I thought that I'd re-open the suboxone discussion. I've been prescribing it now in some circumstances for around 4-5 months and am interested in other peoples' views. It would appear that it dissolves much quicker (supervising nurses say approx 4x) than subutex - which seems a big positive for those who are required to take buprenorphine by supervised consumption. It also appears that the effect if you snort is not predictable ie. some complain of headaches and others a pleasant euphoric opioid effect.
Would be interested in any experiences of other prescribers.

Nat,
We have about ten patients on it and yes it does seem to dissolve quicker - could be as it may taste nicer.
I haven't spoken to anyone that has told me they have snorted it.

Hi there

I was just wondering as I haven't dealt with clients prescribed Suboxone :

Would the prescribing be similiar to methadone as a long term substitute? Or would there be some sort of time limit on Suboxone prescribing?

Thanks

Deon

Yes Deon it's an opiate substitution therapy suitable for maintenance. It's basically buprenorphine (trade name subutex) with naloxone also so that "allegedly" if they either snort or inject the tablet then they get the naloxone (opiate antagonist) effect and go into withdrawal. ie. a sort of incentive to take it sublingually as prescribed.

I have one client on it and he likes it and is doing well, apart from he hates the taste. The psychological effect of the naloxone in it is keeping him off heroin when he was using on top of subutex previously.

I've only seen one who snorted it but he said everyone was doing it in prison, and there is just as good a euphoric effect in his view.

I am interested in the quicker dissolving time though. If they can do it with Suboxone, why not Subutex? Does anyone have connections in Schering Plough?

I said from the start that the effect of snorting it would be unpredictable but Schering-Plough don't hide this. I think it is only quicker dissolving because it tastes reportedly better and it's not been marketed to dissolve faster. Patients report to me that it dissolves quicker.

quote:

Originally posted by harniman:
I have one client on it and he likes it and is doing well, apart from he hates the taste. The psychological effect of the naloxone in it is keeping him off heroin when he was using on top of subutex previously.

hi beverley..
the Naloxone element of the suboxone won't be having any effect to block heroin unless he is injecting or snorting the suboxone. (because its not active if taken orally, or through the oral mucosa apparantly. )

I'm still awaiting the generic buprenorphine being imported by someone from europe.. I've recently heard of someone getting some from belgium.. it tasted nice an lemony and dissolved better than subutex apparatnly (rumour has it) .

It will cetainly be cheaper, so I am still keen not to give people a taste for this non-generic suboxone, when the generic buprenorphine must surely be around the corner. I havn't come across anyone injecting buprenorphine yet in Birmingham, and people seem to snort it only intermittantly when outside prison,,and if they do it probably still works to keep them away from heroin, and they stop when nose gets sore, so I haven't come across anyone with any clinical indication for suboxone.

I haven't got round to emailing the French chap who comes to the conference,who is using generic form in france.. I must do that.

Hi Judith, yes it will be interesting to have more info on the generic buprenorphine as the "lemony and dissolved better than subutex" phenomenon is app what is happening with suboxone. Interesting times......
wouldn't it be good if we had a new maintenance medication every year, it'd keep us on our toes!!

Hi
I have used suboxone on maybe 15 people to date in the community.
It is very hard to say where this drug fits in.
Some interesting cases though.
One snorted it and felt very unwell.
One it actually decreased their cravings for alcohol.
Most seemed to feel no different to subutex except tasted different but still not particularly pleasant.

Certainly there is a problem with diversion of subutex either for recreational use or inwards to prison where it fetches £40 compared to £1 on the street. I have neither heard of anyone injecting subutex- I suspect there is no need as heroin is cheap and freely available at present.
Whether suboxone helps isnt clear as yet. I have witnessed it also being sold now on the street!
Some clients have refused point blank to have it, but it is often difficult to understand their motives- fear of something new is stated by several.

Dr.Mick, do you know how much the Suboxone sold for on the street ?

Interesting Dr Mick about your "diversion into prison" line as I think that's where a significant proportion of prescribed buprenorphine is going - as reflected in the "mandatory drug tests" in prisons which are picking up approx 50% positiive for buprenorphine even in prisons where buprenorphine is not prescribed! Your figures of approx £40 per tablet are akin to the HMP Leeds going rate for an 8mg buprenorphine tablet.
Re suboxone diversion, yes I think we'd all be naive if we were to think there wasn't any as taken sublingually it will still have the euphoric opiate effect. I'd imagine though that the price on the street will be less though on account of 3 factors: - first,it's potential to give the opiate antagonist effect if injected; second it's quicker speed of absorption than subutex when taken sublingually; and third the possibility in some users to give an opiate antagonist effect if snorted

Just back from South West conference, similar prices being quoted for Subutex tablets in prison. Someone even suggested £47. SEEMS the reason is the lack of testing for it in prisons means they won't be punished.
If the prevalence of abuse in prisons is as high as you quote Nat, someone is making a lot of money out there!

sounds like moves to prescribe a lot more buprenorphine in prisons would be excellent, if only to save the partners and families having to stump up all this money to buy it in the "private sector".

I don't even feel its much of a catastrophe if it is sometimes snorted rather than being taken "as prescribed" as it will still be safer than heroin in overdose, and will still have opiate antagonist effect if in high enough doses, and will still be long acting if taken regularly and people seem to get sore noses, so revert to oral mucosa route if prescribed it daily rather than as occasional street treat.

just crush it and spoon it out to all prisoners willing to take it maybe?

Street suboxone same price as subutex £1 -£2 per 8mg tabs.
I agree that occasional snorting is not an issue. Many also dont like it as it is quite unpleasant on the nose.
However diversion is common amongst friends and associates ( just like methadone) and I have now seen several recreational users who have gone on to be chronic continuous snorters who previously didnt have an opiate addiction.

Dr.Mick,
Thanks this is the first cost comparison on the streets that I have had. I would have thought Suboxone may well have had a lower street value, but maybe it is how people are abusing it.

this is interesting isn't it. I agree that on one level the differenc between snorting and sublingual is only a few inches (or centimetres for those young folks!!) and so what's the fuss. The difficulty i have is the abuse and harrassment that users in prison face when on subutex on account of its street currency. that's what's made me go for suboxone as it dissolves so much quicker. I agree Judith that if we could 100% coverage of drug treatment it would be less of a problem. that said we're starting 3000 people a year on maintenance and still have it as a problem -reasons prob complex but the first principle I think is that if we get 100% treatment we only reduce (not eradicate) the illicit market (ie. harm reduction not harm elimination).

I wonder does anyone have anything to add? any new experiences.

In Cumbria, we are looking at the possibility of switching everyone on subutex to suboxone. The reason is we still don't have supervised subutex consumption, despite NICE Technology Appraisals! As a result, there is a lot of diversion of the subutex, with allegedly alot of injecting. The local street price of suboxone is reportedly lower than subutex. At this time, all new buprenorphine treatments are suboxone. The only strong objections so far, are from patients with a history of injecting. We do have a strong culture of injecting here - some patients have never smoked heroin, only used IV. We also had a big problem 10 years ago with IV temgesic.
Has anyone else used suboxone as the main buprenorphine prescriptin, and or tried switching everyone over to suboxone? If so what, if any, problems did you encounter?
Has anyone developed a protocol for crushing suboxone, or does it dissolve so quickly that that isn't necessary?

Lots of thoughts about this, but on the crushing side of things, thee was a fair amount of debate when subutex first appeared, and Susi Harris looked at it in some detail. Somebody may by now be doing it regularly? Here's the historical topic posts: (If you enter "crushing" into the search box behind the magnifying glass at top of page..) which might be helpful..
http://smmgp.groupee.net/eve/forums?a=search&reqWords=c...rum_scope=1064030241

for example here's a thread from last year. It would be interesting if anyone has recent practical experience..?

http://smmgp.groupee.net/eve/forums/a/tpc/f/1064030241/...121054902#1121054902