From the Guidelines
When choosing between Suboxone (buprenorphine/naloxone) and Subutex (buprenorphine), Suboxone is generally the preferred formulation due to its safety feature that prevents misuse by crushing and injecting the combined product. This is because the naloxone component in Suboxone is poorly absorbed via the sublingual route but becomes active if injected, thereby deterring misuse 1. Several key factors should guide the decision between these two medications, including the patient's pregnancy status, as Subutex may be more appropriate for pregnant women to avoid naloxone exposure to the fetus. However, recent data suggests that Suboxone may also be safe in pregnancy. Patients with a documented naloxone allergy should receive Subutex. Liver function is another consideration, as severe hepatic impairment may require dose adjustments with either medication, though both can be used with monitoring 1.
Key Considerations
- Pregnancy status: Subutex may be preferred to avoid naloxone exposure to the fetus, although Suboxone may also be safe in pregnancy
- Naloxone allergy: Subutex is the preferred choice for patients with a documented naloxone allergy
- Liver function: Severe hepatic impairment may require dose adjustments with either medication
- Misuse potential: Suboxone's built-in abuse deterrent makes it a preferred choice for most patients
Medication Initiation and Dosage
Both Suboxone and Subutex are typically initiated at 2-4mg for the first dose, then increased to a target of 16mg daily (range 4-24mg) based on withdrawal symptoms. The medications work by buprenorphine partially activating opioid receptors, which reduces cravings and withdrawal symptoms while blocking effects of other opioids 1.
Opioid Dependence Treatment
Brief treatment periods with rapid medication tapers (medical withdrawal) are associated with high rates of relapse; therefore, longer-term or maintenance treatment is generally indicated for patients with opioid dependence, making Suboxone a preferred choice due to its safety features and efficacy in maintaining patients in treatment 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Factors to Consider When Choosing Suboxone versus Subutex
When deciding between Suboxone (buprenorphine/naloxone) and Subutex (buprenorphine) for a patient, several factors should be considered:
- Pregnancy: Buprenorphine monotherapy, found in Subutex, has been shown to be effective and safe for use in pregnant women 2.
- Risk of Misuse: Suboxone, which contains both buprenorphine and naloxone, is designed to reduce the risk of misuse. Naloxone is an opioid antagonist that can help prevent the misuse of buprenorphine by precipitating withdrawal if the medication is injected 2.
- Patient Population: Combined buprenorphine/naloxone (Suboxone) has demonstrated significant efficacy and favorable safety and tolerability in multiple populations, including youth and prescription opioid-dependent individuals 2.
- Treatment Goals: The choice between Suboxone and Subutex may depend on the patient's treatment goals and individual needs. For example, patients who are at high risk of misuse may benefit from Suboxone, while those who are pregnant or have other specific needs may be better suited for Subutex.
- Behavioral Counseling: Both Suboxone and Subutex are typically used in conjunction with behavioral counseling, which can enhance treatment outcomes. The type and intensity of counseling may vary depending on the patient's needs and the treatment setting 3, 4, 5.
Considerations for Specific Patient Groups
Certain patient groups may require special consideration when choosing between Suboxone and Subutex:
- Pregnant Women: As mentioned earlier, buprenorphine monotherapy (Subutex) has been shown to be safe and effective for use in pregnant women 2.
- Youth: Combined buprenorphine/naloxone (Suboxone) has demonstrated efficacy and safety in youth with opioid use disorder 2.
- Prescription Opioid-Dependent Individuals: Suboxone has also been shown to be effective in this population 2.
Importance of Individualized Treatment
Ultimately, the choice between Suboxone and Subutex should be based on an individualized assessment of the patient's needs and circumstances. A stepped-care model, in which patients may begin with relatively nonintensive treatment and step up to more intensive treatment as needed, may be an effective approach 5.