Rapid Opioid Rip-Off

While I’m on the subject of rip-offs, I’ll mention an extreme form of ‘detox capitalism’; a process called rapid opioid withdrawal, rapid detox, or ‘the Waismann Method.’
The name of the process supposedly comes from a certain ‘Dr. Waismann’ who helped Israeli soldiers get off opioids after they were treated for various injuries.  It sounds like a pretty exciting history, but to be honest there is nothing in the technique that takes a rocket scientist to figure out.  The basic idea is to precipitate withdrawal using an opioid antagonist— something that is done many times over every day in emergency rooms across the U.S.—but to do it while the person is sedated with non-opioid medications.

Put me out, Doc!

I never expected to admit this back when it occurred, but I had the bright idea of putting myself through ‘rapid opioid detox’ shortly before entering treatment ten years ago, when I was desperately searching for a way to free myself from opioids.
Like any typical addict I wanted to do it entirely by myself, figuring that I knew as much about opioids and medicine as anyone else.  I loaded up on naltrexone (an oral form of naloxone) thinking that the antagonist would block my receptors, lower my tolerance, and prevent me from using for as long as I took the naltrexone.
I simplified things a bit by omitting the sedation—a good idea since there was no other doctor monitoring me, but a bad idea because I experienced about a week of withdrawal condensed into several intensely-miserable hours.  I remember being shocked at just how much sweat my body could produce in such a short time, as liquid beaded on my skin as fast as I could wipe it off!
After the real horrible period—the period that I would have slept through had I come up with $15,000 plus airfare—I remained quite ill for a matter of weeks.  And of course that is what happened, since it takes weeks for tolerant mu receptors to be replaced by new, normal mu receptors.  Until the receptors are replaced, the brain’s endorphin pathways remain quiet, causing hypersensitivity to pain—not to mention diarrhea, restless legs, cramping, gooseflesh, and depression.
There are several variations of rapid detox, but the principles are the same for all of them:
–          The addict is given a strong sedating medication or anesthetic
–          While heavily sedated, the addict is given an intravenous infusion of the opioid antagonist naloxone to precipitate withdrawal.
–          After a period of time that varies with the name of the facility, the addict wakes up;  one day of withdrawal gone, and only two more months of withdrawal to go!
–          The process costs from five to ten thousand to tens of thousands of dollars.
–          Different options are tossed in for different programs, everything short of an extended warranty: amino acid cocktails, ‘vital nutrients,’ or long-term sedatives.
–          In some cases a chip of naltrexone is implanted that slowly releases over weeks, supposedly preventing a high from using—provided the addict doesn’t become desperate and use very high doses of heroin, or dig the implant from his/her body using a fork!
Web sites for the procedure point out that opioid dependence is a relapsing illness and that people who use Suboxone relapse when they stop Suboxone (no argument from me), but go on to claim a 70% one-year sobriety rate after their rapid-detox procedure—without any explanation for how they get better numbers than Suboxone patients.  I have never seen peer-reviewed studies showing such success rates.
Speaking of peer-reviewed studies, I have seen a study of rapid detox showing what is intuitively obvious—that since it takes a number of weeks for the body to adjust to the lack of opioids, one day of sedation avoids only a tiny portion of the misery of withdrawal.  Is it worth ten grand to avoid one day of withdrawal, knowing that several more weeks of withdrawal are yet to come?  I suppose it depends on one’s checking account.
But the bigger issue is the poor long-term outcome for these people—a problem similar to what I described in my post about Sneetches.  Early in the spiral of addiction, addicts and their families are under the mistaken belief that the hardest part of ‘kicking opioids’ is to get through physical withdrawal.
They eventually they learn that they are wrong, and that it is much more difficult and rare to STAY clean than it is to GET clean—but ‘rapid detox’ makes money off their ignorance in the meantime.  Quitting opioids by rapid detox, amino acids, magic crystals, hypnosis, or a host of other expensive, highly-promoted methods reminds me of the story about the guy boasting about how easy it was to quit smoking—so easy that he’s done it over 20 times!

Generic Subutex, aka buprenorphine– what's the dif?

I’ll take a break from the book to post a question and answer with a reader:
My daughter’s doctor recently started prescribing her a pill called only ‘buprenorphine,’ instead of her usual Suboxone. Should I be concerned about the change?
My answer:
You don’t mention the age of your daughter, but your question raises the issue of how involved should a parent be in the treatment of a child?  Perhaps a more general issue is whether anyone should be closely involved in the treatment of someone with opioid dependence?  After all, I frequently write that opioid addiction should be seen as ‘just another disease,’ and it is hard to make the case that people should share the details of their medical histories with others, at least after reaching adulthood.
But opioid dependence, while being a disease, does have some unique qualities—such as the effect of a worsening of the disease, i.e. relapse, on patients’ ability to make sound judgments.  Over time, I typically want patients to become responsible for their own outcomes; adult children of too-involved parents sometimes seem to be stuck in a state of chronic defiance, where the addict seems to think that a relapse is a statement of independence or a reflection on the parents, rather than the addict’s own problem.  But early on, it can be helpful to have someone monitor the addict’s behavior, and even control the buprenorphine.  Just remember that only the addict him/herself can determine, in the long run, whether a buprenorphine program will work—or whether it will just be one more failed treatment method.
Suboxone and Subutex (generic or brand-name) are interchangeable for the most part— except generic buprenorphine is about half the price of brand-name Suboxone  ($3 per tab vs. $6-$7).  The main chemical difference is the naloxone in Suboxone, which is not present in Subutex or generic Subutex (aka buprenorphine HCL).  Naloxone doesn’t cross mucous membranes; lipid soluble molecules like buprenorphine and fentanyl tend to pass through mucous membranes, and water soluble molecules like naloxone and morphine do not.  When a person takes Suboxone properly the naloxone ends up being swallowed, absorbed from the intestine into the ‘portal vein,’ and then completely metabolized at the liver before getting into the systemic circulation by a process called ‘first pass metabolism.’  The features of buprenorphine that make it effective for treating opioid dependence (for example the ‘ceiling effect’) do NOT require naloxone. Naloxone is added to Suboxone for one reason—to prevent intravenous injection of dissolved Suboxone tablets.  If Suboxone is dissolved and injected, the naloxone would enter the circulation, block opioid receptors, and cause an hour or two of withdrawal symptoms. 
There is not a great amount of injecting of Suboxone going on out there, and so for most people, generic buprenorphine is fine.  Some people who don’t completely metabolize the naloxone (because of genetic variants of liver enzymes, or perhaps because of taking cytochrome inhibitors like certain SSRIs) develop dysphoria for an hour or two after a dose of Suboxone, because the naloxone gets into their systemic circulation and causes withdrawal.
All patients who are pregnant are generally put on Subutex (or generic buprenorphine) because the low chance of injecting is not enough reason to expose the fetus to one more chemical.
I don’t know if your daughter is pregnant, but that would be one reason to take the generic.  Or it may be a cost issue, or perhaps she sometimes felt sick after taking her dose of Suboxone.  The theoretical risk from switching would be that she could then inject the buprenorphine, without the risk of withdrawal.  If she DID inject, she would not get ‘high’ from doing so;  the injected buprenorphine would have the same effects as when it is absorbed through the oral mucosa, only more quickly (i.e. zero effects, more quickly!).  Even for people NOT tolerant to buprenorphine, injecting buprenorphine is not generally a great way to get high;  the person develops a tolerance to buprenorphine very quickly, and within a day or two is ‘on’ buprenorphine going forward–  incapable of feeling opioid effects because of mu receptor tolerance, and vulnerable to withdrawal if the buprenorphine is discontinued.
I’ll be back with another installment of the book in a few days.  Thanks, as always, for reading; please share the site with other addicts and with those who love them.
JJ

Sick from naloxone, maybe?

A person wrote about feeling sick after taking Suboxone, thinking that naloxone is to blame and frustrated that her physician would not prescribe Subutex:
I first read your blog last week as I was going through the despair and misery of withdrawal from Percocet, and considered suicide. I didn’t want to die, or create anymore suffering for my family; I just didn’t see any options or hope. Your well written words (I thank you deeply) about the hell of withdrawal got my attention & brought me to tears. I continued to read, found out about Suboxone, which led me to message boards from others like me. For the first time I felt hopeful. I found a doctor and made an appt, and after the initial, office administered dose I found myself feeling the best I had in years– no withdrawal and no physical pain – wow! At the 2hr follow-up I told (the doctor) that my pain was completely gone, which she disputed, saying it’s not prescribed for pain. What I know now is that she had given me Subutex in the office, and a Suboxone prescription to take home!!I filled the prescription, took the ½ pill dose, and within minutes my stomach hurt/gnawed, and I developed a very strange headache and mild to moderate chest pain. By the evening I’d vomited and the headache worsened. By next morning I had the worst headache ever and started vomiting large amounts of bile, all of which continued throughout the day. My doc insisted I show up for the follow up appt. that day, even though I was too sick to hold my head up. She insisted I was sick from withdrawal

Image result for chemical structure of naloxone 3d
Naloxone, a mu-opioid receptor antagonist

To date I’m taking 3 Excedrin for migraine within an hour of every Suboxone dose as I get a bad headache every time.  I also wake up with a moderate headache every day. The last few days I’ve noticed I don’t feel emotions, joy, or happiness. I feel depressed & don’t care about things that would typically give me happy goose bumps – my grandkids, my dogs, sunsets.

I asked the sub doc to put me on Subutex which she refused to do. I explained that if someone was this ill from BP or diabetes meds, and there were other options, it would be unethical to not help the patient. I spend $180 for medication that makes me ill- every day.
I’ve spent the day trying to find a doc who will prescribe Subutex, with no success. Ironically, a few years ago my own doc recommended this drug for my back/leg pain.  I don’t know what to do.  I can’t stay on Suboxone or go off. Do you have any suggestions? 
 My answer:
I hope that your weekend is going OK.  I have a few thoughts about your situation, but I don’t know how much help they will be, as ultimately you are dependent on the prescribing doc.  But maybe we will find something that will help.
It sounds like you have a pretty good understanding about buprenorphine and Suboxone, but there are a couple areas that need clarification.  For most people- more than 95% of people in my estimation—there is no difference in the subjective experience from taking Suboxone vs. Subutex.  The active drug, buprenorphine, is present in both, and the naloxone that is present in Suboxone has no significant effect.  The ceiling effect of Suboxone is due to buprenorphine;  naloxone plays no role in that effect.  Both Suboxone and Subutex can be used for pain, and both can be used for ‘induction.’  There are some misguided physicians out there who think that Subutex is a better choice for induction, thinking that naloxone will cause withdrawal during the induction process—but those doctors are wrong.  Both Suboxone and Subutex cause precipitated withdrawal, which comes from buprenorphine, not naloxone.  Naloxone does not pass through the mucous membranes lining the oral cavity, and instead ends up being swallowed, and taken up into the portal vein from the proximal small intestine.  In MOST people, naloxone is then rapidly destroyed by the liver before getting into the systemic circulation.  In a FEW people, though, naloxone causes side effects.  Side effects are of two basic types.  The first type is an allergic reaction to naloxone, causing flushing, wheezing, and perhaps nausea, vomiting, and/or rash.  Allergic reactions can occur from very small amounts of a substance, and so people can have allergic reactions to naloxone even when the drug is essentially cleared by the liver and too little remains to cause symptoms of withdrawal.
A second type of reaction is more common in my experience, and that is where the naloxone is not destroyed well be the liver and instead gets into the systemic circulation and then to the brain and spinal cord, where it blocks the opiate effects of buprenorphine.  In this case the person would have typical symptoms of withdrawal, including headache, depression, anxiety, restlessness, pain, diarrhea, and nausea.  Naloxone is not a long-lasting medication, so I would expect the withdrawal-type symptoms to last only for several hours.
As I mentioned, naloxone is usually destroyed very efficiently by the liver before reaching the systemic circulation, a process called ‘first pass metabolism.’.  There are many medications that interfere with liver enzymes, although I do not know of specific inhibitors of the enzymes that destroy naloxone.  In other cases, people have a genetic background that results in reduced metabolism of certain substances including naloxone.  Your symptoms occur shortly after each dose, which is what we would expect in a person who is not fully metabolizing naloxone.
I do not know why your physician is refusing to prescribe Subutex, but it sounds as if she is concerned about diversion.  In my opinion, concern in this instance is misguided.  Yes, there is a diversion problem with buprenorphine, but there is not a difference between Suboxone and Subutex in this regard—i.e. BOTH are diverted.  Studies suggest that buprenorphine is not generally diverted for the purpose of ‘partying’ or getting high, but rather is taken by addicts who are trying to treat themselves to get off opiates, or who need something to carry them over when heroin or oxycodone are not around.  In either case, the presence of naloxone does nothing to reduce diversion.  As you likely know, naloxone only prevents against intravenous use of Suboxone—a type of diversion that accounts for a very small percentage of cases.
You are welcome to share this with your physician.  Unfortunately there are some thin-skinned doctors out there though, so be careful that you do not get yourself kicked out of treatment!  I have a couple other suggestions that might be safer.  First, you are welcome to send me a list of medications you are taking, and I will check to see if any of them are inhibitors of the liver enzymes that metabolize naloxone.  Prozac, for example, is a potent inhibitor of one group of enzymes, and therefore can affect the half-life of a number of medications.
A second thing you can do has been described in earlier posts.  The idea is to absorb the buprenorphine without absorbing the naloxone.  Since naloxone is taken up only at the intestine, the key is to avoid swallowing the naloxone.  Start with a dry mouth.  Put the tablet in your mouth and bite it into pieces to get it dissolved in a small volume of saliva.  Then use your tongue like a paint brush, and spread the concentrated saliva over the mucous membranes in your mouth for about 10 minutes.   After ten minutes spit out the saliva, which contains the bulk of the naloxone.  Be sure to avoid eating or drinking for about 10 more minutes, as you don’t want to rinse away the buprenorphine that is attached to the surfaces in your mouth.   This method of dosing seems to be more efficient than placing a tablet under the tongue, and allows more control over the absorption of naloxone.   I’ve had a number of patients who initially felt that their dose of buprenorphine was too low, who then felt better dosing this way.  And I have had a few patients who believed they were getting headaches from naloxone, who had fewer headaches after dosing this way and spitting out the naloxone.
One final thought.  I did not address your comments about joy, happiness, passion, or depression because it is usually not a good idea for us addicts to focus on whether we are adequately ‘feeling’ those things.  Opiate addicts tend to spend too much time looking ‘inward,’ thinking about how they feel.  One goal with treatment is to get them thinking about things OUT THERE in the world, rather than about how they are feeling ‘inside’  (Don’t confuse this point, though, with ‘feelings work.’  Addicts tend to have a hard time identifying feelings and recognizing the nuances between one feeling and the next, and there is much to be gained in working on identifying and recognizing feelings during group or one on one psychotherapy.  This work is to be distinguished from the self-obsessed search for happiness that many of us addicts get wrapped up in from time to time).  Once a person decides he/she is not feeling ‘passion,’ the absence of passion becomes a self-fulfilling prophecy.  The same holds for feeling sad, lonely, or depressed.  I do not have an explanation for why Suboxone vs. Subutex would result in a lack of happiness or passion, except perhaps by causing low level withdrawal symptoms that affect mood.  I SUSPECT that those feelings are more ‘psychological’ than anything else.   I also do not know why your symptoms on Suboxone last all day long, although I suppose it is possible that for some reason your body metabolizes naloxone extremely poorly, causing it to sicken you for the entire period of time between doses.
If the ‘spitting technique’ works, that is one more bit of data that you can take to your physician.  Hopefully, if that is the case, she will have a change of heart.

Sick When Starting Suboxone: Abres Los Ojos!

An interesting case from a reader:
Thanks Doc for your efforts. I appreciate you.
I am a four year hydrocodone addict 55 years old. I became addicted when I used the drug for an injured cervical disc.
A couple of years ago I found out about suboxone and got in touch with a Dr. in Tulsa who prescribed it for me. I waited until I thought I was in withdrawl..about twenty hours and took my first dose. I became dizzy, nausiated, numb and all I could do was make it to the bedroom where my nausea eased a bit…I never vomited. I lay there for ten hours in a numbed state half in and out of sleep. The next day I was fine.
The Dr. said I took it too early. So, I waited a week without any hydros and took another pill and got the same results. The Dr. said to flush them and I did.

Two years later I am still an addict. Do you think I should try again? Could I take small slivers of the pill without the negative effects? What do you think?
I am desperate to get clean.
I have also heard about subutex but have never tried it. Could it be that subutex is what I should try for?
Respectfully,
John in Oklahoma
My Response:

High on opiates
High on opiates

How much hydrocodone were you taking in the days leading up to taking Suboxone? Your reaction sound more like a person overdosing on buprenorphine than precipitated withdrawal– do you remember, at the time you were nauseated, were your pupils very large, or very small? If you were in withdrawal your pupils would be huge; if you were overdosing they would be ‘pinpoint’, and if you were having an allergic reaction of some type, they would be about normal.
20 hours should be plenty long for hydrocodone, and your second attempt could not have been precipitated withdrawal, providing you weren’t on some other opiate. Nausea and vomiting are not the main features of withdrawal; more typical would be lower abdominal cramps and diarrhea. Nausea is a big part of overdose, on the other hand. The potency of Suboxone (any dose above 4 mg) is equal to about 30 mg of methadone, or about 60 mg of oxycodone, or about 100 mg of hydrocodone… if you were taking the 5 mg tabs, that would mean that a tablet of Suboxone would equal the potency of about 20 tablets of vicodin. Since vicodin lasts only a few hours, to have an equal tolerance you would need to be taking about 20 times 6 = 120 tabs of vicodin per day. That is a lot of vicodin– enough to kill you by destroying your liver, so you were probably taking significantly less.
Out of junk
Out of junk

I think the Suboxone was just too strong. Yes, you could try working your way up with tiny pieces, but it is
hard to titrate at the low doses because of the unusual dose/response curve. I think a better way, if you are not on a huge dose of vicodin, would be to use clonidine, immodium, and maybe some other things to help with the withdrawal, and use the steps to stay clean… otherwise you will be moving up the tolerance ladder.
Subutex would be another option if I am wrong with my assumptions about your dosing– some rare people do have bad reactions to the naloxone, even though little gets into the system. One other hypothesis… if you were taking tons of vicodin, and your liver was in bad shape, your liver might not have been able to destroy the naloxone (first pass metabolism at the liver is what keeps the naloxone in Suboxone from working), and so the naloxone in Suboxone precipitated withdrawal.
Good luck!
John Writes Back:
Yes, Dr. you may be right. My dose was relatively low, I was taking at or about four or five lortab 10 tablets a day.
I wasn’t aware of the potency of the suboxone. I seem to remember I took the four or five mg. tabs, the small orange hex shaped one.
I did not check my pupils, but if I take it again I will be sure to do that.
I know my dosage is not that of others and that Vicodin addiction is not that of Oxycontin or heroin. That said, I still feel hoplessly addicted to them and have tried the twelve steps twice. That is why I am interested in the suboxone, but like you say it would be stepping up the tolerance ladder, I suppose. Since my willpower is nonexistant at this point, I think I am going to give the suboxone one more try the way I suggested and I will let you know how it works.
Half-wasted?
Half-wasted?

Thanks for your timely reply, and I think you hit the nail on the head.
God bless you
John in Oklahoma
And Me Again:
You might want try a bit of a medication called ‘hydroxyzine’, which is used to reduce nausea from opiates– although it also can be quite sedating, so don’t drive on the combination. A non-sedating alternative would be odantreson (zofran), which is what is given post-op for nausea. In fact, forget the hydroxyzine– premedicate yourself with a dose of zofran, about 4 hours before the induction, and you should do much better.

Suboxone vs Subutex: Where did the high go?

I encourage addicts doing the work of staying clean to ‘bring the memory full circle’; with every pleasant recollection, be sure to think about where the use took you, and where the pleasant sensations ended.

A bit of confusion over how Suboxone and Subutex work:
Subutex gave me a strong buzz during detox…After a year of being on suboxone (which completely suppressed any high the buprenorphine might give, which it did) and being switched back to subutex, one might think subutex would give me that feeling again, with the naloxone being out of my body and all. Is it a matter of tolerance? I’ve been told that tolerance is reset by naloxone…I just don’t know what the real cause is here. I’m on straight subutex, 8mg and the magic is gone. perhaps…forever? Let me know if you have any clue, or if it is just tolerance. (email me at vespafly@gmail.com
My Response:
Suboxone and Subutex are interchangable;  there is no difference between the subjective experiences of them, save for the lack of flavoring in Subutex and the ‘fruity flavor’ of Suboxone.  The naloxone in Suboxone is not absorbed from the mouth, and the naloxone that is absorbed from the intestine is broken down very efficiently by the liver, so that very little gets into the systemic circulation.
The effect one has to the initial dose of buprenorphine, whether it comes from Suboxone or from Subutex, depends on the person’s level of tolerance.  If a person has a very high tolerance, he will feel withdrawal.  If the tolerance is very low, the person will feel a ‘high’.  In either case, they will adjust to the dose of buprenorphine within a few days and feel normal.  In the case of the person who initially felt a buzz, the person becomes tolerant to the buprenorphine;  in the case of the person who felt withdrawal, the person ‘recovers’ from withdrawal as his opiate receptors adjust to the reduced level of opiate stimulation.he
To answer your question, the tolerance is what took away the ‘high’ you got from the initial dose of Subutex.  It had nothing to do with changing to Suboxone, and would have occured in the exact same way had you stayed on Subutex.  A person who is not opiate-tolerant will get a significant opiate effect (I hate to use the term ‘high’, but I guess the term is correct) from the initial dose of Suboxone or Subutex– but it will only last for a day, or maybe two at the most.  Buprenorphine has a very long half-life, so there is no significant drop in the blood level from that first dose to the next– and the constant opiate stimulation from a drug with a long half-life results in the very fast development of tolerance.
I have had a number of patients switch from Suboxone to Subutex and vice versa, sometimes a couple times (in the case of women who take Suboxone, but who change to Subutex during pregnancy to avoid the naloxone).  They have no change in how they feel;  in both cases the buprenorphine is the active substance, and since the dose is the same I would not expect them to feel any difference between the two medications.


As far as ‘naloxone resetting tolerance’, for naloxone to have an effect on human opiate receptors it would need to be given IV or IM, where it can be absorbed sufficiently.  The medication ‘Naltrexone’, on the other hand, is an opiate antagonist similar to Naloxone except for being active when taken orally.  When a person takes Naltrexone, the opiate receptors are blocked;  the neurons with the opiate receptors therefore react as if they are not receiving any input through the receptors.  In response to the lack of input the neurons up-regulate the receptors so that they are more sensitive to stimulation by opiates, which translates into a decrease in tolerance.
I understand your comment about the ‘magic’, but I don’t agree with it.  The ‘magic’, in my opinion, is the ‘normal’ feelings induced by buprenorphine.  After that first couple days patients taking Suboxone feel like non-addicts, and that is what makes it such a ‘magical’ medication.  That other feeling– the high from opiates– is only a small part of the true feelings induced by opiates– and you can’t have one without all the others.  In other words, yes, opiates give a warm, euphoric feeling… but also give an equal or greater amount of depression, fatigue, and bone-chilling coldness.  In the balance, there is no net ‘good feeling’– there is as much or more misery for every amount of ‘magic’.  Addicts stuck in a using pattern tend to see the OC or other opiate with ‘euphoric recall’, remembering only the tiny pleasant part of using, and ignoring the huge amount of misery associated with using.  I encourage addicts doing the work of staying clean to ‘bring the memory full circle’; with every pleasant recollection, be sure to think about where the use took you, and where the pleasant sensations ended.  Keep the memories attached to each other, because in reality they are not separable.

Suboxone / Subutex Difference

I will bop off an easy question before finishing for the night…  again, from the search terms, someone searched ‘Suboxone Subutex difference’.  For those wondering where I am getting the search terms, I’ll explain again– go down the right column of the blog to the list of recent visitors– on a widgent from ‘feedjit’.  Then go to the bottom of that box– above the box that has the map with the red dots– and click on the ‘watch in real time’ link.  You will see visitors come and go, including the site that they arrived from, the site they leave to, and the search terms that were used to find the blog.  I find the ‘real-time’ applications for the internet so interesting– there are sites where you can just watch the world’s searches in real time as they flash across the screen… this is a bit less dramatic, but still pretty cool.  I review the search terms now and then to get an idea of the questions that people have about Suboxone.
There are a few differences between the two drugs;  Suboxone has a fruity taste, and Subutex doesn’t– it is just a bit bitter, or so I have been told.  Subutex is white and shaped different than the orange Suboxone.  The only other difference is that Suboxone has naloxone mixed with the buprenorphine, and Subutex does not.  This means nothing for most patients, but I have had a few patients who didn’t tolerate Suboxone do well with Subutex– one patient who had a rash, presumably from an allergy to naloxone; one patient with GI distress from Suboxone and not from Subutex; and several patients who had headaches taking Suboxone, but no headaches after being changed to Subutex.  Did the Suboxone cause the headaches?  Or would the headaches have gone away in a few days after the patient adjusted to the Suboxone, and the change to Subutex was only a coincidence?  I don’t know which is the case.  The final difference is that Subutex is quite a bit more expensive than Suboxone– making Suboxone the preferred drug in most cases.
There is some confusion out there on other sites;  people have written that the naloxone is responsible for the ‘ceiling effect’… but this is NOT the case.  The ceiling effect is a property of buprenorphine, with or without naloxone added.
The main reason for the addition of naloxone is supposedly to reduce the ability to abuse the drug, as the naloxone is not active orally, but is effective if injected.  But I have seen very little evidence of that type of diversion– mainly, in my opinion, because it is just not practical to use buprenorphine to get high– first, why inject when it is almost as potent to just put it in your mouth?  And second, a person who injects it will get the effects, and then they will be done for the next week– the long half-life and blocking properties of the partial-agonist buprenorphine will prevent repeated injections from having repeated effects.  Instead of injecting, diversion usually provides a way for an addict to avoid using when the supply of oxy is low and the cost is high, or when the addict just is sick and tired and wants a break from using.
I am left, then, with the impression that the naloxone mainly serves political issues– that the addition of naloxone makes the idea of Suboxone programs for opiate addicts more palatable for the people that approved the programs.  Cynical, I suppose.  But I don’t see any other big reason.  And if it worked, and helped launch the program– good deal.