I would like to ask why a clinician may choose to prescribe suboxone over subutex.
I understand some of the reasons suboxone was under development from the start of the subutex introduction to the market, but would be interested to know why it might be preferable now?

well the rationale is that it won't be injected because that will activate the naloxone and send the user into withdrawals. In a prison environement with adequate supervsion this may not be an issue. Now we seem to have generic buprenorphine on the scene suboxone is going to be more expensive - we;ve already had complaints about genneric buprnorphine, I think it must be psychological but users are sying it doen't last as long

With regards to what will happen if suboxone is injected, does this apply to snorting as well or does it just not give as good an effect???

so much in here! 1)the idea is need less supervised consumption if Suboxone hence cheaper but other side why use 2 drugs if one does? We have heard some areas changing over wholesale to Suboxone and I think that is commissioners not understanding (see dr fixit for another view in next Network) 2) many prisons have transferred across to Suboxone because bup now commonest drug on wings 3) same happens with snorting hence bad effect if snort Suboxone and 4) can't agree re psychological effect of generic bup - it tastes different, it dissolves quicker and some people just don't get on with it - having always until now prescribed generically (cause there was only one) I have recently had to prescribe Subutex twice! Some people in fact now prefer Suboxone because it tastes better

thanks Chris, I was hoping to get some other experiences. We have had people saying it doesn't last as long which shouldn't be the case pharmacologically as far as I can make out

quote:

Originally posted by clurr:
With regards to what will happen if suboxone is injected, does this apply to snorting as well or does it just not give as good an effect???

I have rarely had the occasion to use suboxone, but one current client asked for it specifically because he was snorting the subutex and knew that there was no point with the suboxone. Over several months it has worked well, he is happy and I am happy and he is now both stable and on a phased reduction.

Jim,

Did the client try to snort it? I ask because the research quoted by the manufacturer related to naloxone in solution in water administered nasally producing precipitated withdrawal in opiate-dependent subjects.

I wonder what the absorption of powdered suboxone is like in vivo?

quote:

Originally posted by jimjones:
Jim,

Did the client try to snort it? I ask because the research quoted by the manufacturer related to naloxone in solution in water administered nasally producing precipitated withdrawal in opiate-dependent subjects.

I wonder what the absorption of powdered suboxone is like in vivo?

No, I don't think he has ever tried snorting the suboxone, or if he has he has never told me. He wanted to not have the temptation of snorting the subutex and it was actually his idea to change to suboxone.

So, it might be all in the mind.....

Would be interested to hear reports of people who had tried snorting suboxone and whether the bio availability via that route is adequate for it to work as advertised

quote:

Originally posted by jimjones:
So, it might be all in the mind.....

Would be interested to hear reports of people who had tried snorting suboxone and whether the bio availability via that route is adequate for it to work as advertised

Hi Jim,
I have read on some american forums that people do snort it and as you rightly point out, the evidence is on Naloxone liquid. The nasally administered naloxone powser is going to be unpredictable in it's effects. The study I seem to remember was very small.

As Chris says, above, why prescribe two ingredients when one will do? I have not yet found a patient in Birmingham who would benefit from a suboxone script.

The only reason to prescribe suboxone rather than generic buprenorphine would be to discourage someone from injecting subutex, but my patients don't inject subutex. If injecting, they prefer heroin, and avoid buprenorphine of all kinds..

If as Jim Newmark describes, a particular patient described a habit of injecting (or maybe snorting) buprenorphine, and wanted help to avoid this, i would of course offer suboxone, but I have not come across anyone with this problem, and therefore have not prescribed it at all.

If people are injecting, they are injecting heroin, not subutex, and although a few people have described snorting subutex, it is only on an occasional basis, because the nose gets sore, I am told. And ordinary buprenorphine when snorted still works to block heroin use, and is still long acting, so is still having the effect i hope for, so i don't particularly mind if an occasional dose is snorted.

Like Chris, I have generally always prescribed generically, so patients are now being given generic buprenorphine and find it just as effective as the branded version. I have on one occasion been asked to change the script to the branded one , because someone preferred it.

I hope the generic version will become cheaper soon (as buprenorphine is now out of patent) and i presume the branded version will also become cheaper at that point, in the same way as ventolin is now cheaper than generic salbutamol, which will be excellent for all our drug budgets, and for the tax payer. But this will not happen, of course, if people are prescribed blanket suboxone, without any clinical justification for the extra ingredient.

back to suboxone and snorting - had a patient who wanted to stop all illicit drugs, had tried snorting suboxone and had ppt withdrawal so asked for buprenorphine so that she could snort once a week - I will leave it to you to decide what I did but the evidence is that suboxone acts same way if injected or snorted

I'm still having problems with diversion of subutex (joys of prison) so we are currently looking at the price of suboxone. I personally would like it prescribed for the piece of mind of knowing they are having their prescribed dose and nobody will bother bullying people for their meds once the word gets around that we give suboxone!

The price of suboxone at present is exactly the same as subutex.. the loss of patent has yet to kick in. I think you will find that people will be just as happy to divert suboxone as subutex. they'll presumably just not snort it. though some will snort it and find it just as good a hit as subutex, apparantly (as the naloxone elemnet is most effective when injected) I think in prison, any kind of buprenorphine would be welcome, to dull the pain.

Don't you supervise the consumption in prison? I thought you did. Maybe its not so much your dispensed subutex that is on the wings, but rather its coming over the walls? patients have told me that usually there are prison workers of various types who can be prevailed on to bring stuff in from outside.(even drug workers!) I was told that sometimes very bullying methods are used.. eg finding where the worker lives, in conversation, then making threats against his family (via people on the outside.) This was a description of a prison sentance which happened several years ago.. maybe it doesn't happen any more?

If you have lots of prisoners wanting/needing it to produce a market in it, maybe you are not getting enough of them into treatment?

Yes Judith supervised but still trying to conceal, they assure me for their own use.. prefer the effect of snorting! Not a big problem but because shortage of drugs at the moment (security doing a v.good job) those who don't want treatment can't get their hands on drugs... prices go up etc etc.... we aren't convinced suboxone will solve the problem.

i wonder whether there is a great down side to letting them have 'supervised nasal ingestion" if that is their preferred method of ingestion?

I suppose buprenorphine is not licensed for nasal use? Seems a good option, otherwise, doesn't it? Maybe we should just ask the manufacturers to apply for an extension to their license? Now there's a suggestion the makers of subutex might like to take up.. there might be a better therapeutic indication than for the Rx of suboxone?

From your description, it sounds like the market will drive lots more people into treatment, which has got to be good? If they want to get into treatment in your place, can they easily get it?

crikey Judith your forward thinking would have the prison in uproar haha already get accused of giving 'free drugs' (small minded???surely not??) Thankfully yes, treatment is quite easily accessible at the moment and yes lack of supply may well have them queuing which has got to be a good thing!