Suboxone Treatment for Veterans

Suboxone is a prescription medication that was approved by the Food and Drug Administration (FDA) in 2002 to help treat opioid withdrawal and opioid use disorder (OUD). ¹

Opioid withdrawal, although not usually life-threatening, can be incredibly uncomfortable. As a result, medications such as Suboxone are needed to ease these withdrawal symptoms, in hopes of preventing relapse and entering a successful road to lifelong recovery.

Suboxone is a medicine used in medication-assisted Treatment (MAT). MAT uses prescription medications to help wean individuals off an addictive substance such as opioids by reducing withdrawal side effects, cravings, and increasing the likelihood of a successful long-term recovery. MAT is used not only for the acute withdrawal phase but also during long-term treatment. Suboxone is known to decrease lethal overdose rates, reduce incarceration, and decrease relapse likelihood. MAT is often used in combination with behavioral therapies and other evidence-based strategies that induce motivation, change behavior, and improve distortions in cognitive processes.³

Table of Contents

• What is Suboxone?
• Suboxone History and Statistics
• What is Suboxone Used For?
• Side Effects of Suboxone
• Is Suboxone Covered by the VA or Other Insurance?
• How Much Does Suboxone Cost?
• How is Suboxone Prescribed?
• Interactions with Other Drugs and Medications
• Can Suboxone Be Abused?
• Does Suboxone or Drug Use Affect My Veteran Benefits?

What is Suboxone?

Suboxone is a brand name prescription medication composed of buprenorphine and naloxone.⁴

Buprenorphine is a partial opioid agonist, meaning that when it binds to and activates opioid receptors in the brain, it results in relatively less pronounced opioid effects than other full agonist opioids like heroin or prescription painkillers. Because of these pharmacological properties, buprenorphine is often used in opioid addiction treatment to reduce cravings and withdrawal symptoms without eliciting the reinforcing, euphoric high commonly associated with other abused opioid drugs.⁵    

Buprenorphine has proven successful in treating people with OUD, including veteran populations. One study showed that the likelihood of dying by overdose or suicide was greater among veterans who did not receive buprenorphine for their opioid use disorder, compared to those veterans who did receive it. ²

Naloxone is an opioid antagonist or blocker meaning that it blocks opioids (oxycodone, morphine, fentanyl, heroin, etc.) at the receptor in the brain, resulting in acute opioid withdrawal if opioids are in an individual’s bloodstream.  When naloxone (or its brand name Narcan) is used on its own, it is a life-saving medication that can reverse the effects of opioid overdose.⁶ Naloxone is included in the combination formulation of Suboxone to deter attempts to misuse the medication, such as by dissolving it in solution and injecting it.

Suboxone comes as a sublingual or buccal tablet or film meaning that it dissolves under the tongue or inside the cheek. Other medications that act similarly to Suboxone include Zubsolv (sublingual tablets) and several generic buprenorphine/naloxone combinations.

Most prescribing physicians ask their patients to take the drug once per day, typically at the same time each day. A person’s weight, metabolism, and history of drug abuse can lengthen or shorten the action of Suboxone, and therefore it is best to consult with your doctor for your customized dosage based on your medical history.  The FDA advises that people who initiate Suboxone treatment should see their doctor regularly; at least once a week during the first month of treatment.⁷

Suboxone History and Statistics

Suboxone was initially approved by the FDA in 2002 to treat opioid use disorder however buprenorphine and naloxone, independently have been around for almost 50 years .⁸ Buprenorphine was initially developed in 1970 as a safer opioid option than morphine and heroin to treat severe pain.⁸ It was later approved by the FDA to manage opioid withdrawal symptoms and then became the first medication authorized to be prescribed by certified physicians through the Drug Addiction Treatment Act of 2000.^{5, 9}

Naloxone dates back to the 1960s and became FDA-approved for reversing opioid overdose in 1971.¹⁰ Widespread access to naloxone outside of medical and scientific use was not established until the 1990s. Today naloxone is widely available in many states over the counter for the reversal of opioid overdose.¹⁰   

Suboxone can now be prescribed by certified healthcare providers in hospitals, addiction treatment centers, and primary care offices.¹¹ Suboxone is often a part of a comprehensive, whole-person approach to therapy that combines psychosocial and behavioral therapies to increase the overall treatment outcome. ¹²

The 2020 National Survey of Substance Abuse Treatment Services (N-SSATS) shows the following statistics regarding Suboxone use in addiction treatment facilities:¹³

• 7,066 out of the reported 16,066 medication-assisted treatment (MAT) facilities provide opioid therapy using buprenorphine. This includes Suboxone and treatment with buprenorphine only.
• 208 Department of Veterans Affairs (VA) facilities offer methadone, Suboxone, or naltrexone for acute treatment and long-term maintenance.
• As of March 31, 2020; 6,595 veterans received medication assisted treatment (MAT), for opioid abuse with 5,291 veterans receiving Suboxone
• 44% of reported facilities offered buprenorphine treatment services in 2020, compared to 18% in 2010.

What is Suboxone Used For?

Suboxone is generally prescribed as part of a larger, comprehensive treatment plan. While Suboxone may be prescribed during detox, it is most commonly prescribed after a patient is stabilized and working towards long-term recovery.⁷ During detox, buprenorphine is more commonly prescribed to help facilitate withdrawal management.

Veterans with an opioid use disorder have an increased risk of suicide and overdose compared with the general population. A study showed that veterans who received treatment for opioid use disorder with buprenorphine found that rates of suicide/overdose death were 4 times less than those veterans who were not receiving treatment with buprenorphine.²

Side Effects of Suboxone

Just like many medication, when used as directed, Suboxone can result in possible side effects which include the following:^{1, 4}

• Headache.
• Constipation.
• Nausea and vomiting.
• Trouble sleeping.
• Back pain.
• Burning or numbness of the mouth from Suboxone film.
• Pain and swelling in the arms and legs.

Is Suboxone Covered by the VA or Other Insurance?

Yes, Suboxone treatment is covered by the VA health care program, depending on your military status and whether you have VA health care benefits. Check with your local VA hospital administration to determine next steps for you to receive insurance coverage for medication assisted treatment with Suboxone.¹⁸ Veterans who do not have VA health care benefits may still be eligible to receive Suboxone treatment. If you are homeless (or at risk of becoming homeless) or have served in a combat zone, contact your local VA to find out how to receive services.

The Veterans Health Administration (VHA) recommends treatment with an opioid agonist (buprenorphine) as the medication of choice for individuals who are dependent on opioids (risk of opioid withdrawal) or who have an opioid use disorder. ¹⁹

Private health insurance companies that provide coverage for Suboxone treatment include Tricare, Humana, Blue Cross Blue Shield, and many others. Many states’ Medicaid coverage policies list Suboxone as a drug of choice for opioid use disorder; however, different state health programs offer varying degrees of Suboxone coverage, with many states requiring prior authorization for Suboxone treatment.²⁰

How Much Does Suboxone Cost?

Suboxone prices may vary based on a veteran’s treatment needs, health insurance coverage, and the amount of Suboxone needed for treatment. It is best to speak with your VA representative or medical provider to determine your coverage and costs before receiving Suboxone for your opioid use disorder.

How is Suboxone Prescribed?

Suboxone is a Schedule III controlled substance, meaning it has moderate to low potential for physical and psychological dependence and therefore its use is limited under the Drug Addiction Treatment Act.²¹ This act requires people taking Suboxone to be monitored under a doctor’s care and prescribed a limited amount of medication at a time, preferably enough to last until the next treatment visit.²¹

Suboxone is prescribed according to the phase of opioid use disorder treatment. Suboxone is not usually initially prescribed until  12-16 hours after the person has abstained from a short-acting opioid such as heroin or hydrocodone, and 30-48 hours after abstaining from a long-acting opioid like methadone.²² In other words, the individual should already be in mild to moderate withdrawal before initiating Suboxone. A large enough initial dose is given to minimize withdrawal symptoms and then overtime the dosage is slowly tapered, as the withdrawal symptoms and cravings improve. The length of Suboxone taper can be as brief as 3–5 days or as long as 30 days or more.

Everyone has different needs when it comes time to OUD treatment with Suboxone. It is recommended that you work with your doctor to determine which treatment plan is best for you.

Interactions with Other Drugs and Medications

Suboxone is particularly safe and effective when used as prescribed to treat OUD. However, mixing Suboxone with other drugs, particularly alcohol, benzodiazepines, or other opioids, can result in serious side effects.¹ Taking Suboxone with other opioid pain medications such as oxycodone, heroin, fentanyl, morphine, hydrocodone, codeine, etc. can increase overdose side effects, namely respiratory depression, sedation, and even death.^{4, 21} 

Taking Suboxone with alcohol or other sedatives (benzodiazepines and sleeping pills) can significantly increase the intensity of side effects such as sedation, overdose and death. Some common benzodiazepine medications include as Xanax, Klonopin, Valium, and Ativan ^{1, 4, 21}

If you or a loved one is experiencing overdose symptoms—which might include labored or stopped breathing, vomiting, choking, or constricted pupils—call 911 and do not leave them alone. Naloxone, if available, should be administered.

Can Suboxone Be Abused?

Although Suboxone has shown to be effective in the treatment for opioid use disorder , it still has misuse potential and should be carefully managed.⁷ It is important to note that buprenorphine, the opioid agonist in Suboxone, can result in physical dependence (meaning the body becomes used to this substance and will exhibit withdrawal effects when the dosage is decreased or is discontinued abruptly) when taken daily for an extended period.⁴

On the other hand, buprenorphine also has a “ceiling effect”, meaning that its opioid properties eventually level off overt time even when the dose is increased, which can lower the risk of misuse, dependency, and side effects.⁴

Does Suboxone or Drug Use Affect My Veteran Benefits?

Suboxone or other drug use can affect your veteran disability benefits if you have engaged in willful misconduct or intentional behavior that you know to be wrong, with reckless disregard of likely consequences.²⁴ In other words, the illegal use of Suboxone—or other drugs outside of a physician’s care—can negatively impact your eligibility to receive disability benefits.²⁴

Sources:

1. U.S. Department of Health and Human Services—Food & Drug Administration. (2016). Labelling-Medication Guide: Suboxone.
2. Vakkalanka, P., Lund, B. C., Arndt, S., Field, W., Charlton, M., Ward, M. M., & Carnahan, R. M. (2021, May 19). Association between buprenorphine for opioid use disorder and mortality risk. American Journal of Preventive Medicine, S0749-3797(21)00199-9. Advance online publication.
3. Elias, D. & Kleber, H. (2017, September 19). Minding the brain: The role of pharmacotherapy in substance-use disorder treatment. Dialogues in Clinical Neuroscience, 19(3), 289-297.
4. National Alliance on Mental Illness. (2021, January). Buprenorphone/naloxone (Suboxone).
5. National Institute on Drug Abuse. (2021, April 13). How do medications to treat opioid use disorder work?
6. National Institute on Drug Abuse. (2021, June 1). Naloxone drugfacts.
7. Food and Drug Administration. (2018, February). Highlights of prescribing information.
8. Velander, J. R. (2018). Suboxone: Rationale, science, misconceptions. The Ochsner Journal, 18(1), 23-29.
9. U.S. Government Publishing Office. (2000). Drug addiction treatment act of 2000 (DATA 2000).
10. Cambell, N. D. (2019, August 26). Naloxone as a technology of solidarity: History of opioid overdose prevention. Canadian Medical Association Journal, 191(34), E945-E946.
11. Casadonte, P. P. (2013, November 27). PCSS guidance: Buprenorphine induction.
12. National Institute on Drug Abuse. (2016, November 1). Effective treatments for opioid addiction.
13. Substance Abuse and Mental Health Services Administration. (2021, June). National survey of substance abuse treatment services (N-SSATS): 2020.
14. Substance Abuse and Mental Health Services Administration. (2016). Sublingual and transmucosal buprenorphine for opioid use disorder: Review and update. Advisory, 15(1).
15. D’Onofrio, G., O’Connor, P. G., Pantalon, M. V., Chawarski, M. C., Busch, S. H., Owens, P. H., Bernstein, S. L., & Fiellin, D. A. (2015). Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence. JAMA, 313(16), 1636–1644.
16. Seal, K. H., Maguen, S., Bertenthal, D., Batki, S. L., Striebel, J., Stein, M. B….Neylan, T. C. (2016). Observational evidence for buprenorphine’s impact on posttraumatic stress symptoms in veterans with chronic pain and opioid use disorder. The Journal of Clinical Psychiatry, 77(9), 1182-1188.
17. U.S. Department of Veterans Affairs. (2020, June 26). Substance use treatment for veterans.
18. National Institute on Drug Abuse. (2021, April 13). Is medication to treat opioid use disorder available in the military?
19. Substance abuse and Mental Health Services Administration(2014). Medicaid coverage and financing of medications to treat alcohol and opioid use disorders.
20. Food and Drug Administration. (2014, April). NDA 22-410: Suboxone.
21. American Society of Addiction Medicine. (2015, June 1). The national practice guideline for the use of medications in the treatment of addiction involving opioid use.
22. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
23. Centers for Disease Control and Prevention. (2020, December 21). Know the signs and get help for opioid addiction.
24. Cornell Law School. (n.d.). 38 CFR Section 3.301: Line of duty and misconduct.