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The Onion: Anonymous Hero Donates Hospital 200 Human Kidneys

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Suboxone vs Subutex: Where did the high go?

A bit of confusion over how suboxone and Subutex work:

Subutex gave me a strong buzz during detox…After a year of being on suboxone (which completely suppressed any high the buprenorphine might give, which it did) and being switched back to subutex, one might think subutex would give me that feeling again, with the naloxone being out of my body and all. Is it a matter of tolerance? I’ve been told that tolerance is reset by naloxone…I just don’t know what the real cause is here. I’m on straight subutex, 8mg and the magic is gone. perhaps…forever? Let me know if you have any clue, or if it is just tolerance. (email me at vespafly@gmail.com

Suboxone and Subutex are interchangable;  there is no difference between them.  The naloxone in Suboxone is not absorbed from the mouth, and the naloxone that is absorbed from the intestine is broken down very efficiently by the liver, so that very little gets into the systemic circulation.

The effect one has to the initial dose of buprenorphine, whether it comes from Suboxone or from Subutex, depends on the person’s level of tolerance.  If a person has a very high tolerance, he will feel withdrawal.  If the tolerance is very low, the person will feel a ‘high’.  In either case, they will adjust to the dose of buprenorphine within a few days and feel normal.  In the case of the person who initially felt a buzz, the person becomes tolerant to the buprenorphine;  in the case of the person who felt withdrawal, the person ‘recovers’ from withdrawal as his opiate receptors adjust to the reduced level of opiate stimulation.he

To answer your question, the tolerance is what took away the ‘high’ you got from the initial dose of Subutex.  It had nothing to do with changing to Suboxone, and would have occured in the exact same way had you stayed on Subutex.  A person who is not opiate-tolerant will get a significant opiate effect (I hate to use the term ‘high’, but I guess the term is correct) from the initial dose of Suboxone or Subutex– but it will only last for a day, or maybe two at the most.  Buprenorphine has a very long half-life, so there is no significant drop in the blood level from that first dose to the next– and the constant opiate stimulation from a drug with a long half-life results in the very fast development of tolerance.

I have had a number of patients switch from Suboxone to Subutex and vice versa, sometimes a couple times (in the case of women who take Suboxone, but who change to Subutex during pregnancy to avoid the naloxone).  They have no change in how they feel;  in both cases the buprenorphine is the active substance, and since the dose is the same I would not expect them to feel any difference between the two medications.

As far as ‘naloxone resetting tolerance’, for naloxone to have an effect on human opiate receptors it would need to be given IV or IM, where it can be absorbed sufficiently.  The medication ‘Naltrexone’, on the other hand, is an opiate antagonist similar to Naloxone except for being active when taken orally.  When a person takes Naltrexone, the opiate receptors are blocked;  the neurons with the opiate receptors therefore react as if they are not receiving any input through the receptors.  In response to the lack of input the neurons up-regulate the receptors so that they are more sensitive to stimulation by opiates, which translates into a decrease in tolerance.

I understand your comment about the ‘magic’, but I don’t agree with it.  The ‘magic’, in my opinion, is the ‘normal’ feelings induced by buprenorphine.  After that first couple days patients taking Suboxone feel like non-addicts, and that is what makes it such a ‘magical’ medication.  That other feeling– the high from opiates– is only a small part of the true feelings induced by opiates– and you can’t have one without all the others.  In other words, yes, opiates give a warm, euphoric feeling… but also give an equal or greater amount of depression, fatigue, and bone-chilling coldness.  In the balance, there is no net ‘good feeling’– there is as much or more misery for every amount of ‘magic’.  Addicts stuck in a using pattern tend to see the OC or other opiate with ‘euphoric recall’, remembering only the tiny pleasant part of using, and ignoring the huge amount of misery associated with using.  I encourage addicts doing the work of staying clean to ‘bring the memory full circle’; with every pleasant recollection, be sure to think about where the use took you, and where the pleasant sensations ended.  Keep the memories attached to each other, because in reality they are not separable.

Please note that I do most of my posting on a new site, simply addressed as suboxonetalkzone.com.

How Low Can I Go?

An entirely logical question:

Soboxdoc,

I am taking 16mg of Suboxone a day – 8mg in the morning and 8mg at night. You state above that Suboxone has a ceiling effect of about 4mg. Does that mean I could take a half of an 8mg tab once a day and it would have the same effect as the 16mg that I am currently taking? Even after the three day half-life? Or should I still cut it down by 2mg a week until I get to 4mg?

That would be great if I could do it right away with the same benefit! Either way I am still left speechless on how much this medication has changed life for me. Thanks again for all the wonderful info.

My Best Guess:

Thanks for writing!  The 4 mg level for the ‘ceiling’ is an average for patients overall, and assumes that you are taking the Suboxone in an effective way. My addiction to fentanyl initially relied on absorption across mucous membranes, and in order to get the most ‘bang for the buck’ I brought my best neurochemistry training to study the absorption of lipid-soluble medications through tissues. We know that molecules move slowly through tissues, so when I picture under-the-tongue Suboxone dosing I see a pill dissolving around the periphery, saturating the tissue under the tongue with buprenorphine… and then little rivers of buprenorphine run along each side of the tongue, to be swallowed down the esophagus. I have to think a better idea would be to have a small volume of saliva to dissolve the tablet, making a high concentration of drug to move down its concentration gradient… then spread the concentrated slurry over as much surface area as possible, for as long a time as possible. I do think that this method increases the percent of drug absorbed, and it certainly is faster than leaving a pill under your tongue for 35 minutes!

Even so, I would expect a significant amount of waste, as a large amount of drug will miss getting stuck on the mucosal surfaces. I have one patient who spits it out, freezes it, and reuses it to save money!

Most people who have moved from 16 down to 8 or even 4 mg have had very little withdrawal. The ones with the worst withdrawal tend to be people who have had real bad withdrawal many times, and are expecting it to be horrible again. The people who haven’t had very bad withdrawal don’t find Suboxone withdrawal bad at all. Am I avoiding the question? Maybe… but yes, I would think that you could move to 8 and then 4 mg fairly quickly, and then stop there. I would stop at 4 for several weeks before going any longer just to make sure your aren’t ’stacking’ the withdrawal from changing too fast (I picture it like the sound waves stack up against the nose of a supersonic jet, just before it breaks the sound barrier!). I would try going from 16 to12 for three or four days, then to 8 for three or four days, then maybe to four…

The mind is the biggest trouble during this period, as you probably have found. The technique that works best is a combination of determination and distraction. It is awfully hard for any addict to be determined for a few weeks! You need something REAL distracting– maybe you could call and see if Angelina Jolie needs a lift anywhere during the time you are tapering, and you could distract yourself by engaging her in witty conversation. Just a thought… Or get the DVD’s of the Cosby Show entire series and watch that. That would be a good distraction too. One of those should work.

The other problem is that as you lower the dose most people start to have more thoughts of using. This is the biggest mistake I see on the way to relapse from Suboxone– people take less and less, and then start wondering if they are still ‘blocked’… then they get the bright idea that it would be ‘good to know if I am still blocked, so I should take an oxy– just to see. You see where this is going. Sometimes it looks awfully suspicious for the ‘addict inside’ planning the whole thing out, from start to relapse. Watch for that– try to take an honest assessment of your thought every now and then, and pay attention to any emergence of a cocky or joking side of your personality– that is usually how the relapse addict inside all of us makes his appearance.

Thanks again– I hope I provided an answer in here somewhere! WAY past my bedtime!

Please transfer to my new blod:  http:;//suboxonetalkzone.com .

Opiate addiction treatment options– education

I have prepared audio files– on CD or by download– for sale here for less than the price of 40 mg of oxycodone.  I will release a new recording each month;  the current one discusses the treatment options for people addicted to opiates, including the pros and cons and philosophies of each options.  It also discusses the considerations in starting treatment with Suboxone.  The tape is designed for addicts considering treatment, or for spouses, friends, or family members of opiate addicts.  Are your parents confused about the point behind Suboxone?  Send them this recording to help them understand.

SD

Educational Audiotapes: Opiate Dependence Treatment Options

My New Site

Please note that I will be leaving this site soon– new posts can be found at http://suboxonetalkzone.com . Please adjust your bookmarks, and at the new site please click on the link to subscribe!

SD

Recovery

Suboxone is an amazing medication— no doubt about it.  I have written on the web and on this blog about the crowding out of a person’s life by the obsession to use, and about the hope that as the obsession is relieved, ‘normal’ personality will return to some extent.  To some extent… that is a key phrase.  True recovery from addiction varies from person to person.  The goal is to re-acquire a sense of honesty, of self respect, and of personal responsibility— the things that are the mainstays of standard step-based treatment.

Residential treatment remains the ‘gold standard’ of addiction treatment.  Unfortunately it is only available to the few people who can afford it and who have reached a level of desperation that forces them to change their way of looking at the world.  Such profound changes often result in a new life that is many times better than the one left behind.  The question is whether a person on Suboxone can benefit to that degree.  I think the answer will depend on the person;  like they say at AA and NA meetings, ‘you gotta wanna’.  Here is one program that summarizes the principles of recovery into an efficient set of steps, intended for those who are not attending the standard AA or NA meetings for whatever reason. Click Here!

Suboxone Talk Zone

For those of you looking for me here, I have moved– you will find me and my blog here instead.  I am trying to decide what exactly to do with this space;  are there issues out there related to psychiatry and addiction that people would like to hear about or talk about?  Please let me know!

My blog is doing well, and I encourage you to subscribe– just visit http://suboxonetalkzone.com and click on subscribe by e-mail or by RSS.  Likewise more and more people are discovering the community at Suboxone Forum;  you can join for free, even using completely false information for the sake of confidentiality (you do need an e-mail address; make up a new one that is private at hotmail or yahoo for free).  Finally, if you are interested in obtaining psychiatry services in the privacy of your own home, by Tele-Psychiatry, visit me at http://telemedpsychiatry.com.

SuboxDoc

http://suboxonetalkzone.com

http://suboxforum.com

http://telemedpsychiatry.com

Suboxone and Pain

A Question:

I see my urologist, the prescribing doctor on Monday, August 18th and am planning on asking him to write a prescription for Subutex for my pain. This weekend I am trying to collect some useful information to bring to him in support of my request. As I have previously stated it was my physicians’ idea to try this medication. I believe he feels uncomfortable prescribing it as in this country it is being very actively promoted/publicized for addiction. Like may doctors he may be under the impression that he needs a special UIN number to prescribe it.

See:

http://www.helpmegetoffdrugs.com/wst_page9.html

http://www.naabt.org/links/DEA_Bup_for_pain_letter.pdf

As can readily be identified in the above DEA letter he does not need any special qualifications.

Besides showing him the letter I need to find credible medical information to show him as to the equivalent dose Subutex/Suboxone to the “Avinza” 90mg he currently has me on?

As stated I see no downside to my trying Subutex/Suboxone for pain management, do you?

“long half-life results in a very stable subjective experience” I see this as a benefit.

“Tolerance occurs very rapidly…I would expect tolerance also to the analgesic effects. So theoretically it should not be a good pain drug because the rapid tolerance would eliminate the analgesic effect after a few days.” Should this occur than I would of course not be able to sustain.

“In reality, though, patients will claim relief from suboxone for an indefinite period of time in many cases. I have no explanation…”

“Suboxone certainly has advantages over other opiates, if it is found to be effective. The tolerance with buprenorphine is limited, whereas the tolerance to a pure agonist has not limit—so there is a lower amount of withdrawal if/when the drug is eventually discontinued. The stable blood level prevents the temporary ‘highs’, the miserable lows, and the cravings that can accompany the use of agonists. The patient feels much more clear headed on suboxone compared to opiate agonists. And suboxone can be dosed once per day, which has a couple effects—first, it just is less trouble to take, but more importantly the absence of ‘as needed’ dosing all day long will help prevent the patient from focusing as much on the pain.”

Again I see no down side to trying it, not focusing on my pain or if and when I might start having break through pain, not having my mood go up and down as a medication blood level changes (very important to me is leveling out my mood), possible cravings (I have not had yet),. I would be much relieved to be more clear headed. I have been having cognitive problems for several years now and have had neurological testing for it. Having a clear head and a level mood(good or bad) could potentially provide me with some relief from some of the problems and might provide some answers as to why they are occurring which might enable me to address the cognitive deficits more effectively.

“…many people have told me that suboxone seems to work as a ‘mood stabilizer’…”

As I suffer form treatment resistant depression and have read several accounts where buprenorphine has helped depression I am interested in trying it as for me it has a potential dual purpose.

“Chronic pain is a very difficult issue…I encourage you to avoid opiates as much as possible—there is generally little future in opiate treatment of pain, since tolerance always chips away at the effects of the opiate over time…”

I have a limited understanding here but as buprenorphine is a partial agonist, having this ceiling effect I was thinking it might be helpful to me in the long run as far as building up tolerance to opiate medications? For instance if I am able to obtain adequate pain management with buprenorphine over several years would I not benefit from this over taking morphine or oxycontin, full agonists over the same period of time? My tolerance for the full agonists could potentially increase during this time and if I need to continue with opiate pain management the tolerance will minimize the ability for pain management with full agonist medications if I need to go on them at some later point.

It is not clear to me whether my tolerance for buprenorphine will increase quickly or not. You stated that in theory tolerance occurs rapidly but in practice this is not always the case.

“Suboxone certainly has advantages over other opiates…”

You have in the above statement impressed upon me several advantages to using buprenorphine for pain management if it can be accomplished.

I would appreciate any input or advise you might have for me on this issue. I would also appreciate it if you could provide any relevant links to credible medical information about buprenorphine and pain management and/or suggested equivalent starting doses.

I believe my email is in my profile but to b sure you have it:

XXXXXXXXXXX

Thank you for your consideration,

“tiggy”

My Reply:

I agree with everything you wrote– although I recognize that most of the quotes are from things that I have written, so how could I not agree?!  I’m joking– I suppose I should write LOL to clarify that…

As for the question about starting dose– because of the ceiling effect, the Suboxone dose is always going to be in the same general area, regardless of the opiate requirement for pain or the opiate tolerance of the patient on maintenance addiction treatment.  I have disagreed with a couple earlier posts that suggested different Suboxone doses (or using methadone instead of Suboxone) for people who have high opiate tolerance;  I have helped patients go on Suboxone from HUGE doses of methadone or oxycodone, and I do not think that a high tolerance argues for methadone over Suboxone or vice-versa.  I see tolerance as dynamic;  in any one person, tolerance is a function of two things, time and opiate dose, with the latter being most important.  My own addiction to intravenous fentanyl (anesthesiologists have access to very powerful medications!) resulted in an extremely high tolerance, despite being ‘active’ for only a few months, because I kept pushing the dose higher and higher.

I have come to see withdrawal as the subjective symptoms of lowering one’s tolerance level.  Suboxone has an opiate agonist potency equal to about 30 mg of methadone per day.  Taking Suboxone will make one’s tolerance ‘reset’ at that level, and stay there for as long as the person is on Suboxone.  A person who starts Suboxone from a lower tolerance level will get ‘high’ for a couple days, until his tolerance stabilizes at the higher level;  a person who starts Suboxone from a higher tolerance level will have ‘precipitated withdrawal’ as his tolerance is ‘yanked down’ to the lower level.  That is why we usually ask an addict to stop using for 24 hours or so;  that way his tolerance will come down a bit (and he will experience withdrawal), and starting the Suboxone will not cause an instant surge of withdrawal symptoms.  People sometimes ask why Suboxone causes withdrawal when one stops taking it; the reason is because there is no free lunch– Suboxone protected the person from needing to go through all of the withdrawal necessary to get tolerance down to zero, and when one stops Suboxone there is still work to be done to bring the tolerance down.

I tend to wander a bit… but as for specifics, the starting dose of Suboxone would be about 4-8 mg.  The usual ‘final’ dose is about 16 mg.  Some pain patients claim more pain relief from higher doses, but I am skeptical of anything more than a placebo effect, as we know that buprenorphine’s effects at mu opiate receptors are subject to the ‘ceiling’ that I have been referring to.  Similarly, dosing once per day will result in complete, constant binding of all of your mu opiate receptors–  dosing twice or three times per day will cost more and be more trouble but probably has no benefit beyond the placebo effects.

You are correct about the requirements for Suboxone prescribing;  any doc can use it for pain.  It may be helpful to write ‘for pain treatment’ on the script; that way the pharmacist may be less likely to question it.  BUT…  that does not mean thats a doctor will prescribe it or that a pharmacist will fill it.  There is a great deal of ignorance about Suboxone, and many docs just don’t want to mess with something that they are not familiar with.  Moreover I have noticed that many pharmacists have become more active in controlling prescriptions; many times I have run up against pharmacists who simply refuse to fill something for reasons that are highly suspect, including ‘I don’t like the looks of the guy’  (I honestly have heard that!).  Sorry Walgreens, but when I have had problems it almost always has been from one of your pharmacists.  Surprisingly, I have had problems with many different Walgreens locations!  I don’t think this is true, but I sometimes wonder if Walgreens trains their pharmacists to be jerks– patients have told me that they were told ‘your doc is breaking the law’ or ‘your dose should be lower’…  Then I had the Walgreens pharmacist call after cutting all of the controlled-release pills for a patient in half because he didn’t have the lower dose in stock, and asking for me to write a script instructing him to do what he had already done (which, by the way, results in the dangerous, instant release of 12 hours of medication)…

I had better stop before I get carried away.  But I don’t like that particular pharmacy chain.

Anyway, as I was saying, your doc or pharmacist may not go along with you, and there is nothing you can do about that.  I do not recommend that you threaten your doc; he is not required to prescribe what you want him to.  And frankly, it is always a bit dangerous for a doc to prescribe meds that he/she is not familiar with.

You asked if there was any ‘downside’; understand that you must not take Suboxone when you have opiate agonists in your system or else you will get VERY sick.  I took naltrexone once in a misguided attempt to get clean back in my using days;  I never want to be that sick again!  The other rules of Suboxone apply as well, the primary issue being to avoid taking benzos or other CNS depressants until you are tolerant to the Suboxone.   The other downside is that while you are on Suboxone, no other opiate agonists will work.  If you need emergency surgery you can be put to sleep OK but it can be difficult or impossible to get good pain control for a day or two afterward.  It takes AT LEAST several days to get the Suboxone out of your system.

I do not have references for use of buprenorphine for pain– I am actually out of town this week and don’t have access to everything I usually have access to.  The references are out there– as are references for use of buprenorphine for depression or other mood problems.  Understand that opiates are not ‘indicated’ for treatment of mood, and it is possible that a doc could get into trouble by using opiates for such an indication.  Given the issues of tolerance and addiction, I consider use of opiates as mood stabilizers or antidepressants to be extremely risky at best.  Yes, they do have the mood ’side effects’, but that is a completely different issue than using an opiate primarily for mood effects.  I would not be surprised if there were state laws against using opiates for such purposes.

You are accurate with the ‘tolerance’ comments.  Suboxone causes tolerance that will reduce efficacy for pain treatment, but so do all other opiates.

I have to run– good luck with your doc.  Let us know what happens.

SuboxDoc

http://suboxforum.com

http://wisconsinopiates.com

http://subox.info