Difference Between Suboxone and Subutex
Suboxone (buprenorphine/naloxone combination) is preferred over Subutex (buprenorphine alone) for most patients with opioid use disorder because it has abuse-deterrent properties that prevent misuse by crushing and injecting. 1, 2
Composition and Formulation
- Subutex contains only buprenorphine, a partial mu-opioid receptor agonist 2
- Suboxone contains buprenorphine plus naloxone in a 4:1 ratio (e.g., 8mg buprenorphine with 2mg naloxone) 2
- Both medications are administered sublingually 3
Mechanism of Abuse Deterrence
- The naloxone component in Suboxone is inactive when taken sublingually as prescribed but becomes active if crushed and injected intravenously 4
- When injected, naloxone precipitates immediate withdrawal symptoms in opioid-dependent individuals, making intravenous abuse highly unpleasant 5
- Research demonstrates that patients who attempted to inject Suboxone reported it was like injecting "nothing" with no euphoria or described it as a "bad experience" 5
- Suboxone has significantly less abuse potential than buprenorphine alone 5, 4
Clinical Indications for Each Formulation
When to Use Suboxone (Preferred for Most Patients)
- Standard treatment for opioid use disorder in non-pregnant patients 1, 2
- Patients at risk for diversion or intravenous abuse 4
- Outpatient maintenance therapy 4
When to Use Subutex (Limited Specific Situations)
- Pregnancy - Subutex is recommended for pregnant women to avoid naloxone exposure 2, 4
- Documented naloxone allergy 2
- Severe chronic pain requiring divided dosing - buprenorphine can be administered every 6-8 hours for better pain control 2
Efficacy and Safety Profile
- Both formulations are equally effective at reducing illicit opioid use and retaining patients in treatment 6, 4
- The therapeutic dose range is 8-16 mg daily of buprenorphine for most patients, with a target of 16 mg 2
- When switching from Subutex to Suboxone at equivalent buprenorphine doses (average 22 mg), 71.9% of patients maintained the same dose without adjustment 5
- Suboxone is demonstrably safer than high doses of full mu-opioid agonists 1
Common Pitfalls When Switching Formulations
- Dose adjustments may be necessary when transferring from high doses (>22 mg) of Subutex to Suboxone, particularly in later phases of treatment 5
- During the first 4 weeks after switching, 50% of patients reported adverse events, though only one patient discontinued due to adverse events 5
- The transfer should be carefully discussed and planned in advance with patients, with regular monitoring of adverse events after the switch 5
- At the 4-month follow-up, adverse events decreased to 26.6% of patients 5
Regulatory and Prescribing Considerations
- Both formulations require DATA 2000 waiver (X-waiver) for prescribing beyond 72 hours, or appropriate referral to addiction treatment programs 7, 2
- Medication-assisted treatment must be combined with counseling and behavioral therapies, not used as monotherapy 7, 2
- Both medications are contraindicated with QT-prolonging agents due to cardiac arrhythmia risk 8, 2