Suboxone and other medications; Xanax?

Q/A with a person from suboxforum.com:

I have a question regarding suboxone and i cant figure out how to post comments so i figured i would email to see if i can get my questions answered that way.
1) I know that suboxone has some kind of ceiling effect to where if you take too much it is either pointless or does the opposite, Is this true?
2) I am prescribed to xanax and zoloft as well.Will my anxiety medicine or my depression medicine (xanax/zoloft) not work with me being on suboxone? Does it block out benzos like xanax and valium and soma? Or does it just block opiates?
3) My boyfriend is on suboxone as well but I worry that he is abusing it? Can he get high off taking more than his prescribed amount or is it absolutely impossible to get high off suboxone alone?

My Response:

Hi–

I encourage you to keep fiddling with the site, using the username and password below– you can change the password on the site if you like. That way you can participate in the discussions. But for now…

Yes, Suboxone has a ‘ceiling’ at a dose of about 4 mg, assuming it is being taken correctly (it has to be absorbed through the mouth; whatever is swallowed is destroyed and inactive). Above about 4 mg there is no more opiate effect; at very high doses (above 40 mg) it starts to ‘block itself’ and have even less effect, so a person can cause withdrawal by taking a real large amount.

The active ingredient in Suboxone is buprenorphine; buprenorphine selectively activates and blocks the mu opiate receptor and will not interfere with xanax or other benzos, and will not interact with soma. BUT… buprenorphine will cause respiratory depression in people who do not have a high opiate tolerance, at least until the person gets used to Suboxone (after a few days). Benzos also depress respiration and there have been deaths from the combination of Suboxone and benzos in people who are naive to one or both of the drugs. Also, Xanax and other benzos cause tolerance even faster than opiates do; the first-line treatment for anxiety is serotonin (an SSRI) and benzos are best avoided by people with addictions. Benzos will reduce anxiety, at least for a few weeks, but they are very addictive in their own way, and the withdrawal from them can be fatal. The early withdrawal consists of severe anxiety, which patients often misinterpret as their own ‘anxiety disorder’, for which they think they need more benzos… and the cycle continues. All of us opiate addicts are too focused on how we ‘feel’, and benzos only reinforce turning our attention inward, when what we really should be doing is trying to ignore how we feel and instead focus on things ‘outside’ of us. You can tell, I’m sure, that I don’t like benzos. But patients sure love their benzos– patients get more attached to their benzos than to any other med in my experience, and it is very hard to get a person to give them up.

As for your boyfriend, a person can get high off suboxone if he/she takes it only intermittently and never becomes tolerant to it. That would be very difficult for most addicts to do, as the person would have to take it and then come down, wait a few days, and take it again. Most opiate addicts would not be able to ‘come down’– they would just keep taking it. I cannot imagine how a person could get a high with regular use, as tolerance would prevent it. BUT… I have had Suboxone patients who (unfortunately) took oxycodone or another agonist while taking Suboxone; they had no effect from the agonist but they still could not stop taking it. It appears silly on the surface, taking something so expensive like oxy and getting no effect, yet not being able to stop. But opiate addiction is complex– it is more than just taking something because it feels good. In fact most addicts will admit that they have not had a ‘high’ in years, but they still have to keep using. Using ‘serves many masters’, and each person may have a different master. For example, a person who is actively using becomes completely absorbed in the drug– finding it, playing with it, using it, worrying about finding it again… Some people after starting Suboxone have a great deal of anxiety– the way I see it is that suddenly they don’t have the obsession with opiates occupying their minds, so they are free to worry about the other things in their lives. One reason for their use, then, is to reduce anxiety… and perhaps that is what is going on with the people I know who are on suboxone but are still using. By the way, I do not keep people in such a state– I may give the person who uses one more chance, maybe with a higher dose of Suboxone, but if he/she can’t stay clean (and after crossing that line, most do not stay clean) then methadone or residential treatment is their only hope.

I am going to answer your question ‘publicly’ but I will take away your e-mail info. Please continue to visit the site, and post when you get it figured out–

SuboxDoc
http://suboxforum.com
http://suboxonetalkzone.com

And again, check out this site about Warmal Globing!

About jjunig

Psychiatrist in solo practice with additional training and experience in pain treatment, anesthesia, and neurochemistry.
This entry was posted in addiction, buprenorphine, opiate, Uncategorized and tagged , , . Bookmark the permalink.

21 Responses to Suboxone and other medications; Xanax?

  1. AlexM says:

    I found your site on technorati and read a few of your other posts. Keep up the good work. I just added your RSS feed to my Google News Reader. Looking forward to reading more from you down the road!

  2. autumnraew says:

    I have been an opiate addict for about 5 years now. I started off on prescription pain pills like Vicodin, Percocet, Lorocet, etc.. Then when that wasn’t good enough, I moved onto Oxycontin. I have an extremely high tolerance to pain pills. Last summer I checked myself into a 7 day in-patient detox hospital, and they put me on Suboxone. Starting at 8mg/day and tapering down to 4mg/day. I stayed on the 4mg/day for quite awhile. I then tapered off the Suboxone by myself. It took me about 2 weeks to really start feeling ok. About 3 months after I was clean of everything, I relapsed on Heroin. I did Heroin for about 5 or so months. I was doing about 10 bags/day at $20/bag. When I realized I couldn’t go cold turkey off the Heroin, I reached out for help again. I went back to my Suboxone Dr. and he put me on 16mgs/day to start. I tapered down eventually to 4 mgs/day. I stayed on the 4 mgs for about 5 months and about 4 days ago, I came off of the Suboxone totally again. I tapered of course. Well, when I came off of the Suboxone, I just so happened to run out of my Xanax at the same time. So I was going through Opiate and Benzo withdrawal at the same time. It was pure hell. I thought I was going to lose my mind. I was going to go to the hospital, but thank God my Dr. wrote me a script for 150 0.5 Xanax’s with me taking up to 5 per day. The Xanax is really helping me a lot with the Suboxone withdrawal. But I know it’s just another Narcotic drug, and just another crutch. I seem to be in a vicious cycle here. Should I stay on the Xanax for the time being while I’m coming off the Suboxone? So far, I’ve been taking Xanax for about 4 months. And before when I was a very active drug user, I took benzos whenever I could get them. So I have an extremely high tolerance for them as well. Am I making this worse on myself by continuing to take the Xanax, or is it ok until my Suboxone withdrawal is all gone. I know I can’t come off the Suboxone cold turkey. I’ll have to taper for sure. Any feedback from anyone is greatly appreciated. Thank you.

  3. pill lover says:

    its hopeless, i have been on xanax and valium since highschool, im gonna be 40
    now im addicted to oxycodone too
    and i love my beer
    find a dr that takes cash
    keep looking you will find one
    theres no way out trust me
    besides death
    my 14 yr old is on her way , shes getting high off wip cream
    its just the way it is
    like with elvis

  4. jroche420 says:

    im 5 days into seboxone withdraw…day 3 was terrible….its now day 5, into the wee hours of day 6, and ive been up for almost 3 days , again, i took a couple zanax, didnt help, creepy crawly feelings in my back and arms…..its horrible!!

    • freudian55 says:

      I feel for you! I also have to say, though, that for my detox from opiate agonists I was in a locked psych ward for a week, no shoelaces so I couldn’t hang myself– not that it mattered, though, since I could barely walk the length of the 50-foot hall for the first 3 days (days 3-6 of my withdrawal, as I was in bed or on the toilet at home for the first two days). I wrapped my legs with my sheets to try to keep them from kicking…. I could never get a clonidine pill, because my systolic blood pressure would not go above 90, I was so dehydrated. My normal weight is 175 (I’m 6′ tall); my addiction and detox resulted in me weighing 138 at the end of detox– admittedly some of that weight loss occured in the month leading up to detox.

      I didn’t come close to sleeping– literally at all– for over a week. I went from detox to the treatment center, and spent the first week or two on the couch in the living area, as it was unbearable being awake and alone in my room all night long. Finally at about week 5 or 6 I started sleeping, and about the same time, the prozac started kicking in for my depression. My appetite was the last to return, and didn’t come back until just before I left treatment, at week 14. I now realize how horrible it is to eat when there is no appetite– truly an unpleasant experience that i never would have appreciated without going through it.

      They pushed us to excercise in treatment and I was able to do that without feeling exhausted at about the 8th week.

      My withdrawal was typical for withdrawal from opiate agonists. I suppose that if I went through w/d from buprenorphine now, 9 years later, it would feel like ‘the worst w/d I ever had’. But it wouldn’t be… I see people come off both agonists and buprenorphine every day, and there is no comparison between the two. But at some point, misery has its own ‘ceiling effect’. In other words, is it more painful to have two limbs torn off than one? Probably not.

      As I write that I feel humbled by the soldiers who literally go through that misery, after making all of the right choices– choices that I ignored so many times!

  5. Pingback: Suboxone Talk Zone: A Suboxone Blog

  6. Molly says:

    I was taking oxycontin and dilaudid and percs since about dec (now it’s sept) after 2 major back surgeries. The doc put me on Subuxone, but I was tired of having crap in my system, so I took it for about 3 weeks and stopped. Now I am having terrible withdrawal symptoms (this is day 4). Any guess how long this will last? It shouldnt be that long bc I wasn’t on it long, right?? Also, does taking a xanax help the symptoms? thanks

    • freudian55 says:

      Remember that you are not only withdrawing from the Suboxone– you are withdrawing from the oxycontin and dilaudid that you have taken for 9 months. If you had simply stopped those meds and NOT taken Suboxone, you would be sick for at least a month, and probably longer; going on Suboxone prevented you from having the withdrawal THEN, but you don’t get out of it completely– you still have to go through it, but over a longer period of time, in a milder fashion.

      Realize too that the vast majority of people who do what you are doing end up back on oxycontin and dilaudid very quickly. Opioid dependence is not cured by a few weeks of Suboxone! I bet that during the last 9 months, you tried to stop pain pills many times, but always started up again– why should this time be any different? I don’t mean to discourage you– only to help you realize that history will repeat itself UNLESS you make a major change in your thinking.

  7. Molly says:

    Thanks for responding. I honestly never tried to stop during those 9 months bc I was so afraid of what the back pain would be like without my meds! Looking back, I could have definitely dealt with the pain versus having to deal with how I feel now. I am literally STRUGGLING to care for my baby. And now we want to try for another baby…I just want all of this crap out of my system completely. So, I guess I’m really just trying to figure out how long this horribleness is going to last.

    • alicia says:

      yah i went through all that crap after i had my son back in march of 09 I have scoleosis n had a lota complications during and after my prgnancy i wne on suboxon for about 2-3 months then i went off it cuz i was tired of all the crap. it’ll take a good cpl weeks to get rid of the skin crawls nsickness but when u finally do then it’s great feeling just when u get off it all then attend aa meetings and stuff thats what helped me n i’ve been clean since january with opiates n been clean off subs since end of feb early march it’ll get beter though trust me i’ve only taken subs a cpl times from my old script cuz dentist put me on vics then i came off them jusst had 3 front teeth out but u’l be fine within a month or 2 it’ll b flushed out just make sure u reach ouyt to ppl

  8. Molly says:

    Oh and also if anyone has any input as to whether or not xanax can help with some of the w/d symptoms, I’d appreciate it.

  9. matt says:

    i was prescribed oxycontin at the early age of 15 for back and nerve pain. i am 29 now and have a 5 month old child. at 24 i cleaned up for a few years cold turkey thats when i met my wife and life looked a lil brighter. i then started a real stressful job and a buddy of mine would occasionally give me ultram. and they were getting me high as hell. i didnt even think ultram was addicting. from there i started taking fentynol,loretabs,methadone and about anything i could. so within the 14 past years only 2 and a half was spent in soberiety. i missed out on all sorts of life like graduating high school and even gettin g my drivers liscense. what a loser huh…. finally enough is enough 3 months ago i went to a sub doc and started to get treatment. all is well for now, but they seem to slowly quit working for me. i get real tired easy and wake up extremely drowsy. am i doing something wrong or is this way they work? i always have had pain and anxeity i also would like to know what could i do for that without getting completely back on? oh and i never spoke about any of this to almost anyone…….

  10. maria says:

    My husband is addicted to pain killers bad he can take at the least ten perks at a time he is wanting to stop because of the withdraws he has started buying suboxone off the street he liked how they helped him with the withdraws from the pain killers so we made him an app with a suboxone doctor but now after finding this site and seeing how hard it is to come off suboxone and all the horrible wihdraws form them i was wondering if you all could let me know out of your experience of withdraws from pain killers and suboxone which is worse. He has only been on suboxone for 2 weeks 8 mg a day should he stop so he dont get addicted to those and have the crazy withdraws and just cope the best he can with the pain killer withdraws is there anything other than suboxone to help? I dont want to have to see him go through the with draws of suboxone it kills me enough seeing him withdraw from the pain killers. PLEASE I NEED ALL THE ADVICE I CAN GET!!! You can email me at purdygirl0@gmail.com or just comment back on this site thankyou

  11. so42020 says:

    delete the above message, this dragon speaking software is crap!

    ce of bupe is 4mg?
    you are wrong… 24m 3 8/2mg′s (strips or tabs) is the highest absorbable does. NOT 4!
    i been doing thsi dance with bupe/benzo’s for a decade. 4mg and it stops working?
    then why do i start my really sick addicted kids on 3 8/2mg t.i.d prn to start then taper over a year or two?
    doc townsend

    • freudian55 says:

      I have NO idea why you treat ‘really sick addicted kids’ on 24 mg of Suboxone, then taper– obviously you don’t read the literature. You don’t even appear to receive the ‘best practice’ guidelines that are regularly released by ASAM and the DEA, that point out that ALL mu receptors are occupied at 12 mg doses. The same guidelines have a nice little graphic for docs who don’t have the time to read– showing a green light for doses UP TO 16 MG, and a yellow for anything higher– stating that doses higher than 16 mg are almost NEVER indicated.

      Why do you do what you do? I have no idea– but I suggest you learn a little more about the standard of care!

  12. Gina k says:

    I am furious I took suboxone for four months before I found out it was addictive I weened down to two milligrams and then could not afford more I’m on day seven and this is a nitemare I can’t take much more when will it end someone please help me

    • freudian55 says:

      You will find help at suboxforum.com . Understand, though, that despite what some people write, withdrawal from buprenorphine is far less severe than coming off opioid agonists. For opioid agonists, people generally start to feel back to normal at 2-3 months; for Suboxone the length of time is similar, but the intensity of symptoms is less. Specifically, people coming off buprenorphine are able to type at a computer and write about how horrible they feel; people coming off oxycodone or heroin are laying in a corner, shaking, and running to the john every few minutes— all night long, night after night.

      I never have sympathy for people angry about the ‘addictiveness’ of Suboxone; if you started Suboxone you obviously couldn’t stop taking pain pills- and you probably tried a number of times without success. You are addicted to OPIOIDS— not to Suboxone. The buprenorphine in Suboxone at least offers a chance at stopping– whereas there is virtually no chance with opioid agonists without hospital detox.

      Check the forum though– you might find some help. Realize, though, that most people there are grateful to be out of the madness of addiction to pain pills— and realize the benefit of taking responsibility for their situation.

  13. Ed The Repair Man says:

    Actually, the ceiling effect is 4 – 8mg/2mg which would be 32mg. This is what I am currently prescribed for chronic pain. I had been on Vicodin and Oxycodone for years, but I was tired of popping all these pills, so I tried this as another option. The 4 films a day with 4 – 2mg Xanax a day and 1 – 10mg ambien to sleep, my pain is tolerable. I am 26 and was injured in an overturned truck accident at 18, 180’ed and flipped at 90mph, and have had other accidents and injuries since. But I am one of those rare cases that takes Suboxone strictly for pain, and it does help. I like the ceiling effect, that way I can’t over take the meds, and some days I only take 2 or 3.

    • freudian55 says:

      The ceiling occurs at a much, much lower dose. The whole mechanism of buprenorphine relies on the ceiling effect; if the blood level is above that ‘ceiling’, then any changes in blood level do not change opioid effect– meaning changes do not result in cravings. I have many patients who take 4 mg per day and are clearly above the ceiling dose. The reason that people get stuck at 4 mg, when tapering, is because THAT is where they start to fall below the ceiling level.

      The ceiling effect is, of course, dependent on dosing efficiency; I suppose if a person was swallowing the tabs instead of working on trans-mucosal absorption, it would take more tabs— since only a fraction of a tab would be absorbed. But typical dosing results in 27-30% absorption, and for most people, 4 mg is plenty to get to the ceiling level. Buprenorphine is an extremely potent opioid, and is dosed in micrograms for other indications (like pain); 4 mg is 4000 micrograms, whereas a typical pain dose is 50-100 micrograms.

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