Many patients relapse even while on Suboxone therapy. If you are on Suboxone treatment and you relapse, reach out to friends, family and medical professionals right away to help get you back on track.
Suboxone is a combination of the drugs buprenorphine and naloxone.[1] Both buprenorphine and naloxone can block the effects of opioid agonists like oxycodone, methadone, fentanyl or heroin.
One of the notable traits of Suboxone is called the “ceiling effect.” A typical opioid becomes more powerful (and more dangerous) with bigger doses. At a certain point, the buprenorphine in Suboxone does not continue to get stronger. People reach a limit or peak effect, and they do not continue to get more intoxicated when they take more Suboxone.[9]
Because Suboxone binds more strongly to opioid receptors in the brain than full opioids like oxycodone, heroin or fentanyl, a person may actually require higher doses of opioids in order to achieve the “high” that they would normally experience without Suboxone in the system.
In this way, taking a small dose of opioids while on Suboxone will actually have a minimal effect, and the Suboxone protects against an overdose. The risk is really when an individual takes very high doses of opioids while on Suboxone in an attempt to overcome the effects of Suboxone blockade. This can result in overdose and even death. [2]
Conversely, if a person uses a full opioid and then takes their suboxone too soon after, the Suboxone “kicks” the opioids off the body’s receptors and causes what is called “precipitated withdrawal”.
In summary if you:
Take Suboxone > Then Take an Opioid at your regular dose = Less euphoric/high effects
Take Suboxone > Then Take an Opioid at a higher dose than you are used to = increased risk of overdose
Take an Opioid > Then Take Suboxone shortly after = Precipitated withdrawal
Yes. As described above, if a person is on Suboxone and takes a low or standard dose of an opioid, the Suboxone will continue to bind to receptors in the brain and will not let the opioid bind, limiting the ability to get “high” and the simultaneous risk of overdose.
However, if a person attempts to take more opioids than normal to overcome Suboxone’s blocking/ceiling effect, they can easily overdose.
This is particularly true if a patient has been substance free for a while and takes a dose that they have taken prior, thinking it is a dose their body can handle. Because the body is not used to this high dose anymore, there is an increased risk of overdose. If you previously had a history of heavy opioid use and were then in recovery, your tolerance for opioids may reduce, and taking a dose that used to simply make you high may now cause an overdose.[3]
Anyone who uses illicit opioid drugs (like heroin or street-purchased painkillers) can overdose. However, research suggests that using medications like Suboxone can reduce your risk of dying from an overdose.
In one study of people who survived an opioid overdose, buprenorphine use for the following year was associated with a 38% reduction in the risk of a subsequent overdose death.[10]
Staying in treatment is the best way to lower your risk of an opioid overdose. If you relapse while on Suboxone, it’s critical to get back on track as soon as you can.
Many factors can increase a person’s risk of a relapse.
One study showed that people taking Suboxone for opioid dependence were at a greater risk of relapse if they were on a higher buprenorphine maintenance dose, taking benzodiazepines (benzos) or had an anxiety disorder.[5]
A separate study suggested that living alone in rural areas had an increased relapse risk. People who lived with many family members had higher treatment success rates.[11]
Researchers also say that experiencing a high-risk situation, such as a divorce or death, was associated with relapse. People who felt capable of handling challenges were more successful in managing these issues without relapsing.[12]
Studies like these suggest that some relapse risk factors are outside of your control. Needing more medications or dealing with an anxiety disorder aren’t issues you can change.
However, these studies also suggest that life after OUD can be stressful, and some people aren’t ready for those challenges. Knowing that your risks of relapse are higher could prompt you to reach out for help when you’re faced with life changes, few social connections or other common triggers.
The U.S. Department of Veterans Affairs notes a few common warning signs of relapse, including these:[6]
If you’ve noticed these signs, or you’ve already relapsed to drugs, it’s time to take action. Even if you engage in drug use after a period of sobriety, that doesn’t negate the progress you have made. What’s important is acknowledging when you have relapsed and reaching out immediately to your support systems and your medical care team to get you back on track.
A relapse can be very disheartening. A person who is relapsing will likely feel in crisis, frustrated, angry or depressed.
It is important to remember that relapses are a natural part of recovery. Be gentle and forgiving with yourself.
If you’ve relapsed or are on the cusp of relapsing, take these steps to get back on track:
1. Contact a crisis hotline. Many people start by calling the SAMHSA helpline or similar drug crisis hotlines.[7] SAMHSA is a national substance abuse services organization that provides help to people dealing with substance use disorder (SUD). Their helpline, available at 1-800-662-HELP (4357), is designed to help people get access to various treatment resources. It’s confidential and available in both English and Spanish.
2. Talk to your treatment team. It’s important to work with a professional after a relapse, preferably one who specializes in treating opioid use disorder. They can help you identify what went wrong and what changes in your life may help you better resist relapse in the future. Social support is very important following relapse.[8]
3. Assess your situation. If you’re struggling to stay sober while living at home, perhaps enrolling in an inpatient facility would give you the break you need.
4. Be kind to yourself. Instead of feeling guilt, shame or anger, take action! Prioritize reaching out to your support systems immediately as well as to medical professionals to help get back on track right away.
Relapse is a natural and expected part of long-term recovery, even for patients on Suboxone or other forms of MAT. You can learn from the experience and move forward with a stronger sense of your own triggers for relapse and a clear plan to prevent future relapses.
Peter Manza, PhD received his BA in Psychology and Biology from the University of Rochester and his PhD in Integrative Neuroscience at Stony Brook University. He is currently working as a research scientist in Washington, DC. His research focuses on the role of the brain dopamine system in substance use disorders and in aging. He also studies brain function in obesity and eating disorders.
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