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  • Writer's pictureDr. Soroosh Hashemi, M.D.

Suboxone vs. Naltrexone





As I’ve mentioned in my previous posts, Suboxone is a great drug for the initial management of Opioid Use Disorder. It stimulates Opioid receptors allowing for a milder, more comfortable detox, and for a prolonged period of relatively craving free living. As long as you’re on Suboxone, it is likely that you will not have Opioid cravings and will also be protected from relapses, as this drug blocks the effects of other opioids. 


Naltrexone does not stimulate Opioid receptors. It does not help lessen the discomfort of withdraw and in fact can make it worse. It is a long acting complete blocker of the Opioid receptor and is used mainly to prevent relapses. If you use Opioids on Naltrexone, you most likely will not feel their effects. 


Naltrexone is also thought to help prevent cravings for Opioids, though to a lesser extent than Suboxone. Especially when one is first coming off Opiates, they may find this drug inadequate to address their symptoms. Naltrexone is best used after the initial stabilization of Opiate withdraw and addiction. Oddly, Naltrexone also helps with alcohol cravings. 


In my opinion, Suboxone is better for initial therapy. After the chronic use of Opiates, the brain becomes dependent of the stimulation of its Opioid receptors. Initial withdraw can be unbearable as the mind needs time to reset afterwards. Suboxone allows for a slow, long acting stimulation of these receptors. The result is a period of adjustment in which patients experience less cravings and have less struggles in early sobriety.


Suboxone is easily accessible. Same day prescriptions are available and often patients are able to pick up and start this medication after-hours using a late night pharmacy. Naltrexone, however, is a bit more complicated. Though there is an oral form, which I prefer, most people opt for Vivitrol. 


Vivitrol is a long acting Naltrexone injection. It is injected once monthly into a patient’s gluteal muscle. The process of obtaining Vivitrol is a long and complicated one. Vivitrol is not available in retail pharmacies. It must be special ordered from specialty pharmacies and often the first dose takes weeks to arrive. Additionally, specialty pharmacies require regular contact with both patient and doctor, meaning patients need to call their pharmacy at least once monthly in addition to presenting to their doctor’s office for the injection. 


Suboxone as well as oral Naltrexone are available via telemedicine, meaning followup visits can be provided from the comfort of your home or workplace. These drugs are generally much more convenient that Vivitrol. Vivitrol requires in-office injections as well as followup with both physician and specialty pharmacy.


The side effects of Vivitrol include injection site reactions and, rarely, elevations in liver enzymes or mood changes. Suboxone often doubles as an antidepressant and anti anxiety medication. There is no injection so there is no risk of an injection site reaction. Liver enzyme elevations are also possible, though rare. 


Oral Naltrexone, or Revia, is easier to initiate and can be found in retail pharmacies and started same-day. It has the same side effects as Vivitrol, minus injection related issues. It is also my preferred treatment for Alcohol Use Disorder. There does appear to be a national shortage of Revia at this time, but with a few phone calls I can often find it for my patients fairly quickly. 


Both of these drugs can precipitate withdraw if taken too early after the last dose of Opiates. Patients need to be off opiates for 12 - 72 hours for Suboxone, and for 1 - 2 weeks before they can start Naltrexone. Close management and supervision of the first dose of either of these medications is necessary. 


I believe the best way to manage Medication Assisted treatment of Opioid Use Disorder is to start with Suboxone. I believe stimulation of the Opioid receptors is necessary in early sobriety and allows the brain to adjust to life without stronger, shorter acting opiates. I recommend 6 months to 1 year on Suboxone to allow the brain’s reward centers to reset. Afterwards, when my patients are ready, I taper them off slowly. Interestingly, some patients do so well on Suboxone they choose to stay on longer. 


I believe Naltrexone is a good next step. After the brain adjusts to life without illicit or prescription Opioids, Naltrexone acts as a safety net to prevent relapses. The usual time course for Naltrexone is also about 6 months to a year. This is optional, as are all treatment modalities. Treatment courses are as unique as our individual patients. 


We do not offer Vivitrol, or Naltrexone injections, at Hashemi Healthcare, but we can make referrals. Our patients find initial therapy with Suboxone or oral Naltrexone comforting and adequate. Suboxone is much more convenient in regards to its dosing and followup requirements. Often patients feel well enough to forgo subsequent treatment with Vivitrol, but this is always an option.

 

            

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