Why would you choose Buprenorphine (Subutex) versus Buprenorphine and Naloxone (Suboxone)?

From the Guidelines

Buprenorphine and Naloxone (Suboxone) is generally the preferred choice over Buprenorphine (Subutex) due to its abuse-deterrent feature, which helps prevent misuse by causing withdrawal symptoms if injected, as noted in a study published in the American Family Physician in 2013 1. When deciding between Subutex and Suboxone, several factors should be considered, including individual patient factors and treatment goals.

• Subutex contains only buprenorphine, while Suboxone combines buprenorphine with naloxone.
• Subutex might be preferred for pregnant women, patients with documented naloxone allergies, or those initiating treatment who are in active withdrawal.
• However, a more recent study published in the American Journal of Obstetrics and Gynecology in 2019 found that the data do not support the theoretic concern that the naloxone component in Suboxone poses a risk to the fetus 1. The typical starting dose for either medication is 8-16mg daily, adjusted based on response.
• Both medications effectively reduce opioid cravings and prevent withdrawal symptoms by partially activating opioid receptors.
• The decision between these medications should be made with a healthcare provider who can consider the patient's specific medical history, risk of misuse, and treatment setting.
• Both medications are taken sublingually and require proper administration for effectiveness. It is essential to prioritize the patient's safety and well-being, and the healthcare provider should carefully weigh the benefits and risks of each medication before making a decision, as supported by the most recent and highest quality study available 1.

From the FDA Drug Label

Following induction, buprenorphine sublingual film or buprenorphine sublingual tablet is preferred due to the presence of naloxone when clinical use includes unsupervised administration The use of Buprenorphine Sublingual Tablets for unsupervised administration should be limited to those patients who cannot tolerate buprenorphine sublingual film or buprenorphine sublingual tablet; for example, those patients who have been shown to be hypersensitive to naloxone.

You would choose Buprenorphine (Subutex) versus Buprenorphine and Naloxone (Suboxone) in patients who:

• Cannot tolerate the presence of naloxone
• Have been shown to be hypersensitive to naloxone 2, 2, 2

From the Research

Comparison of Buprenorphine and Buprenorphine-Naloxone

• Buprenorphine (Subutex) and Buprenorphine-Naloxone (Suboxone) are both used to treat opioid use disorder, but they have some differences in terms of their composition and effects 3, 4.
• Buprenorphine-Naloxone is a combination of buprenorphine, a partial opioid agonist, and naloxone, an opioid antagonist, which helps to reduce the risk of overdose and diversion 3, 5.
• Studies have shown that both buprenorphine and buprenorphine-naloxone are effective in treating opioid use disorder, but buprenorphine-naloxone may have a lower risk of overdose and better treatment retention rates in certain patient populations 3, 6, 5.

Patient Characteristics and Treatment Choice

• Patient characteristics, such as homelessness, parole and probation status, medication preference, and presence of pain, may influence the choice of treatment between buprenorphine and buprenorphine-naloxone 6.
• For example, homeless patients may have a lower relapse rate with extended-release naltrexone compared to buprenorphine-naloxone, while patients who are not homeless may have a higher relapse rate with extended-release naltrexone 6.
• Individual patient characteristics and preferences should be taken into consideration when choosing a first-line opioid agonist treatment 3.

Efficacy and Safety of Buprenorphine-Naloxone

• Buprenorphine-naloxone has been shown to reduce mortality and increase remission rates in patients with opioid use disorder 5.
• The combination of buprenorphine and naloxone may provide a safer and more effective treatment option for certain patient populations, such as those at high risk of methadone toxicity or with a history of overdose 3, 5.
• However, further studies are needed to guide the use of buprenorphine-naloxone in different patient populations and to compare its efficacy and safety with other treatment options 4, 7.