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New section: NIDA NEWS

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Mind-Meds Doctors

Please read Disclaimer   |    Ask the Doctor archives

What is SUBOXONE?

SUBOXONE is the first opioid medication approved for the treatment of opioid dependence in a private office setting. Buprenorphine (one of the two medications in Suboxone) is a partial opioid agonist that blocks other opioids from attaching to receptors in the brain. Suboxone treatment can help you stop misusing opioids. What is a partial opioid agonist? A partial agonist (‘agonist’ means ‘something that acts’) is an opioid that produces less effect than a full agonist when it binds to opioid receptors in the brain. The way different opioids work can be explained using a lock and key example. Receptors are like a lock to a door. Only the right key will fit the lock, and only opioid-like drugs fit opioid receptors.

With a full opioid agonist such as oxycodone, hydrocodone, morphine, methadone, or heroin, the key fits the lock, opens the door wide, and produces full opioid effects (the feeling of euphoria, or being high, as well as the side effects). With a partial opioid agonist such as buprenorphine, the key fits the lock but doesn’t open the door all the way, so it produces less than full opioid agonist effects and, at the proper dose, blocks other opioids from opening the door fully

An opioid antagonist such as naltrexone or naloxone fits in the lock but does not open the door at all and, at the proper dose, blocks other opioids from opening the door.

At appropriate doses SUBOXONE can:

* Help to suppress withdrawal from prescription pain medications, heroin, or similar full opioid agonists
* Help to decrease cravings for other opioids
* Reduce the effects of full opioid agonists

What is Naloxone and why is it in SUBOXONE?

Naloxone is a medication that is used to reverse overdoses of opioids. It does this by knocking other opioids off the brain receptors, preventing negative effects such as respiratory depression (slowed breathing.) Naloxone does not interfere with buprenorphine’s effects when the medication is taken under the tongue as prescribed.

When SUBOXONE is placed under the tongue as prescribed, very little naloxone is absorbed into the bloodstream. The patient should not feel the effect of naloxone. The naloxone in the medication is there to deter people from dissolving it and injecting it. When SUBOXONE is used incorrectly (by injection), its naloxone component can cause withdrawal symptoms to rapidly occur.

Except from Embrace Treatment, Gain Control: Suboxone
pamphlet copyright 2007 by Reckitt Benckiser Healthcare

Adderall®: The Long & Short of It

If you are wondering about the safety and long term effects of Adderall® and other amphetamine-type stimulants, you are not alone.

Amphetamine-type drugs have been around for decades, so that our knowledge of both their risks and potential benefits is fairly substantial and solid.

In the short-term (up to one year), Adderall® and related stimulants have numerous physiological and psychological effects. Adderall® and other amphetamines cause an increase in brain activity of dopamine and norepinephrine. These neurotransmitters are involved in brain regulation of blood pressure and heart rate (so-called ‘fight or flight’ stress responses); brain regulation of hormone levels, alertness, activity level, ability to stick with a task (such as studying for an exam, or staying awake on the battlefront for 2 or 3 days in a row); and they are specifically involved in the levels of pleasure you experience as you go about your day.

Medications like Adderall® are proven to heighten concentration, task performance, alertness, and sex drive. One reason that people abuse stimulants such as cocaine and amphetamine is that these drugs cause heightened ‘cerebral’ sexuality. Thinking about sex, reading pornography, and even non-stop masturbation are sometimes concomitants of stimulant use and abuse. Ironically, people flying high on amphetamines or cocaine almost always have great difficulty making their sexual fantasies real. Stimulants often deeply inhibit actual sexual performance, for a variety of reasons.

The side effects of Adderall® and other amphetamines, as dramatic as they sometimes are, are not particularly frequent, if the medication is prescribed and used properly. People with familial or personal predispositions to manic-depression (also known as ‘bipolar disorder’) may become edgy, irritable, or frankly manic as a result of taking amphetamine stimulants. Visualize someone who is talking faster than you can comprehend; visualize someone who is expansive, is planning to conquer the world, is preoccupied with sex, with spending money, or with paranoid notions; then you have visualized the person with hypomania (mild mania) or actual mania. Mania, by the way, is not a good thing! Although most of us like to be ‘on’—to speak and think and perform at our personal best—a person with mania is out of control, often embarrasses himself by making inappropriate remarks or behaviors, and—worst of all—is at high risk for developing a severe sometimes suicidal depression.

Those are the worst case scenarios. Most of the time, Adderall® and similar drugs enhance performance, enhance enjoyment, help the hyperactive child or adult to slow down and focus, and are relatively side effect-free. Some pediatricians have expressed concern about potential long-term effects of stimulant medications, such as delayed physical maturation and growth. Fortunately, there is little evidence of this and some doctors suggest that their younger patients take ‘medication holidays’ (during non-school months, for example) in order to minimize the possibility of long term developmental problems.

Another issue with Adderall® and related drugs is that of drug tolerance. Many drugs that act on the brain and behavior start to lose their effect over time. As a result, the dosage of stimulants sometimes needs to be increased. Those who prefer to act as their own doctors may step up the dose of stimulant medication on their own. The wiser course is to talk to your doctor about any side effects, and to discuss if relevant your sense that the medication isn’t working as well as it did before.

There are several reasonable strategies that can be pursued if and when drug tolerance becomes a problem. One strategy is to simply take an occasional break from Adderall® or Ritalin®. Here in New York, I sometimes advise patients to skip a day or two of medication each month in order to allow their nervous systems to ‘recharge’ and become more responsive to the medication when renewed. Other medications can also be added or substituted for amphetamines if necessary. Medications like Wellbutrin®, Strattera®, and Provigil® also have activating effects on the brain and body, and these may be used to supplement or replace an amphetamine when drug ‘punk out’ becomes a problem.

Suboxone® Update

Suboxone® (buprenorphine/naloxone) has been in use for a number of years now, both in the U.S and abroad. For those who take Suboxone and pay for the medication out of pocket (or have sky-high insurance co-payments, there's light at the end of the tunnel. Next year (2009) Suboxone® goes off-patent, which means that a generic form of this medication will become available. Generic usually means less expensive!

When Suboxone® is available as a generic formulation, we will need to assess the generic's potency. Federal law permits generic medications to be as much as 30% less potent than the brand-name medication. Some generics are 'as good' as the parent brand name medication, and some are clearly less powerful. 

Doctors who prescribe Suboxone® have variable amounts of time and experience with the drug. We recently conducted an informal survey of Suboxone® doctors and were very pleased to find that their experiences are very consistent: for the vast majority of patients who were formerly dependent on opiates, Suboxone® not only replaces the former drug of abuse, but also greatly reduces or eliminates craving for the old drugs. Not only that, but most patients who have been taking Suboxone are showing a very low rate of relapse. These patients are doing great (!), have gotten their lives back, and have way more time and energy to devote to the things they love. Also, many Suboxone® patients do not need other psychotropic medications, such as antidepressants or anti-anxiety drugs.                

Suboxone® doctors are also seeing a fair number of patients who had been taking the medication for six months or longer who have been able to taper and then discontinue Suboxone® without relapse to drug abuse or dependence. Contemporary doctors who prescribe Suboxone® now get to feel what doctors of the last century must have felt when penicillin arrived on the scene!

Who benefits from Adderall® and related stimulant drugs?
(from "Ask the Doctor")

Adderall® is the brand name for a stimulant medication that contains a mixture of two types of amphetamines, dextro-amphetamine and levo-amphetamine. These are molecules of amphetamine that are structurally mirror images of each other. Each of these components of Adderall® varies in its effect on heart rate, blood pressure, mood, and concentration.

The brand name ‘Adderall®’ refers to the disorder for which it is often prescribed, A.D.D. (attention deficit disorder.) People often wonder how stimulant drugs such as Adderall®, Ritalin®, and Concerta® help children and adults with attention deficit disorder ‘slow down.’ After all, don’t stimulants like Adderall® cause people to move, talk and think faster? The answer is, drugs like Adderall® usually do—in people without A.D.D. One theory holds that people with A.D.D. have a higher ‘stimulus threshold’ and require greater levels of sensory (sound, light, movement, emotions) input in order to feel okay. When someone with A.D.D. takes Adderall®, the heightened sensory input now comes from the medication. The Adderall® is making the show happen inside the person’s brain, so they no longer need to move about as much or speak as rapidly in order to elicit maximum sensory input from outside the body.

The second most popular question regarding Adderall® and similar drugs is, why would someone without A.D.D. take them? The fact is that stimulants like Adderall® are proven to enhance energy, concentration, and ability to stick with a task in most people. Subjects given Adderall® and other amphetamine-type drugs perform better on a variety of tests of memory, task persistence, and psychomotor coordination.

In addition, Adderall® and similar drugs are well known to have a significant anti-depressant effect. Psychiatrists sometimes treat depression with stimulants like Adderall® in addition to more conventional anti-depressants because the stimulant drugs work right away; a positive clinical response to a stimulant actually predicts whether the depressed person will benefit from the co-administered conventional anti-depressant.