Subsys (Fentanyl Sublingual Spray) Addiction and Abuse

Subsys, an oral form of the strong opioid fentanyl, can result in addiction, misuse and abuse. Treatment can help people struggling with Subsys addiction. 

Subsys, one of the brand names for the opioid fentanyl, is an opioid narcotic available in a spray formulation. The drug is FDA-approved for cancer pain in adults and can be useful in people with trouble swallowing pills. As an opioid that is up to 100 times stronger than morphine, fentanyl can be highly addictive. Even though Subsys is a controlled substance, misuse and drug diversion can occur, paving the way to addiction.

Subsys Addiction

Since Subsys is an opioid, it binds to specific central nervous system receptors, reaching its max concentration in the body in about 1.5 hours. Like all opioids, Subsys can change how the body sends pain signals and senses pain. The drug is also a central nervous system depressant, slowing breathing and heart rate.

Subsys can cause a euphoric feeling, which is one reason it’s addictive. Subsys changes the amount of certain neurotransmitters in the brain, such as dopamine. That accounts for the euphoria people may experience, but also triggers a reward response. A pleasure and reward response in the brain can lead to an addiction.

Because of the risks, Subsys is only available through facilities that participate in the TIRF REMS Access program. It is also classified as a Schedule II drug by the DEA. Schedule II indicates that fentanyl, the active ingredient in Subsys, has a high likelihood of severe psychological and physical dependence. For this reason, possessing Subsys without a valid prescription is illegal.

What Is Subsys (Fentanyl Sublingual Spray)?

Subsys (Fentanyl Sublingual Spray) is a brand-name form of the opioid fentanyl which comes as a spray. It is intended to be prescribed to people with cancer experiencing breakthrough pain on an existing opioid regimen. Because the drug is so strong, only those on the equivalent of morphine 60 mg around the clock for at least a week can take it. Further, the drug is only approved to be taken in conjunction with a long-acting opioid and used for breakthrough pain only.

Subsys is not the only form of fentanyl available. Other dosage forms of fentanyl include an oral lozenge, a skin patch, a nasal spray, a tablet and a liquid for injection in hospital patients.

Signs, Symptoms & Side Effects of Abuse

The symptoms of Subsys misuse are similar to other opioids. If someone is prescribed Subsys, they may take it more often than prescribed or claim to have more pain than they do to get more of the drug. Any time a drug is taken outside of how it’s intended and prescribed by a medical professional can be considered misuse. Stealing Subsys or diverting it from medical use in any way is misuse.

There are certain behavioral and psychological symptoms that can be associated with opioid misuse in general. Someone who’s misusing Subsys or another opioid might seem to have rapid mood swings. They might go from seeming euphoric to being depressed or irritable. Someone who’s misusing opioids might also start to lose interest in other activities or they may have changed eating or sleeping habits.

Physical symptoms of Subsys misuse can include:

• Cravings for Subsys or other opioids
• Excessive sleepiness
• Changes in sleeping habits
• Weight loss
• Flu-like symptoms
• Decreased sexual urges
• Hygiene problems

Addiction is a diagnosable disease with specific symptoms. Although a person might not have all the signs of addiction, some common signs to be aware of include:

• Obsession with taking and obtaining the drug
• No concern for the harm done to oneself or loved ones because of drugs
• Loss of control when it comes to taking the drug
• Hiding the drug
• Wanting to stop taking the drug but not being able to
• Changes in mood or behavior
• Loss of concern over appearance and personal hygiene
• Withdrawing from friends and family
• Declines in performance at school or work
• Failing with regard to responsibilities
• Continuing to take the drug even when there are negative side effects

Subsys Overdose

A Subsys overdose can happen quickly. If you suspect someone is having an overdose with Subsys, you should administer the opioid reversal agent naloxone, sometimes sold under the brand name Narcan, and seek emergency medical help right away. Some of the symptoms of a Subsys overdose can include:

• Slowed breathing
• Extreme drowsiness or stupor
• Flaccid muscles
• Cold and clammy skin
• Small pupils, although pupils can also be enlarged
• Slow heartbeat
• Low blood pressure
• A snoring sound
• Death

Subsys and Alcohol

Mixing alcohol and an opioid like Subsys can be dangerous. Both alcohol and Subsys are central nervous system depressants. Although they have different mechanisms of action, both slow the functions of the central nervous system down and can, therefore, have additive effects.

At a minimum, taking alcohol and Subsys together can lead to severe drowsiness and confusion. The worst-case scenario is that a person’s breathing could slow so much that it causes an overdose. This can lead to brain and organ damage or death because of a lack of oxygen. If someone is struggling with two substances like Subsys and alcohol simultaneously, they may require specialized addiction treatment.

Long-Term Consequences

The consequences of taking Subsys over the long-term are unclear. The drug has not been studied in people who have taken it for longer than 149 days. Further, it is possible to develop an addiction to the drug at any time, even if you are taking it as prescribed. As a result, experts recommend taking Subsys only at the lowest doses and for the shortest duration possible.

Subsys Withdrawal

Subsys and other opioids can change levels of neurotransmitters in the brain and can alter the brain’s overall function. When the brain begins to rely on the presence of Subsys, physical dependence occurs. If someone who is physically dependent on Subsys suddenly stops taking it, they can experience withdrawal symptoms while their brain readjusts to functioning without the drug.

Withdrawal Symptoms

Subsys withdrawal symptoms are similar to those of other opioids and can include:

• Nausea or vomiting
• Anxiety
• Trouble sleeping
• Hot or cold flashes
• Sweating
• Muscle cramps
• Runny eyes or nose
• Diarrhea

Withdrawal Timeline and Symptom Duration

Everyone experiences a slightly different Subsys withdrawal timeline. Some of the factors that play a role in how long withdrawal symptoms last include how long the drug was taken, whether it’s stopped cold turkey and the dosage. Taking other substances simultaneously with Subsys can also affect the withdrawal timeline.

With any medication that is fentanyl-based, withdrawal symptoms can begin anywhere from eight to 24 hours after the last dose and can last up to 10 days.

Managing Withdrawal Symptoms

Managing symptoms of withdrawal on your own can be difficult because opioid withdrawal is extremely uncomfortable. A full detox is necessary for treatment, but some people lapse back into taking the drug because they find that managing the symptoms of Subsys withdrawal without help is too difficult.

Several different strategies exist for managing or minimizing withdrawal symptoms. One is to slowly taper the dose of opioids under a doctor’s care. Another strategy is to replace the opioid with a longer-acting opioid that can prevent both cravings and withdrawal symptoms.

Subsys Medications & Detox

Certain therapies are approved to help ease withdrawal symptoms from opioids like Subsys. This strategy is called medication-assisted treatment, or MAT. Multiple medications are available and approved for this purpose:

Any medication prescribed during Subsys detox is intended to be part of a larger treatment program. There’s no magic cure for withdrawal or addiction. Approved medications are instead tools to help increase the likelihood that someone will succeed in overcoming their struggle with Subsys.

Medical Detox

Medical detox is the first step in recovering from Subsys. A medical detox typically takes place in an inpatient environment, where there is supervision from a team of medical professionals to prevent complications and treat Subsys withdrawal symptoms. Medical detox can include mental health care, treatment and, if necessary, medications.

The detox can occur in a standalone facility or be part of an addiction treatment center. Many people find that it’s better to go through detox in the same place they’ll receive addiction treatment for continuity of care and fewer transitions during a difficult time in their lives.

During a Subsys medical detox, doctors can prescribe MAT if needed, as well as medications for common withdrawal symptoms such as insomnia or diarrhea.

Rehabilitation Programs

After medical detox, rehab can begin to teach you the skills that you need to learn to live life without Subsys. Rehabilitation programs can take place in different settings and last for varying lengths of time. However, all programs should have some core concepts that are foundational to the treatment provided. Some of the principles for effective treatment include:

• No one treatment is right for everyone
• Addiction is a disease that’s complex but treatable
• Addiction affects both brain function and behavior
• Addiction treatment should address all of a person’s needs
• Staying in treatment for a long enough period is essential

Rehab can take place in either an inpatient or an outpatient environment.

Choosing A Rehab Center for Subsys Addiction Treatment

Due to the highly personal nature of Subsys addiction treatment, many of the factors to weigh when choosing a rehab center are based on the individual. Some people will fare better in one type of treatment over another. Specific things that are relevant when choosing a rehab center include:

• How severe is the Subsys addiction?
• How far from home does the person want to go for treatment?
• Is the person able to pause their daily life to focus on treatment as an inpatient?
• What will insurance cover regarding the cost of treatment?
• Does the individual require a medical detox?
• Does the person struggle with multiple substances, or with just Subsys alone?
• Does the person have any co-occurring mental health problems that need treatment?

Our caring addiction experts at The Recovery Village can answer questions you may have about medical detox and inpatient and outpatient addiction treatment to put you on the right path as you overcome your struggle with Subsys. Reach out to The Recovery Village today to seek assistance.

Editor – Rob Alston

Rob Alston has traveled around Australia, Japan, Europe, and America as a writer and editor for industries including personal wellness and recovery. Read more

Medically Reviewed By – Dr. Jessica Pyhtila, PharmD

Dr. Jessica Pyhtila is a Clinical Pharmacy Specialist based in Baltimore, Maryland with practice sites in inpatient palliative care and outpatient primary care at the Department of Veteran Affairs. Read more