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There is a formulation of buprenorphine without naloxone called subutex; I used this formulation when the patient has apparent problems from naloxone, including headaches after dosing with suboxone. I in addition have treated addicts who've had gastric bypass, where the first the main intestine is bypassed as well as the stomach contents empty into a more distal area of the small intestine. In such cases the naloxone escapes ?first pass metabolism', the procedure with normal anatomy in which the drug is taken up from the duodenum and transferred right to the liver from the portal vein, where it is quickly and completely destroyed. After gastric bypass naloxone can be taken on by servings of the intestine which aren't served from the portal system, causing blood numbers of naloxone sufficient to cause brief, relatively mild withdrawal symptoms.
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