Suboxone Maintenance Treatment



Suboxone maintenance treatment is a comprehensive treatment program that involves the long-term prescribing of suboxone (burenorphine and naloxone combination tablet) for the treatment of opioid dependence/addiction.
SMT has been used for many years to bring life back to those suffering from addiction to opioids such as oxycodone (OxyContin® or Percocet®), fentanyl, hydromorphone (Dilaudid®), heroin, morphine, codeine, etc.
Tolerance to suboxone develops slowly, so clients can be maintained in MMT indefinitely. If it is prescribed properly, buprenorphine is considered medically safe as a treatment for opioid dependence/addiction.
For more information about buprenorphine as a pharmaceutical agent, its other uses, side effects, and other properties, visit "About Suboxone".



What is Suboxone Maintenance Treatment?

Suboxone (buprenorphine) maintenance treatment is a widely used form of treatment for people who are dependent on opioids.

Buprenorphine itself is a long-acting opioid 'partial agonist', which is prescribed as a treatment for opioid dependence/addiction. People who are dependent on opioids may be dependent on either oral or injectable forms of opioids. Some individuals may also snort or smoke opioids. Buprenorphine maintenance treatment can be an appropriate form of treatment for opioid dependence, regardless of the route of administration of the drug of dependence.

There is no universal definition of what a buprenorphine maintenance treatment "program" is--although the common thread is clearly the use of buprenorphine. Program components and policies vary widely around the world, and within Canada. A comprehensive approach to maintenance treatment, however, generally includes a number of key components--which can be delivered in a variety of ways and at varying levels of intensity--including:

  • stable dose of suboxone;
  • medical care;
  • other substance abuse treatment (such as cocaine);
  • counselling and support;
  • mental health services;
  • health promotion, disease prevention and education;
  • linkages with other community-based supports and services; and
  • outreach and advocacy.

Isn't Detox Better Than SMT?

Within the context of opioids, the definition of detox or detoxification is the management for relief of withdrawal symptoms such as aches, runny nose, chills, sweats, and insomnia, while the patient comes off opioids most often suddenly or "cold turkey".  It is usually the first serious attempt at trying to control one's uncontrollable substance abuse.  It is also one often urged by family and friends as in "drugs are bad for you; why don't you just stop using?"  The problem with detox is that it ignores a key component of opioid abuse.  It assumes that a person is entangled in a vicious escalating cycle of substance abuse simply because of a cluster of flu-like symptoms that may last 5-10 days after stopping all opioid use.  Through detox, the person will get over the physical withdrawal symptoms, just as someone gets over a bout of flu.  However; the problem with the concept of detox emerges when one looks at the statistics that show detox has over a 90% failure rate.  Almost all the opioid-addicted individuals that finish detox (not even counting those that leave before the end), relapse to abusing their opioid of drug of choice after leaving detox.  The reason is that detox attempts to oversimplify a complex mental health diagnosis, i.e. addiction, into a basic flu-like physical ailment.  Very often, the opioid-dependent patient was using opioids for their euphoria, to deal with stress, or self-treat a mental health disorder such as anxiety.  The individual's brain cells have thus become dependent on the external opioids just as much the rest of the body, in effect forgetting over time how to make their own natural opioids (i.e. endrophins).  Endorphins are essential in the brain's regulation of mood, thinking, sleep and emotional response.  So once the physical withdrawal symptoms have gone away after detox, the brain cells have not lost their dependence on the opioids for the person's mood, energy and functioning needs.  It is the mental withdrawal effects and the ensuing depression, anxiety, insomnia and cravings that soon cause the person to go back to using the opioids. This is why detox is widely unsuccessful in achieving long-term or meaningful recovery for addiction. 

There is only a minority of patients whom detox may prove successful for. These are typically those patients who have an almost "purely physical" dependence on the opioids, with almost no mental aspects.  These patients may have taken opioids for definitive pain that has now subsided, and now wish to stop the treatment.  These patients have not been taking self-escalating doses of the opioids, or been seeking a "high", "escape", mood change, or stress relief by using them.  They usually do not have a history of substance abuse with other classes of drugs such as cocaine, and have not previously engaged in reward-seeking behaviours such as self injection, snorting, smoking, chewing, drug mixing, or overdose.

As discussed, "opioid-addicted" patients (those with any history of seeking mood alteration from the opioids) are usually not good candidates for a detox program.  If chosen by the patient to enter the maintenance program, he or she can be stabilized on an appropriate dose of methadone or Suboxone.  While on a stable dose, the patient then can go back to fixing the tolls that addiction took on their lives.  A stable dose in maintenance allows the patient to feel just normal, alert and functional without feeling any of the highs and lows that come with the abuse of the short-acting opioids such as oxycodone (OxyContin or Percocet), fentanyl, hydromorphone (Dilaudid), heroin, morphine, codeine, etc.  This stability also allows the patient's brain to slowly adapt to a new chemical balance.  Once a patient has been stable in this way, and avoided all abused drugs for a considerable duration, then an attempt could possibly be made in tapering the dose slowly while carefully monitoring for signs of relapse.  To lower the chance of relapse, the process should take at least one year from the last date of problematic drug use, but could take much longer for many opioid-addicted patients. 

Sometimes buprenorphine itself is used in a medication-assisted detox program by starting it and then reducing the dose over a short term, e.g. 2-4 weeks. The same mentioned issues that make non-assisted detox unsuccessful play at medication-assisted detox, in making it a productive option for only a very small minority of patients.

Who is SMT for?

If you’ve been using opioid drugs such as heroin, OxyContin, codeine, Dilaudid, Percocet and others, and you’ve come to a point where you know you can’t go on using, but you can’t seem to stop either, the maintenance treatment may be right for you.  A physician consultation and examination is required who is a candidate. The program is generally useful for those over 18 who meet a diagnosis of opioid dependence based on the DSM IV (Diagnostic and Statistical Manual of Mental Disorders). The DSM IV criteria are based on a pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12‐month period (emphasis ours):

  • Tolerance, as defined by either of the following: A need for markedly increased amounts of the substance to achieve intoxication or desired effect; or Markedly diminished effect with continued use of the same amount of the substance.
  • Withdrawal, as manifested by either of the following: The characteristic withdrawal syndrome for the substance; or the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms
  • The substance is often taken in larger amounts or over a longer period than was intended.
  • There is a persistent desire or unsuccessful efforts to cut down or control substance use.
  • A great deal of time is spent on activities necessary to obtain the substance (e.g., visiting multiple doctors or driving long distances), use the substance (e.g., chain‐smoking), or recover from its effects.
  • Important social, occupational, or recreational activities are given up or reduced because of substance use.
  • The substance use is continued despite knowledge of having a persistent physical or psychological problem that is likely to have been caused or exacerbated by the substance (e.g., current cocaine use despite recognition of cocaine‐induced depression, or continued drinking despite recognition that an ulcer was made worse by alcohol consumption).

How long is SMT?

This is a very common question. The best possible answer is that most people who are successful coming off suboxone show three important characteristics:

1- Their lives have been stabilized after they've been on maintenance treatment for more than a year.

2- The decision to stop taking suboxone is made with their doctor, who gradually decreases the dose while providing support.

3-They've made changes in their lives that show they're stable. For example, they may have a stable family life, support from the non-drug-using community, steady satisfying employment and fewer financial or legal difficulties.

It is important to understand that suboxone, when taken as prescribed, is a safe and effective medication that individuals can take for years. Sometimes people stay on it as long as they need to and many patients have stayed on it indefinitely.

How Do I Get on SMT?

First you have to see our physician, who will do an assessment. If found to be suitable for the treatment, you could be started in the program the same or next day. You can make call for an appointment here.  You need to be in withdrawal from other opioids to be started on suboxone.  Due to its dual nature, buprenorphine acts as an antidote to other opioids when present in the body; however, when the patient is in withdrawal it would act like another opioids such as morphine or oxycodone in relieving the withdrawal symptoms.  Most patients would need to avoid taking any opioids for 24 hours in order to start suboxone treatment. 

What is the Goal of SMT?

Suboxone maintenance is a long-term treatment for addiction to opioids. Once a patient is stabilized on a stable dose, the negative thoughts, associated with addiction, often diminish and go away. The patient’s life tends to normalize and functioning increases, which can include caring for their families, working, achieving educational goals, addressing both mental and physical health co-occurring disorders and enjoying an active, healthy lifestyle. Achieving a healthier, normal life through maintenance is a valid form of recovery from opioid addiction. Improvement in all areas of health and social integration increase with the length of time in treatment. The greatest positive change comes in the first year of treatment.

Similar to the medications prescribed for diabetes, asthma, high blood pressure, depression, or other chronic medical problems, suboxone is not a magic treatment. No single medication or behavioral intervention can be a magic bullet for all patients seeking help for opioid addiction and the medical, psychiatric or social problems which may co-exist with it maintenance treatment has proven to be the most effective way to treat opioid addiction. Proper use of medication eliminates withdrawal symptoms and the craving for heroin, oxycodone, hydromorphone or other opioids and the structure and counseling required and offered provides an opportunity for patients to address problems and issues related to their addiction.

How is Suboxone Taken?

A Your doctor will provide the pharmacy with a prescription for your suboxone or its generic form. This prescription must be renewed periodically by your doctor. He or she will determine how often you come for appointments, depending on your needs and progress. Suboxone is a medication that is taken sublingually and not by swallowing. When you first start, you will be asked to go to your pharmacy each day to take the medication. As you progress in your treatment, you may be eligible to take home some doses. These are called "carries." Your carries must be stored safely to make sure the medication is not taken by anyone else, especially a child.

Is Suboxone a Cure?

It depends on how one defines cure. Suboxone is a medication that will control your addiction, so you can get back to normal functioning in life. If one defines cure as absolute abstinence from all opioids, there is no medication or technique that has been shown to achieve that. However if one defines cure as getting back to normal functioning, work and family life, then maintenance can be viewed as an effective cure since it has been shown more than any other medication or method to achieve these goals.

How do I get off SMT?

Unless ordered by a court, SMT is voluntary, so you can stop it at any time. However, studies and experience have shown to successfully stop suboxone without a very high chance of relapse to abusing other opioids, one has to be in the program at least 1 year (preferably 2) from the last use of illicit hard drugs. A successful taper of suboxone can be tried very gradually, while carefully monitoring for signs of relapse to illicit drug use.