptoms of addiction (lose of control, cravings, compulsive buprenorphine use) begin to develop and cannot be mitigated. - back to top -

How long should I stay in buprenorphine treatment?

Not unlike other conditions, you should continue the treatment until it is no longer necessary, is no longer effective, or the side effects outweigh the benefits.² To determine if it is necessary you have to first understand what it is supposed to do. The purpose of buprenorphine is to suppress symptoms of cravings and withdrawal so that you can make significant changes in your behavior, environment, and thinking. It is these changes that will affect the biology of the brain and in time diminish the brain structures responsible for the cravings. So to determine if the medication is still necessary you need a way of assessing if your effort of change has been significant enough to enter the medication-free stage of treatment. A counselor or therapist can help. But ultimately it's an educated guess.⁴ You have to look at the changes you've made and determine if your life is now significantly different than it was while in active addiction. Have you eliminated sources of stress, depression, and anxiety or other things which could put you at risk of relapse? If so, a slow taper can begin, pausing the taper should strong cravings return. If you have been successful you will be able to control any urges, which will be passing, not constant. Eventually you may be able to taper down to very low doses and stop completely.⁴ - back to top -

Why do some buprenorphine doctors demand cash-only, don't accept insurance, and have long waiting lists?

The federal government rations buprenorphine treatment with a policy which limits how many people a doctor can help with buprenorphine concurrently, regardless of how many people in the community may need help. Doctors can only treat 30 patients, at any one time, through the first year following certification, and up to 100 thereafter (up to 275 for qualifying practitioners). This creates low supply in a high demand environment. Low priced doctors reach their government-mandated limit quickly and remain full, while others continue to raise their prices until it begins to affect patient enrollment. These high prices then attract a disproportionate amount of profit-focused doctors who maintain the high cost structure. Additional regulatory burdens not imposed on other treatments also add to the cost and subtracts from the number of doctors willing to treat addiction with buprenorphine. Ending the patient limits and reducing the regulations is what's required for improved access to treatment and for the price to come down. More doctors and treatment spots will introduce competition and drive prices down and quality of care up. - back to top -

What name-brand and generic versions of buprenorphine are there?

As of mid 2018, in the U.S. there were 5 name brand products and at least 5 generic tablets (2 bup/nx and 3 bup only) FDA approved for the treatment of opioid addiction (or opioid dependence in FDA speak) See cost page for details on approved products and related savings plans.

• Suboxone Film^®- since tablet forms of Suboxone have been discontinued in the U.S., only the film version remains and comes in 4 bup/nx doses: 2mg/0.5mg, 4mg/1mg, 8mg/2mg, and 12mg/3mg.⁹ When tapering, Suboxone Film can easily be cut to very small pieces. Suboxone Film holds about 62% of the market.
• Zubsolv^® - sublingual bup/nx tablet - similar to the original Suboxone tablets but with a smaller tablet size, better taste and mouth feel. It also has a more efficient method of absorption. As a result less buprenorphine is required for the same effect as higher doses of Suboxone or generic bup/nx. The lower actual dose may reduce some side effects too. It's available in 3 bup/nx doses - 1.4mg/0.36mg, 5.7mg/1.4mg and 8.6mg/2.1mg.¹⁰ To make conversion easy these doses correspond to the 2mg/0.5mg, 8mg/2mg, 12mg/3mg generic bup/nx tablet (and Suboxone film) dose sizes. Zubsolv holds about 5-7% of the market.
• Bunavail® - Discontinued in 2020 - bup/nx buccal film - is a film that adheres to the inside of the cheek instead of under the tongue. This improves taste, mouth feel, and lessens saliva build up. It also has better bio-availability than Suboxone (or its generic tablet equivalents) so much so only about 1/2 the buprenorphine is required for the same effect. The reduced dose is thought to reduce some side effects such as constipation. It is available in 3 bup/nx doses: 2.1mg/0.3mg, 4.2mg/0.7mg, and 6.3mg/1mg, which correspond to the Suboxone 4/1, 8/2 and 12/3 doses.¹¹ Notice the ratio of buprenorphine to naloxone is less with Bunavail as (6-7):1 compared to 4:1 as with other products. Note: there is no equivalent dose for the Suboxone 2mg/0.5mg dose, the lowest Bunavail dose is the equivalent of 4mg/1mgs of Suboxone. Bunavail holds <1% of the market so far.
• Probuphine® -Discontinued in 2020 bup subcutaneous IMPLANT - slow release (6 month) buprenorphine rods which go under the skin. Doctors insert the Probuphine rods in an in-office procedure, and over the course of the next six months the rods release a constant dose of buprenorphine. Because the dose is constant it can be lower, overall. This may result in less side effects such as constipation.
• Sublocade™ - from the makers of Suboxone®, is a once-monthly buprenorphine subcutaneous INJECTION, FDA approved 11/2017 for the treatment of opioid use disorder (opioid addiction).
• Generic FILM bup/nx - on 6/14/2018 the FDA approved first generic versions of Suboxone sublingual film. Expected to become available in the coming months. On 9/7/2018 the FDA approved 16mg dosage strength for the film.
• Generic bup/nx - At least two companies have released generic sublingual tablets of bup/nx. The doses available are the original 2mg/0.5mg and 8mg/2mg tablet sizes.
• Generic bup-only - At least three companies have released bup-only tablets. These are generics for Subutex sublingual tablets, discontinued in the US. The doses available are the original 2mg/0.5mg and 8mg/2mg tablet sizes. All generic bup products combined hold about 30% of the market.

There are other buprenorphine products on the market which are not specially FDA approved for the treatment of opioid addiction. A 1914 law makes it illegal for doctors to prescribe opioid-based medications for the treatment of opioid addiction. Another law in 2000 made an exception for drugs specifically approved for the treatment of opioid addiction. It is currently a crime to prescribe buprenorphine patches, injections, or pharmacy-compounded buprenorphine for the treatment of opioid addiction.
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Does Buprenorphine Show Up In An Employer Drug Test?

Buprenorphine has to be specifically tested for and still isn't commonly included on standard drug screen panels. Buprenorphine will NOT cause a positive result on tests for other opiates. The typical urine tests used to detect methadone, oxycodone, heroin, and other opioids check for a different metabolite than that found with buprenorphine and will not show a positive result in buprenorphine (only) maintained patients. Many employers are not likely to know this and may think they are testing for it with the opioid panel.

A typical employer multi drug screen might consist of a test for Amphetamine (AMP); Barbiturates (BAR)(Phenobarbital, Secobarbitol, Butalbital); Benzodiazepines(BZO)(Valium, Xanax, Librium, Serax, Rohypnol); Cocaine (COC); Marijuana (THC); Methylenedioxymethamphetamine (MDMA)(Ecstasy); Opiates (OPI); Oxycodone (OXY); Phencyclidine (PCP); Propoxyphene (PPX)(Darvon compounds); and Tricyclic Antidepressants (TCA)

Employers that expand their tests might include some of the following: Hydrocodone (Lortab, Vicodin), Methaqualone (Quaaludes), Methadone, Ethanol (Alcohol)

Some government employers are only authorized to test for illegal drugs, see your state laws.

Buprenorphine can be detected with drug tests for 7-10 days at typical doses, although this time could vary considerably with much higher or much lower doses along with the individual's metabolism rate.

To know if buprenorphine will be detected (providing the employer is indeed testing for buprenorphine) you can purchase your own test kit ahead of time and monitor the detectable levels of buprenorphine to aid in scheduling the employer's drug test.
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Is Buprenorphine Addictive?

The following assumes the reader understands the difference between physical dependence and addiction.

Is buprenorphine addictive? Yes and no...it could lead to addiction but usually doesn't, particularly when prescribed to people already addicted to opioids. This requires some background info to make sense. Most people prescribed buprenorphine are those who are already addicted to opioids. As such, they would have a significant tolerance to opioids. This existing tolerance renders the limited euphoric effects of buprenorphine barely detectable. Therefore there is no reinforcing chemical reward to perpetuate the addiction cycle. The result is, those previously addicted to other opioids generally regain control of their opioid (bupe) use, do not crave opioids, do not use compulsively, hence, do not develop addiction to the buprenorphine.

However, if a person who is opioid naïve (that's not an insult, it's the clinical phrase used to describe someone without experience with opioids and therefore without a tolerance to opioids) were to take buprenorphine (in the typical dose used for treating addiction) they would initially experience an opioid effect indistinguishable from opioids of abuse. Although it's true that buprenorphine has a limit to its effects and alone is unlikely to cause a fatal overdose, to the opioid naïve without the experience of other opioids to compare to, the buprenorphine would cause euphoria and they could develop an addiction to it. It's true that they would not reach the dopamine levels of someone addicted to heroin, but neither does someone addicted to gambling, yet the addiction is still devastating. So buprenorphine can be addictive, albeit rarely with someone with a tolerance to opioids.

Since buprenorphine can lead to addiction, does buprenorphine present an unusual risk to those who are opioid naïve and because of that should be strictly controlled (like it is)? Well, that would be hard to justify. You must put the misuse into context. Is there something about buprenorphine to make someone more likely to misuse it, than some other opioid? No, in fact for someone intent on misuse buprenorphine is a poor choice. Why? Several reasons; it is more expensive to purchase than other opioids, it has a limit to its effects which is at or just beyond typical therapeutic doses, it blocks the effects of other more powerful opioids, and it can cause withdrawal under certain conditions.

Considering this, it would be hard to make the case that buprenorphine is more desirable as a drug of abuse than other opioids and holds some unusual danger. That means an opioid naïve person who decides to take buprenorphine does so because a preferred opioid choice isn't available. So the question becomes what has the potential to cause more harm, buprenorphine or another opioid. Since other opioids do not have a ceiling to their effects a fatal overdose becomes a possible outcome with a non-buprenorphine selection, adding risk when compared to buprenorphine. A combination of opioids would have a cumulative effect instead of being blocked as would be with buprenorphine, again more risk. The level of intoxication which can be achieved with other opioids is far higher than that of buprenorphine which has a limit to its effects. Also, unlike other opioids buprenorphine has a slow onset and lasts a long time, both shown to reduce the likelihood of producing addiction.

In virtually all plausible abuse scenarios, the choice to take buprenorphine over that of any other opioid results in lower risk to public health. That's not to say it's safe, only less dangerous in comparison to other opioids. So although it is possible to become addicted to buprenorphine particularly for the opioid naïve, the risk is lower than when compared to other opioids. To make the case that buprenorphine poses unusually high risk for addiction and justify the current restrictive policy, you'd have to show that buprenorphine has some sort of disproportional attraction to the opioid naïve than other opioids, and as we've pointed out the opposite of that is more likely.

So to sum it all up, those already addicted to opioids are not likely to become addicted to the buprenorphine, while those who decided to abuse buprenorphine as their first opioid are nearly as likely to become addicted to it as they would some other opioid, albeit with less risk of fatal overdose. - back to top -

Harm reduction and buprenorphine

Sometimes buprenorphine treatment is mistakenly classified as harm reduction and prohibited by some judges on moral grounds. The harm reduction label marginalizes the treatment by implying it enables ongoing drug use albeit in a more controlled, safer way. But harm reduction is not treatment, it's something else and shouldn't be applied to buprenorphine when used for the treatment of opioid addiction.

According to Harm Reduction International ‘ Harm Reduction’ refers to policies, programs and practices that aim primarily to reduce the adverse health, social and economic consequences of the use of legal and illegal psychoactive drugs without necessarily reducing drug consumption. Harm reduction benefits people who use drugs, their families and the community. Source: Harm Reduction International http://www.ihra.net/what-is-harm-reduction

Although harm reductionists recognize that some people need treatment for their addictions, the main focus of harm reduction is on those who are not experiencing consequences of drug use sufficient enough to outweigh the desire to continue to take drugs. Not everyone who takes drugs becomes addicted and the harm reductionists advocate for this population and try to minimize legal and health consequences making ongoing or occasional drug use less risky.

Drug prohibitionists view harm reduction as a slightly lesser evil. As such they hold a moral opposition to the category. Some judges prefer patients endure a significantly higher risk of death than enroll in what they believe is a harm-reduction program. We see this in some states where buprenorphine treatment is forbidden by courts, as it is seen as some sort of legalized addiction. Someday people will look back on this the same way we look back on the treatment of witches in Salem.

It is wrong to characterize buprenorphine treatment for opioid addiction as Harm Reduction Buprenorphine treatment is not harm reduction in the sense of the harm reduction movement. Although buprenorphine treatment literally reduces harm, it is not meant as a means to enable ongoing recreational drug use. Instead it is a means of ending addictive behavior by suppressing cravings and withdrawal and allowing the patient to make substantial life changes that will in effect rewire the brain from an addicted brain to a non-addicted brain. - back to top -

Why do some people consider buprenorphine treatment controversial?

Simply put, it's because they don't understand it. They have the common misunderstanding that buprenorphine is merely switching one addiction for another albeit legal and controlled. They see it as a way to enable or encourage weakness by letting people indulge in irresponsible selfishness instead of taking responsibility and stopping. They view buprenorphine as a way to avoid action rather than action itself. This destructive attitude comes from not only a misunderstanding of buprenorphine but a misunderstanding of addiction itself.

Those who dismiss or don't bother to consider the current body of evidence often conclude that addiction is just poor choices, lack of willpower, and an unwillingness to see the damage being caused. They often share the belief that treatment consists of convincing the patients that drugs are bad and they should stop, and punish those who don't comply. Detox treatments are favored by this crowd because the horrible withdrawal is seen as punishment and thought to serve as a reminder why patients shouldn't do drugs, as if they don't know that already.

Not until addiction is understood as a brain disorder, and cravings are identified as the manifestation of this brain disorder, can suppressing cravings be seen as a reasonable tactic. Detailed description of addiction and the purpose of evidence-based treatment are beyond the scope of this FAQ but found elsewhere on the site.

Once addiction is understood as a craving-causing brain abnormality (caused by chronic non-medical use of opioids in this case) suppressing cravings to allow the behavioral changes to reverse some of the brain changes, begins to make sense.

Buprenorphine treatment stops the addiction in its tracks, it greatly reduces the chance of accidental overdose death, increases survival rates, allows people to; return to work, repair relationships, and improve their quality of life. It also assists in making profound behavioral changes which in time can reverse the craving-causing brain adaptations of addiction. Eventually, the patients may no longer require the medication to remain addiction free and taper off.

Anyone who would characterize this kind of lifesaving treatment as controversial clearly has an insufficient understanding of it. - back to top -

Why is this site only about buprenorphine?

Our focus on buprenorphine should not be interpreted as a rejection of other treatments. (Except for Ultra-Rapid-Detox, which we think is a scam¹⁴) Many people have had success with other treatments long before buprenorphine entered the picture. Information about these treatments is plentiful on the web, whereas accurate info about buprenorphine isn't. We decided to focus on buprenorphine treatment because we know people who benefited from it, but almost didn't, based on the misinformation they read.

Addicted people need to assess their own situation and pick a treatment which is best for them. Obviously, non-pharmaceutical treatments should be considered first, such as attempting to taper off of whatever opioid they've become addicted to. The next step might be naltrexone which blocks the effects of opioids. But if cravings are too strong and the depression, anxiety, and stress of withdrawal is too much, it may come down to a choice between methadone and buprenorphine.

Methadone is a better pain reliever than buprenorphine because it doesn't have the same ceiling effect. So patients with chronic pain, often the reason which drove them to opioids in the first place, may benefit from the dual effect of methadone. The downside to methadone is it is dispensed by government regulated clinics which usually requires daily visits, at least at first. They also may require witnessed urine testing, group therapy, 12 step, and or therapy to participate in the program.

Abstinence-only or detox treatments aren't really treatment at all, but the absence of treatment. There really isn't a choice between abstinence and buprenorphine because if you can just quit and be abstinent you don't even need to consider buprenorphine. Buprenorphine is only for those who cannot remain abstinent. Detox treatments are usually ineffective because although the drugs are out of the system, the brain changes of addiction remain and continue to cause cravings. After all, it's the craving-causing brain changes which is the disease, not the presence of drugs.

Naltrexone is more of an anti-relapse tactic than it is a treatment for addiction. Unlike buprenorphine it doesn't suppress cravings caused by the biological adaptations of addiction. Although, since it renders opioids ineffective, it can temper the inner dialog of "should I or shouldn't I take opioids". It can be particularly effective for those who have completed treatment with buprenorphine and want an added safeguard. Or for someone in a risky situation who wants to prevent addiction, such as someone in an environment where they are exposed to others using opioids and may not be able to remove themselves from the situation. It also may be effective for those who have just crossed the threshold of addiction from physical dependence and the craving-causing brain adaptations of addiction have not fully developed.

Inpatient treatment is sometime needed if outpatient has failed. But it can be a big waste of time and money to go to an inpatient resort unless the far less expensive outpatient treatment has already been ruled out. Remember, the whole point of addiction treatment is to make changes in behavior. If a week or 28 days of change is followed by a return right back to the identical situation as before, chances are the person will relapse. Inpatient should only be considered if the current living situation is detrimental to recovery and there is a plan to change that after the inpatient stay. Since taxpayers are now on the hook for inpatient addiction treatment (through Obamacare subsidies), many new specialists have sprung up, some without any regard to evidence-based practices what-so-ever.

12 step groups can be used with any treatment option. It's important to understand the role of 12 step; it is not a treatment but a form of support which helps the patient maintain motivation and make behavioral changes. Thinking 12 step is a form of treatment and pitting it against medical treatments such as buprenorphine is a mistake. It can be used in conjunction with buprenorphine treatment. Peer support is important and 12 step is just one example, on line support forums are another form of peer support.

Each person's situation will dictate which treatment is best, as one treatment will emerge as the most appropriate for a given individual. - back to top -

Why don't you make a site about ALL addictions and ALL treatments?

Why don't you?