How Suboxone Works in the Brain to Stop Withdrawal and Cravings

Suboxone works by stabilizing opioid receptors in the brain, relieving withdrawal, reducing cravings, and helping patients return to normal daily function.

I am William Conway, MD, FACP, FASAM. I have been treating patients with Suboxone since 2011 in Nashville.  My practice is Suboxone+Primary Care ™

I provide a private, physician-led Suboxone treatment integrated with primary care in a concierge medicine practice, with Dr. Conway personally involved over time.

It is not essential to understand how Suboxone works to benefit from Suboxone, but many patients feel more confident when they understand the treatment. I wrote this blog for patients who want a clear explanation.

What You Will Learn About Suboxone

• How Suboxone is special
• How Suboxone works in the brain
• How Suboxone stops withdrawal
• How Suboxone is a treatment
• Suboxone and recovery
• Duration of treatment with Suboxone
• Suboxone Treatment in Nashville

What Happens in the Brain During Opioid Addiction

H3: The Complicated Biology of Reward Pathways and Mu Receptors

The brain’s reward pathways are a complex electrical-chemical machine, intricately designed and operated. For the brain to function, chemical signals stimulate sites on cells specifically designed to respond to them.  We call those sites receptors.

The body has an innate, or endogenous, chemical system that stimulates pleasure or relieves pain. The body has its own intrinsic opioid system called endorphins.

Opioid receptors are called mu receptors. These mu receptors have an intrinsic responsiveness to endorphins. These mu receptors can increase or decrease their level of responsiveness.

When the brain receives a constant external supply of opioids such as hydrocodone, OxyContin, or fentanyl, the mu receptors become much less responsive. This decrease in responsiveness is called tolerance. For the mu receptor to respond, a steadily increasing external opioid concentration is required.

Tolerance

For the brain to feel normal with consistent illicit or prescribed opioids, it requires constant external opioids. Tolerance is a mu receptor requiring more external opioids. Every patient with opioid addiction understands tolerance. It is the ever-increasing requirement for more opioids each day to avoid withdrawal.

Dependence

Dependence is the mu receptor requiring constant external opioids.  The machinery of the body has incorporated the opioid into its operation. We call this dependence.

Withdrawal

In the absence of external stimulation, the body goes into withdrawal. Withdrawal is the mu receptor failing to receive sufficient external stimulation.

Suffering from Opioid Addiction

Suffering from opioid addiction is not a weakness. The suffering occurs because the brain has been reprogrammed for survival around opioids.

How Suboxone Works at the Mu Opioid Receptor

The Mu receptor is key to understanding disease progression. The fundamental concept is that the normal person has a mu receptor, which is very responsive and sensitive to the body’s intrinsic opioid system and to occasional opioids given for pain.

With constant use of hydrocodone, OxyContin, or fentanyl, the receptor reduces its sensitivity, and the receptor requires a constant external ingestion of opioids to keep normal.

Suboxone contains buprenorphine. Buprenorphine binds to the mu receptor very tightly. When binding to the mu receptor, buprenorphine partially activates it.

Suboxone does the following:

• Receptors are occupied and stabilized.
• Prevents other opioids from attaching.
• Normal receptor responsiveness is stabilized over time

Why Suboxone Stops Withdrawal Symptoms

With the consistent use of Hydrocodone, OxyContin, Fentanyl, or other opioids, the MU becomes much less responsive. The MU receptor, when less responsive, requires constant external administration of opioids to feel normal.

Withdrawal is under-stimulated Mu receptors.  Suboxone, or buprenorphine, provides sufficient Mu receptor activation to stop physical withdrawal.

When Suboxone relieves withdrawal, the following symptoms are relieved.

• Muscle aches
• Anxiety/restlessness
• GI distress
• Sweating
• Chills

For the patient with opioid addiction who is beginning Suboxone, rapid stabilization occurs within hours. The patient feels normal again. The patient is no longer getting “high.” The patient is returning to baseline function.

How Suboxone Reduces Cravings

Cravings are intensely uncomfortable. Cravings are receptor-driven or biological. Cravings are also learned behavior.

Suboxone keeps the receptors occupied, reducing withdrawal symptoms and the biological drive. If the patient slips and takes opioids, Suboxone blunts the reward of cravings.

Suboxone is a long-lasting drug. The long duration of action is produced.

• Stable blood levels
• Stable biological effect
• Eliminates the cycle of High, Crash, Craving, Use

With Suboxone, patients regain mental space.

Suboxone vs. Other Opioids: Why It Is Different.

Suboxone acts differently at the Mu receptor. In fact, Suboxone has unique qualities that provide effective, healing benefits for my patients.

Buprenorphine, the active component of Suboxone, is classified as a partial opioid agonist. This means:

• It activates the Mu receptor, but only to a limited extent.
• After a certain point, increasing the dose does not increase the opioid effect further.
• Buprenorphine has a ceiling effect on respiratory depression, which makes it safer than full opioid agonists, but serious respiratory depression can still occur, especially when combined with benzodiazepines, alcohol, or other sedatives.
• The natural ceiling effect is central to its safety and effectiveness.

Buprenorphine is a long-acting drug.  Buprenorphine has a long duration of action, tight receptor binding, and slow dissociation. This steady receptor effect helps reduce the cycle of intoxication, crash, cravings, and use.  This is what my patients consistently demonstrate in the clinic.

• The cycle of intoxication and crash is reduced. In my patients who remain on treatment, the cycle is eliminated
• The risk of death from respiratory depression is much reduced.
• The brain and the patient are stabilized rather than overstimulated.

Buprenorphine binds to the mu receptor very tightly. This means.

• Other opioids cannot easily attach.
• If other opioids are used, their effect is blunted or blocked.

Buprenorphine is designed not to create a “high” or euphoria.

The purpose of buprenorphine  is to

• Stabilize the brain.
• Restore function.
• Allow normal life to return.

My patients consistently tell me that Buprenorphine has given them their lives back.

Is Suboxone Addictive or Just Replacing One Opioid with Another?

This is a common misunderstanding. Suboxone is a treatment for opioid use disorder. Suboxone treatment is different from active addiction. Patients do develop physical dependence, but this is not addiction. Addiction requires compulsive use despite harm.

In my practice, this belief that suboxone is just replacing one opioid for another is one of the most common reasons for failure of suboxone treatment.

Is Suboxone Safe for Long-Term Treatment?

I have prescribed buprenorphine to patients since 2011 in Nashville. I have studied Buprenorphine since 2011. Unlike methadone, buprenorphine is a relatively new drug. We do not have 50 years of experience with buprenorphine. The consensus opinion and the standard of care are that buprenorphine can be used long-term safely without causing organ damage.

Patients often ask if Suboxone can be used long term under medical supervision. The answer, based on both clinical and medical evidence, is yes.

Suboxone can be used as long-term treatment of opioid use disorder. I have patients who have been on Suboxone for up to 15 years. Many of my patients have been on suboxone for many years.

Suboxone allows.

• Return to work, family life, and stability.
• Eliminates cycles of withdrawal and relapse.
• Reduces risk of overdose.

H2: How Long Should You Stay on Suboxone?

The duration of treatment with Suboxone for a given patient in Nashville is a matter of judgment and preference.  In my experience, patients commonly choose one of the four courses.

• Discontinue in the first month. This patient choice carries the risk of relapse and overdose.
• Discontinue in the first year.
• Discontinue in a few years.
• Long-term use with no plan for discontinuation

The objective of treatment is stability. When the patient believes that he has achieved stability, or when the patient decides that the costs of treatment exceed the benefits of treatment, then the patient elects to discontinue Buprenorphine.

The clinical effect of buprenorphine changes over time, in my anecdotal, limited clinical experience with a few patients over a brief time. However, for those patients who elect to stay on buprenorphine long term, each patient has decided that buprenorphine is profoundly beneficial.

Stages of Recovery While Taking Suboxone

In my experience watching patients recover in my practice, recovery can be divided into three distinct stages.

• Early recovery is concerned with stabilization.
• Middle recovery is concerned with comorbidities.
• Late recovery is involved with aging.

What Are the Main Risks of Suboxone?

In common, ordinary life in Nashville, Tennessee, the use of buprenorphine has increased risk in one of two circumstances.

• Benzodiazepines, alcohol, or other CNS depressants can produce serious respiratory depression, including respiratory arrest.
• Short-term use of buprenorphine, followed by return to prior illicit opioid use, has been associated with unexpected mortality.

Benzodiazepines, Alcohol, and Sedatives

Benzodiazepines are sedatives. Benzodiazepines range from habit-forming to addictive. Use with buprenorphine increases the risk of dangerous sedation or respiratory depression. Benzodiazepines increase risk when combined with buprenorphine, but buprenorphine treatment should not be automatically withheld. The safer approach is careful physician management.

My experience with patients with benzodiazepine addiction has confirmed to me the profound hold benzodiazepines have on patients, and the profound difficulty patients have in achieving recovery from benzodiazepine addiction. The addition of benzodiazepine to Buprenorphine changes a relatively safe treatment into a treatment with greater risk.

However, FDA guidance states that buprenorphine or methadone treatment should not be withheld solely because the patient is taking benzodiazepines or other CNS depressants.  I have had patients with long-term benzodiazepine prescriptions from another physician, who have had real difficulties in discontinuing benzodiazepines.

Relapse after stopping Suboxone.

When patients participate in a buprenorphine recovery program, the machinery of the brain’s reward pathways returns to normal within a relatively brief period. The profound tolerance that the patient had to Fentanyl, OxyContin, hydrocodone, or other opioids quickly reduced.  This means that the brain’s mu receptors and respiratory receptors will respond to much lower doses of opioids than before the patient entered buprenorphine recovery treatment.  Death can occur in the following scenario.

• The patient takes Buprenorphine in a recovery program.
• The patient discontinues the buprenorphine recovery program.
• The patient immediately relapses, taking the same dose of Fentanyl, OxyContin, or hydrocodone as before.
• Stopping breathing (respiratory arrest) occurs at the time of death.

A common setting in America where this occurs is when patients in corrections who are on Buprenorphine in prison are discharged home, immediately discontinuing the Buprenorphine, and immediately beginning illicit opioids again.

Monthly physician visits matter

Monthly physician visits help monitor stability, cravings, other medications, and your current concerns.

Recovery is about consistency. Recovery is about making small changes before slips or relapses occur. Seeing your physician monthly will benefit you.

Private Suboxone Treatment in Nashville

Private Physician-Led Practice

At Nashville Suboxone+Primary Care™, I provide Suboxone treatment within a primary care practice. I serve as your physician, not just your Suboxone provider. For patients who value having one doctor assist them with their recovery and medical problems, our practice can be especially helpful.

Concierge medicine means more personalized care, greater continuity, and a physician who has the time to get to know the patient. My practice is intentionally small. I have patients who have stayed with me for years because they value being known, remembered, and cared for over time. My goal is to make private, physician-led care more accessible than many traditional concierge medicine models.

When to Call Dr. Conway

My practice is designed to be private medicine. My primary care internal medicine practice in Nashville is intentionally small, so that I can have ample time with everyone, allowing me to know you, your medical history, and your preferences.  If this suits you, please contact me.

Frequently Asked Questions about SuboxoneIs suboxone safe?

Is suboxone safe?

Suboxone is generally safe when taken as prescribed and monitored by a physician, especially when patients avoid alcohol, benzodiazepines, and other sedatives.

Is Suboxone a foundation of recovery from opioids

Yes, Suboxone is a foundation of recovery from opioids.

How long should you remain on Suboxone?

It is best to remain on suboxone until you are stable and capable of maintaining a recovery. You have choices regarding the duration of your treatment.

Conclusion: Suboxone Can Help the Brain Stabilize and Life Stabilize

My work is to walk with you through those decisions — quietly, steadily, and without judgment. I am William Conway, MD, in Nashville. If you are in taking suboxone, or looking for private Suboxone care with primary care included, please contact me..

📞Call 615-708-0390

 

Bibliography

American Society of Addiction Medicine. The ASAM National Practice Guideline for the Treatment of Opioid Use Disorder: 2020 Focused Update. Journal of Addiction Medicine 14, no. 2 suppl. 1 (2020): 1–91. https://doi.org/10.1097/ADM.0000000000000633.

Food and Drug Administration. Suboxone (Buprenorphine and Naloxone) Prescribing Information. 2021. https://www.accessdata.fda.gov/drugsatfda_docs/label/2021/020732s024lbl.pdf.

Food and Drug Administration. “FDA Recommends Changes to Labeling for Transmucosal Buprenorphine Products Indicated to Treat Opioid Use Disorder.” December 25, 2024.

Johnson, R. E., E. C. Strain, and L. Amass. “The Clinical Pharmacology of Buprenorphine.” Clinical Pharmacokinetics 42, no. 2 (2003): 135–146.

Substance Abuse and Mental Health Services Administration. Medications for Opioid Use Disorder. Treatment Improvement Protocol (TIP) 63. Updated edition. Rockville, MD: SAMHSA.