Steven asked
What would happen if you take hydrocodone after Suboxone?
Answer
If you are currently on therapy with Suboxone (buprenorphine/naloxone), taking hydrocodone in addition to it will often have negligible effects. In other words, the effects of taking hydrocodone will be greatly diminished if you are already taking Suboxone. This is due to how Suboxone interacts with the mu opioid receptors in the body. Below, I discuss in detail how Suboxone works and why taking ANY opioid afterwards will have little effect.
There are three well known opioid receptors in the body:
- Mu
- Kappa
- Delta
The mu and kappa receptors are the most common targets for drugs. Drugs that act as an agonist (i.e. stimulator) to the mu receptor produce a variety of effects such as analgesia, respiratory depression, euphoria and sedation. Drugs that act as an agonist to the kappa receptor can produce similar effects, but is more recognized for causing dysphoria and alterations to our response to pain.
Suboxone is a combination drug that contains both buprenorphine and naloxone. It is commonly prescribed for opioid dependence and less commonly for chronic pain. It is available as sublingual tablets or as sublingual films. It is important to note that naloxone in these formulations in NOT absorbed well and generally will NOT have any noticeable effect if taken as prescribed. Naloxone is simply added to Suboxone to prevent abuse of the drug, as will be explained below.
Buprenorphine is the medication in Suboxone that is responsible for the effects of the drug. Unlike commonly used opioids such as morphine, oxycodone and hydrocone, which are full opioid agonists, buprenorphine is a mixed agonist/antagonist. Specifically, it is an agonist (technically a partial agonist) at mu receptors and an antagonist at the kappa receptors. In other words, it increases mu activity and blocks kappa activity. This translates to buprenorphine producing analgesia, but has less effect on respiratory depression, dysphoria and euphoria. Basically, it helps with pain relief and doesn't have the propensity to cause breathing issues or the effects that abusing traditional opioids do.
Naloxone is a full opioid antagonist at the mu receptor. It is actually used for opioid overdoses as it reverses effects of opioids acting on the mu receptor. When Suboxone is used as directed (sublingually or buccally), the effect of naloxone is minimal due to low absorption. It is added to Suboxone for the sole reason of deterring abuse. If Suboxone is injected however, not only will the effect of buprenorphine will be minimized, it may even precipitate withdrawal, a potentially serious consequence.
Now, let's focus on why taking hydrocodone (including any product containing hydrocodone such as Vicodin and Norco) with Suboxone will cause minimal effects.
Buprenorphine binds very strongly to the mu receptors. Most of the available data indicates that this blinding typically lasts for 24 hours or more. This essentially "blocks" other opioid drugs from binding to the mu receptor. The caveat to this, is that buprenorphine has relatively low activity on the opioid receptor, even though it binds strongly. Due to the low activity, it doesn't typically produce the high degree of analgesia that other opioids do. If you took hydrocodone after Suboxone, it won't be able to bind to the blocked mu receptors at the levels needed to produce analgesia.
There is a lot of discussion on how to successfully treat acute pain episodes in patients that are taking Suboxone, as traditional doses of commonly used opioids will have a muted effect (as discussed above). There is no one size fits all approach on how to approach these situations. In cases where additional analgesia is needed for acute pain, strategies include adding a potent/high dose short-acting opiate agonist (e.g. fentanyl) to achieve appropriate pain relief, or discontinuing Suboxone while simultaneously switching to another opiate agonist.
Lastly, it is very important to make the distinction that the above information is specifically in regard to someone being on Suboxone therapy and THEN taking hydrocodone. If the situation is reversed, and someone was dependent on an opioid such as hydrocodone, administration of Suboxone may very will precipitate withdrawal. It is a common misconception that the naloxone component of Suboxone is the culprit, but that is not the case as we have shown above. Withdrawal will happen due to the long lasting blockage, and relatively low activity at the mu receptor from buprenorphine. Other opioids will be displaced and will not be able to bind to the receptor. If you are dependent on opioids and they can't bind to the receptor, there is a good chance withdrawal.
