What is Suboxone, and how does it work?
Suboxone is a brand name medication commonly prescribed by clinicians to treat opioid use disorder. It combines two drugs: buprenorphine and naloxone. Buprenorphine eases opioid withdrawal, quiets cravings and lowers overdose risk. Naloxone keeps the medicine from being injected or misused. The FDA has also approved generic versions of Suboxone.
Buprenorphine acts like a partial opioid in the brain. That makes it different from methadone, oxycodone, heroin and fentanyl. Because it is a partial opioid, it cuts cravings and withdrawal without the euphoria, or “high,” that full opioids bring. It also has a ceiling effect—past a certain dose, there is no added opioid effect. That lowers the risk of overdose. Naloxone (often called Narcan) is an opioid blocker. It blocks opioids in the brain. Pairing buprenorphine with naloxone discourages misuse of the medicine.
What are the side effects of Suboxone?
All medicines can have side effects, and Suboxone is no different. Luckily, its side effects are uncommon and usually mild. Common ones include nausea, headache, dizziness, tiredness, trouble sleeping, heavy sweating and stomach cramps. As with any new medicine, do not drive or do other risky tasks until you know how your body reacts. After that, Suboxone taken as prescribed puts no limits on your activities.
Should I take Suboxone strips (AKA Suboxone films) or Suboxone pills (AKA Suboxone tablets)?
Suboxone usually comes as a film (strips). Generic buprenorphine/naloxone also comes as tablets (pills). Films/strips and tablets/pills work equally well for opioid use disorder, including cravings, withdrawal and overdose prevention. Films and tablets have the same strength. Neither one is stronger.
Insurance companies often decide which form (films or tablets) they cover. That decides which one gets prescribed.
Suboxone tablets often cost less than films. That matters for patients paying out of pocket. Some patients say they like the taste of one more than the other, but that is a personal choice.
In the end, both tablets and films can work well in recovery. You and your doctor will choose together. You will weigh your medical history and what your insurance covers.
How do I take Suboxone?
For sublingual Suboxone pills (AKA Suboxone tablets):
- Drink water before taking the tablet(s) to wet your mouth.
- Do not cut, crush, chew, or swallow the tablet(s).
- Place the tablet(s) under the tongue and leave them there until fully dissolved. This usually takes less than 15 minutes. If you take 2 or more tablets at once, put each one in a different spot under the tongue.
- Do not eat or drink anything until the tablets are fully dissolved.
For the sublingual Suboxone strip:
- Drink water before taking the strip(s) to wet your mouth.
- Do not cut, chew, or swallow the strip(s).
- Place the strip(s) under the tongue and leave them there until fully dissolved. This usually takes less than 15 minutes.
- If you take 2 or more strips at once, put each film in a different spot under the tongue.
What is the Suboxone Spit Trick?
You may have some chalky residue in your mouth after the Suboxone dissolves. This is where the Suboxone spit trick comes in. Once the film or tablet has fully dissolved, spit out the saliva. You may want to rinse and spit again. Suboxone is absorbed under your tongue, so spitting afterward is perfectly fine.
What are the alternatives to Suboxone?
Medication for opioid use disorder (MOUD) includes buprenorphine, methadone and naltrexone. All three cut opioid cravings, withdrawal symptoms and overdose risk. Buprenorphine is one part of Suboxone. The United States Food & Drug Administration (FDA) approves buprenorphine, methadone and naltrexone for this use. MOUD works best when paired with counseling and social support.
Methadone is a long-acting full opioid. That means it is like other opioids such as oxycodone, heroin and fentanyl. It fills the opioid receptors in the brain, which blocks or dulls the effects of other opioids. Compared with methadone, buprenorphine has many advantages. Buprenorphine/naloxone (Suboxone) is widely seen as safer than methadone. Taken as prescribed, it has a lower risk of sedation and overdose.
The right dose is well known and can be safely reached within 1-2 days for most patients. The right methadone dose varies from person to person and can take weeks to reach. Licensed, trained medical providers can prescribe buprenorphine/naloxone (Suboxone) in any treatment setting. Methadone is tightly regulated and can only be given through federally licensed outpatient programs. Naltrexone is an opioid blocker that fills the opioid receptors in the brain. That keeps people from feeling the high of drugs like heroin or fentanyl. It is basically a “blocker” and cuts cravings for both opioids and alcohol.
When should I start taking Suboxone?
Wait until you feel mild-to-moderate withdrawal before your first dose of Suboxone. Otherwise, you may go into what is called “precipitated withdrawal,” where strong withdrawal symptoms hit very suddenly. It can be miserable and, in some cases, dangerous. How fast withdrawal comes depends on your tolerance, what you usually use and your dose. In general, patients should wait the following number of hours before starting Suboxone:
12-24
Hours
for short-acting opioids (heroin, oxycodone, Percocet, Vicodin, Dilaudid).
36
for intermediate-acting opioids (fentanyl, Oxycontin, MS Contin)
48-72
for long-acting opioids (methadone)
What are common opioid withdrawal symptoms?
Opioid withdrawal symptoms are uncomfortable, but your medical provider can prescribe treatments to ease them. Clonidine helps reduce anxiety, irritability, muscle aches, sweating and runny nose. Loperamide (Imodium) helps stop diarrhea.
Naltrexone extended-release injection (Vivitrol®) is used with counseling and social support. It helps people who have stopped heavy drinking avoid drinking again. It is also used with counseling and social support for people who have stopped abusing opiate and opioid medicines or street drugs. It helps them avoid abusing them again. Naltrexone acts as a blocker at the dopamine receptors, cutting cravings and blocking the high. As a shot (called Vivitrol®), it only needs to be given once a month. People often confuse naltrexone with methadone or suboxone. In fact, it is not addictive. There are no withdrawal symptoms when you stop it.
Librium (chlordiazepoxide hydrochloride) comes as a capsule taken by mouth as our doctor directs. It works by boosting GABA (gamma-aminobutyric acid), the brain’s natural calming chemical. GABA slows or stops certain signals in the brain, which calms and sedates. Librium is a benzodiazepine. It helps reduce anxiety, stop seizures, relax muscles and cause sleepiness. Because of these effects, Librium can help control some symptoms of withdrawal from alcohol and drugs.
Baclofen has shown early signs of cutting cocaine use in cocaine addiction. It was given along with drug abuse counseling three times a week. The effects were clearest in people with long-term cocaine addiction at the start. These results support a full-scale trial of baclofen, especially in this group. This medicine is usually used for clients with cocaine addiction. You can review a sample induction protocol from the American Society of Addiction Medicine here.
Frequently asked questions about Suboxone
We do not recommend that patients stop taking Suboxone. Addiction is a long-term condition, so we recommend long-term use of Suboxone. People with diabetes or high blood pressure take daily medicine to stay healthy. People with addiction must do the same. Our program is long-term and steady. It supports patients over months to years, and the evidence backs it. You can learn more here about why Suboxone is NOT “just trading one drug for another.”
But if patients firmly want to wean off Suboxone—while knowing the risks—our providers help them build the safest possible plan. We also help them reach their recovery goals.
How long does Suboxone stay in the system?
Buprenorphine/naloxone (Suboxone) stays in your system for 28-42 hours after you take it under the tongue (sublingual). That is the most common way to take it. Shots, IV and skin-patch forms last different lengths of time in your blood.
Can you get high on Suboxone?
It is very hard to get “high” on Suboxone. A few people might feel a little bit of a “high.” They are people who have never used opioids, or have NO opioids in their system… for them, a partial opioid like buprenorphine might bring some euphoria. That is not true for patients with active opioid use disorder. Their bodies are used to full opioids (e.g., oxycodone, heroin, fentanyl).
Can you overdose on Suboxone?
Buprenorphine/naloxone (Suboxone) has a ceiling effect on slowed breathing. So Suboxone is seen as very safe and low-risk for overdose when used alone. Every overdose with Suboxone in the system involved high doses of benzodiazepines. So there is some risk when it is mixed with other drugs.
Does Suboxone show up on drug tests?
Buprenorphine is not part of the standard drug screen. For buprenorphine/naloxone (Suboxone) to show up on a urine or saliva test, the test must look for buprenorphine on purpose. If a medical provider prescribes you Suboxone, the law protects you from job discrimination.
Is it safe to taper/stop Suboxone?
Medication for opioid use disorder (MOUD) is vital to prevent overdose and death. Research shows that with MOUD, 75% of patients are still in recovery one year later. But studies show something else too. Within one month of stopping buprenorphine, more than 50% of patients go back to illegal opioid use. Suboxone helps patients feel normal and healthy. Taken as a provider prescribes, it treats addiction. It does not bring the damage that uncontrolled drug use does to a person’s life, goals and daily life.
Is Suboxone an opioid?
Partly. Buprenorphine, the main ingredient, is a partial opioid. It settles into the same receptors as full opioids like oxycodone, heroin and fentanyl. That is why it stops withdrawal and cravings. But it does not bring the same high. It also has a ceiling effect: past a certain dose there is no added opioid effect. The naloxone in Suboxone blocks opioids and discourages misuse.
Why do people with opioid addiction take Suboxone?
Because it lets them feel normal again. Suboxone eases opioid withdrawal, quiets cravings and lowers the risk of overdose. Taken as prescribed, it treats the addiction without the damage uncontrolled drug use does to a person’s life, goals and daily life. Addiction is a long-term condition. So, like a daily medicine for diabetes or high blood pressure, Suboxone is usually taken long term.
How do people act when they take Suboxone?
For someone with opioid use disorder, a steady Suboxone dose does not bring a high. It brings relief from withdrawal and cravings, so most people simply feel like themselves. Until you know how your body reacts, avoid driving or other risky tasks. After that, Suboxone taken as prescribed puts no limits on your normal activities.
What are the worst side effects of Suboxone?
Most side effects are uncommon and mild: nausea, headache, dizziness, tiredness, trouble sleeping, heavy sweating and stomach cramps. Starting it too early can cause precipitated withdrawal, a sudden and intense wave of withdrawal symptoms. That is why timing matters. The real danger is mixing it with other drugs. Overdoses with Suboxone in the system have involved high doses of benzodiazepines.
How do you prepare for Suboxone treatment?
Switching from opioids to buprenorphine/naloxone (Suboxone) can feel scary. Thinking about giving up opioids after depending on them can be daunting. So can the switch itself (also called “induction”). Some people have had a bad time taking buprenorphine/naloxone (Suboxone) before going into opioid withdrawal first. That can make someone feel very sick, though it is usually not dangerous.
Most people who depend on opioids have felt withdrawal at some point. Opioid withdrawal can bring clear symptoms like nausea/vomiting/diarrhea, anxiety and restlessness. It can also bring less obvious ones like dilated (large) pupils and goosebumps. It is true that you will go through some withdrawal to switch from opioids to buprenorphine/naloxone (Suboxone). The care team will be with you along the way to make the switch as safe and comfortable as possible.
Why do I have to go through withdrawal symptoms?
Opioids work at the “opioid receptors,” which are proteins all over the body. There, opioids do things like ease pain and cause euphoria. Buprenorphine sticks to those receptors much harder than opioids do and knocks opioids off them. When that happens, the patient can get sudden, severe withdrawal called “precipitated withdrawal.” This “precipitated withdrawal” can be avoided by going through moderate withdrawal before taking buprenorphine/naloxone (Suboxone).
Even with withdrawal symptoms, most patients can safely start buprenorphine/naloxone (Suboxone) at home. Home is comfortable and familiar. You avoid the dangers of driving while in withdrawal or while taking a new medicine. In the COVID-19 era, managing it yourself with expert support matters even more, to avoid catching the virus in health care settings. Your medical provider can help you decide if this path is right for you.
Different opioids take different amounts of time to reach enough withdrawal to start buprenorphine/naloxone (Suboxone). These are rough estimates of the hours it takes to withdraw from various drugs. The time also varies from person to person:
- Short-acting opioids including heroin, oxycodone/Percocet, hydrocodone/Vicodin/Lortab, and kratom: approximately 12-16 hours
- Long-acting opioids including Oxycontin, MSContin, Opana ER: approximately 20-24 hours
- Methadone: approximately 48 hours
- Fentanyl: approximately 72 hours but varies by method of use
How do I prepare for opioid withdrawal and Suboxone induction?
The best way to prepare for induction is to talk with your medical provider and get all your questions answered ahead of time. Our providers will walk you through the process before your first dose. Get your medicines before withdrawal starts. That includes buprenorphine/naloxone (Suboxone) and comfort medicines. That way you do not have to go to the pharmacy once you feel sick.
Set up a comfortable spot at home with a bathroom nearby. You may have unpleasant symptoms like vomiting and/or diarrhea.
How do I manage withdrawal symptoms?
Your medical provider can pick medicines that target specific withdrawal symptoms like diarrhea, nausea, anxiety and muscle aches. Stay in your comfortable, safe and private space with a bathroom nearby. Use distraction, meditation or other comfort steps that work for you.
Use the withdrawal tool to measure how bad your withdrawal is. It helps you judge when you are ready to take buprenorphine/naloxone (Suboxone). It gives each symptom a number score. A similar tool can be found here. Listen to your body. Say you feel so sick that you cannot stand any more withdrawal. Then you are most likely ready to start a small amount of buprenorphine/naloxone (Suboxone). Check your symptoms against the withdrawal tool to be sure.
If something feels wrong (like so much vomiting that you get dehydrated), contact us during business hours. After hours, think about going to urgent care or the emergency room. Starting buprenorphine/naloxone (Suboxone) at home is seen as safe for most people. Emergency help is rarely needed.
What happens in the first 10 days of Suboxone treatment?
Day 01
- Meet face to face with your medical provider at our St. Louis clinic for an assessment.
- Receive written instructions on how to safely start buprenorphine/naloxone (Suboxone).
- Get a short prescription for buprenorphine/naloxone (Suboxone) and comfort medicines if you meet the criteria for opioid use disorder (addiction to opioids). The provider usually prescribes about 12mg of buprenorphine/naloxone (Suboxone) the first day. That rises to 16mg on day 2.
What you do at home:
Stop your opioids and allow the withdrawal process to begin.
- Monitor your symptoms using our tool to measure withdrawal severity.
- Take comfort medications as needed.
- Start a small amount of buprenorphine/naloxone (Suboxone) once your withdrawal is strong enough on the SOWS scale.
Day 02
(or one day after your anticipated start)
- Meet with your medical provider again. They will check how you are doing, adjust your medicine and answer questions.
- Get instructions and reminders to do urine or saliva drug screens at home.
- Stay on your 12mg dose of buprenorphine/naloxone (Suboxone) or raise it to 16mg (based on your provider’s advice).
- Track your symptoms – above all cravings and withdrawal – to report to your medical provider at each visit.
- Do the first urine or saliva drug screen at home and show the results with your cell phone camera.
Day 07-10
- Meet with your medical provider from time to time. They will check how you are doing, adjust your medicine and answer questions.
- Track your symptoms – above all cravings and withdrawal – to report to your medical provider at each visit.
Day 10
- Once you feel comfortable on your dose, your medical provider will see you weekly until you are stable with good drug screens.
How can you make opioid withdrawal easier?
Here are some tips to help you get through withdrawal and the induction process:
- If you have caring friends and family who know about your condition, ask them to check on you from time to time.
- Plan to take a day or two off to switch from opioids to buprenorphine/naloxone (Suboxone). If you work, you might start on a weekend. If you have young children, line up help caring for them if you can.
- Do not start withdrawal on purpose before talking to your medical provider. Once you feel sick, it is hard to talk clearly.
- You do not need to cut down your opioid dose ahead of time. Cutting down before starting buprenorphine/naloxone (Suboxone) rarely helps but does cause needless discomfort.
- Know that buprenorphine/naloxone (Suboxone) stops withdrawal symptoms in almost all patients, even those with severe withdrawal or on high-dose opioids. If you feel this medicine is not easing your symptoms, please contact your medical provider for help.
Sources
- Mattick RP, Breen C, Kimber J, Davoli M. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database Syst Rev. 2014;2014(2):CD002207. PMID 24500948 · DOI 10.1002/14651858.CD002207.pub4.
- Kosten TR, Baxter LE. Review article: Effective management of opioid withdrawal symptoms: a gateway to opioid dependence treatment. Am J Addict. 2019;28(2):55-62. PMID 30701615 · DOI 10.1111/ajad.12862.
- Nosyk B, Min JE, Homayra F, et al. Buprenorphine/Naloxone vs Methadone for the Treatment of Opioid Use Disorder. JAMA. 2024;332(21):1822-1831. PMID 39418046 · DOI 10.1001/jama.2024.16954.