Hope to see you there!

JJ

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.

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 .

SD

Educational Audiotapes: Opiate Dependence Treatment Options

SD

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!

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

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

The message:

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.

My reply:

First, understand that many of us have been where you are; there are several ‘solutions’ that range from temporary fixes (not a great term in this setting!) to life changes that have the potential to help you find a much better life.  I want to point out a couple things for you and for other readers before getting into treatment issues.

You have been using for ‘about five years’.  There is an opiate addict ‘inside’ of you; your use has been fueled by a combination of genetics, psychodynamic personality factors, conditioning, fear of withdrawal…  what makes you think that Suboxone will make any of these things go away?  You go on Suboxone– it treats your cravings and prevents withdrawal, and things stabilize… but when you go off if it you are right back to where you started.  Nothing has changed, and in such cases opiate use always returns.  Why wouldn’t it?

I think that the way you have used Suboxone (perhaps the fault lies in your doctor) invites disaster;  We know that people who take a break from using and then return often pick up at a higher level of use– such as going from oxy to heroin, or going from snorting to needles. Subxone does nothing by itself to ‘fix’ the underlying factors that result in addiction.  So my first suggestion is to get back on Suboxone and stay there until significant changes have occurred in your life– including getting off the Xanax. You have things backward in stopping the Suboxone and then stopping Xanax;  you should stay on Suboxone until the other things are changed– which may not happen for a long, long time.

Xanax has been addressed in other notes.  It is a bad med for many reasons (as are all of the benzos); the tolerance results in ever-increasing dosages; the withdrawal consists of severe anxiety, which patients mistake for an anxiety disorder;  it is very hard to get off of; benzos interfere with cognition in people who often have ADD; benzos ‘fire up’ the addictive pathways in the brain, and finally, opiate addicts tend to focus too much on how their bodies ‘feel’, and it is important that they learn to direct their attention ‘outward’… but benzos reinforce paying attention to physical feelings.  People on benzos long-term tend to get worse and worse, as they become more and more tolerant to benzos:  after each dosing cycle the anxiety returns, fueled by benzo withdrawal… the anxiety becomes more and more the center of their attention… benzos cause their sleep to fall apart… and eventually you have a big mess.

I do recommend getting off benzos, but benzo withdrawal can be fatal– so consider getting assistance from your doc.  It is often easier to go on a longer-acting benzo like clonazepam and then taper that down.

The doc that gave you 150 Xanax tablets is a fool.  You wrote that you were greatful, but that is the type of practice that kills people– either quickly or slowly.

Suboxone will keep things stable and treat addiction just as medications treat hypertension.  Addiction and hypertension are both chronic disorders;  they both respond to medication, and many times they both can be treated by other things.  For hypertension we recommend diet changes and exercise.  For addiction the only proven treatment is ‘step-based’.  In our modern culture people like the quick solutions that come in pill form; for both hypertension and addiction the best answers lie in taking the longer path.  I have mentioned AA and NA before;  I strongly encourage you to look into them.  If you can ‘get it’ through meetings– find the ability to let go and change– then you can think about stopping Suboxone.

The alternative is to stay off Suboxone and get to a meeting TODAY… I recommend getting to one soon, before another relapse, as each relapse tends to be a bit worse.

In a rush today– maybe more later…

whats up man, i have been taking sub’s 4 about 6 months now….the reson that i have been on thim for so long is cuz i was really off bad when i was useing…it was like 3-4 o.c. 80s a day …so my doc told me i really need to stay on the sub’s for like a year or so ,and i really love being off the shit … but….i really need xanax not to get fucked up. just to calm me down (idc if u know what i’m talking about but i fill on edge all the time ,and cant sleep) i was going to ask my doc. for mybe like a 1mg dose 2 times a day. but i’m shour u know how docters fill about mixing thim ..but its not like that wit me “i mean shit i know people that get 2mg bars and o.c. 40s” its B.S. enyways…..what do you think i sould say to him to get the xanax? cuz i really need it~

OK man– I dont spose U R bein str8 wit me… but… no, U R thru wit the Xanax.  Done.  (sorry– I have to go back to my boring talking).  It is time to ‘live life on life’s terms’–  If U keep doing xanax you will only end up where you started, back with the oxys.  The danger is in mixing them, although that can be dangerous if you aren’t used to at least one of them… but the real danger is in continuing to think that a substance is needed to deal with life.  I ask you (and others), if your grandmother and grandfather could face life without Xanax, why can’t you?  If all the straight people you see getting up every day, going to work, busting their butts to pay the bills… if they can do it without xanax you can to. 

And yes, by the way, I have been there too.  I remember detoxing in a locked psych ward, no shoelaces (so I wouldn’t hang myself), legs kicking every which-way uncontrollably, puking, running to the bathroom with diarrhea…   after a couple weeks I had lost 20 lbs and was so weak I could hardly walk, but I still couldn’t sleep at all.  That was the worst part– being awake all night long while the rest of the house was asleep– my career gone, my family gone, depressed, sick, lonely, ashamed…  I remember looking at the clock after what seemed like hours, and seeing that 10 minutes had passed.  Yuck.  I remember my first NA meeting and how self-righteous I felt– all just cover for my shame.  But I also remember about six months later, when I finally had a good night’s sleep– I remember going outside, the sun hitting my face, and thinking about how my body was free of all that crap. 

I am not a bit ’12-stepper’ but for someone having a hard time with a bunch of feelings there is nothing better, and like they say– ‘it works if you work it’.  Skip the Xanax and instead check out a meeting.

Good luck man–

SD

The active ingredient in both Suboxone and Subutex is buprenorphine.  Buprenorphine is a ‘partial agonist’ that has a self-limiting effect on opiate receptors.  There is a common misperception that the naloxone in Suboxone is responsible for the ceiling effect or for precipitating withdrawal during inductions;  neither is true.  The naloxone is in there supposedly to prevent injection of dissolved Suboxone, as the naloxone is inactive orally (for the most part) but is active if injected.  I say ‘for the most part’ because there are some situations where the naloxone may make a difference.  I don’t have any data to support what I am about to say– and I don’t know if any data exists.  But I think that my ideas are sound, using some basic knowledge of how the body works.  Some background:  Naloxone is not absorbed well through mucous membranes and buprenorphine IS absorbed well; the naloxone therefore is swallowed, and some is absorbed by the small intestine.  From there it enters the portal vein and goes to the liver.  Some medications are efficiently destroyed by the liver; this is called ‘first pass metabolism’.

Times when I change patients to Subutex: 

-During pregnancy.  Even though little naloxone gets into the circulation, and even less crosses the placenta, and even less survives going through the fetal liver, there is a general principle to expose the fetus to as few drugs as possible.  Suboxone has two, Subutex has one, so Subutex wins.

-After gastric bypass.  In some gastric bypass procedures the distal small intestine is pulled up and attached to the stomach;  I would assume in such cases that the naloxone would then pass from the stomach to the ileum instead of the duodenum, and it would get absorbed by capillaries that do not empty into the portal system.  The result would be that the naloxone would bypass the liver and bypass ‘first pass metabolism’, potentially causing a touch of withdrawal.  So I give the patient Subutex.

-Some people get headaches after taking Suboxone and not after taking Subutex.  Are the headaches from the naloxone?  I don’t know.  Subutex costs considerably more, and some insurers therefore will not cover it… so it may depend on how bad the headaches are as far as making the switch.

-Same thing for the taste– Subutex supposedly doesn’t have the ‘fruity’ flavoring, and some people like it better.  It costs 50% more– is it 50% better tasting? 

Keeping it short tonight… Son back from college and so I want to talk to him a bit.  Hey– I have a radio show about psychiatry… if you want to check it out you can click on it from the Fond du Lac Psychiatry web site.  Thanks for checking it out.

Fond du Lac Psychiatry

hi doc,

i am a 35 year old man with a very active career and full life with 10 years recovery from alcoholism.

i struggled with ongoing pain issues including migraines since age 10 and a diagnosis of fibromyalgia.

i have AA sponsees, a very good spiritual life, and in general love my life, with the exception for being knocked down hard from three day headaches. i eat very well, am in great shape physically and otherwise have a good mental outlook. i see an acupuncturist regularly as well as a massage therapist bi-weekly.

in any case, i found myself abusing my pain medication last year and am now on 16 mg suboxone 2x a day. i had a knock down drag out month emotionally and then another injury that put me over the edge. i had strong narcotics at my displosal and then began abusing them to numb myself from physical and emotional pain. fortunately i came clean to my friends and family after only one month of abuse and decided to do treatment. i have way too much to lose in my life.

for the most part, suboxone has been incredibly helpful. i am in an out-patient program and am on half time disability. this past week i was hit with one of my monster migraines, completely debilitated and wanting to put my head through the wall, except that i couldn’t move because of the nerve pain in my face from inflammation.

my addiction doc and my pain doc both said to go to the ER, where it would be ok to use the dilaudid shot that always works for me. i had already taken torodol at home, which was doing nothing.

my question is this, can i intermittantly treat these monsters with narcotics and remain on suboxone?

suboxone has actually been very very helpful for the muscle pain and daily headaches. i feel truly stuck. the pain issues are real, no matter how much mind of matter, prayer and juggling other medications that i have done for the past ten years, i get one of these 72 hour monsters anywhere from no times in a month to once a week. it depends on what is going on in the air with the weather and pollen.

any thoughts?

i have friends who can hold medication for me, i just hate the ER ordeal as it is a waste of time for me and the physicians who probably would rather be treating more critical patients (even though the pain in my head has me wanting to die)

thanks so much,

XXXXX

Answer:

Hi XXXX,

Ouch! The combination of chronic pain and opiate dependence puts a person in a tough spot, as you have learned all too well. There is no great solution, and unfortunately you will quickly find that doctors are uncomfortable when they are at a loss, and they take that discomfort out in ways that sometimes makes patients feel as if they are doing something wrong. So my first comment would be that if you start to feel a bit paranoid and misunderstood, the reason is because your doctors won’t want to really understand what is going on– instead they will try to ‘pigeon-hole’ you into certain categories, particularly into the ‘addict’ category. If you get angry about that, it will only reinforce that opinion. So try to understand ‘how things are’, and do your best to work with the medical system with all of its flaws.

My best answer will probably leave you unsatisfied– but opiates are just a dead end for chronic pain. There are many reasons that I have come to that conclusion over the years… tolerance always takes away the vast majority of the analgesia from opiates; addiction always becomes a problem eventually (despite the oft-heard statement that people taking opiates for real pain will not become addicted); and the emotional and physical withdrawal from opiates makes life a constant struggle. There are other reasons that are just as important but more difficult to understand and accept; when pain patients are using opiates, their pain complaints eventually become very intertwined with psychological factors that are not really pure addiction, but that have addictive components. For example, a patient who is trying to avoid opiates will start thinking about how ‘maybe the pain is so bad that an opiate is justified’… that idea will grow like a weed until the patient is convinced that the opiate is absolutely necessary. I have watched that ‘weed’ grow in people over and over, sometimes over a week, other times over an afternoon– I will get a series of e-mails where one can see it clearly, and watch as it grows– watch as the patient loses more and more insight and perspective, until they have entirely lost sight of the original position they were in. I have considered that perhaps the pain is increasing and that is what causes the insight to disappear, but after enough times I know that there is a different reason– that the ‘addict inside’ gets a foothold and takes over, actually changing the person’s personality. It is a scary and fascinating thing for an intelligent person to be susceptible to something akin to a ‘split personality’… and the only way to avoid it completely is to avoid opiates completely.

But… you probably already know that, and have decided that there is just no way to make it without opiates. I don’t know if that is completely valid because of your degree of pain, or if the ‘addict inside’ is doing the talking. So I will just appeal to the ‘true you’ to really give it some thought– in light of the fact that active opiate addiction will eventually rob a person of everything he/she holds dear. I do think that a person on a sufficient dose of Suboxone, by having the cravings suppressed, is more likely to be ‘running the show’ as far as the ‘split personality’ thing goes… but not in all cases. I also admit that in spite of tolerance some chronic pain patients seem to get a long-term benefit from a small, constant level of a potent opiate. I have no idea why that is the case.

You are talking about something a bit different in that intermittent dosing would avoid some of the tolerance, although just being on Suboxone is going to keep your tolerance constant at a raised level. If you wanted to get pain relief from an opiate it would take a significant dose, even if you waited for the suboxone to leave your system (and that takes a long time). To be more specific, I sometimes need to provide pain relief for a Suboxone patient who is having surgery (I have had three patients deliver babies over the past three months– two by C-section. The moms and babies are fine, by the way). If a person took 8 mg of Suboxone in the morning (I usually maintain people on 16 mg once per day) it is very, very difficult to relieve postoperative pain– it requires going to an ICU and taking 20-50 mg of morphine every 2-3 hours. Stopping Suboxone for three days helps a bit, but still results in the need of large doses of opiates to relieve pain– I have prescribed oxycodone, 30 mg every 4-6 hours with some success at that point. So to answer your question from a practical standpoint, it is a very difficult thing to do– to use opiates for intermittent analgesia while on Suboxone. You mentioned that the headaches can last 72 hours– I suppose in those cases you could stop taking Suboxone and start taking oxycodone at doses of 30 mg or so… and after a day or two they may start working. Not a good solution.

People do not generally get sick from being on Suboxone and adding an opiate agonist. They precipitated withdrawal occurs in the other direction– when a person on opiates goes back to Suboxone. A person with an intermittent need for opiate agonists is not a great candidate for Suboxone– although the key word is ‘need’. Given the destructive power of opiates, how genuine is the ‘need’? Only you can answer that question. I do not want to imply that you are ‘faking’ anything– I have no idea what your pain feels like. But if there is any way for you to tolerate it using relaxation, etc, that is called for here. Finally, a Suboxone patient who may need opiates should probably be on a lower maintenance dose. Suboxone relieves withdrawal at very low doses– down as low as 2 mg per day. Higher doses are usually required to stop cravings. But finding a compromise of 4-8 mg per day may help to get some relief from opiates on rare occasions.

I re-read your message and note that you say you take 16 mg Suboxone per day times 2? If that is right, that is quite a high dose– about double what is used on average and above ‘indicated’ dose.  I recommend talking to your doc about at least getting down to 16 mg, and maybe lower, as there will be no hope for opiates to act with that much blockade going on.  You may even be getting headaches from the high amount of naloxone in such a big dose of Suboxone;  Buprenorphine itself can even have an antagonist effect of its own at high doses.  In my experience, patients get little out of doses above 16 mg (presuming they are taking it correctly).  Patients can, however, get into a misguided dosing schedule where they think they need to dose more than once per day–  in those cases the symptoms they feel late in the day (sweats, etc) are ALWAYS a product of the mind, and not true withdrawal.  One can easily prove that to one’s self because if the person doesn’t happen to have Suboxone to treat the ‘symptoms’, or the person gets distracted, the symptoms are gone 15 minutes later– not the case with real withdrawal.  This is a tangent, but I strongly encourage patients to dose ONCE per day, in the morning.  Use discipline in regard to those late-day feelings, ignore them, and they will go away completely in a few days.  If you feed them by dosing, THEY WILL GROW.

A couple random thoughts…

Some patients with chronic pain will claim that taking an opiate relieves their pain, even while they are on Suboxone. I don’t have an explanation for why that happens– I tend to ascribe it all to a placebo effect that is perhaps ‘jazzed up’ a bit by addiction. But when I discuss it with the affected patients they do not buy a placebo effect– they insist that it is ‘genuine’ pain relief. The thing is… the placebo effect is just as ‘genuine’– patients getting pain relief have the same subjective drop in pain sensation as do patients getting ‘real’ pain relief.

Opiates often cause headaches, and some patients get in a cycle of post-analgesic headaches causing the person to take more opiates, etc…

Some people find that tramadol (Ultram) is helpful. Don’t confuse it with toradol– which is an NSAID– tramadol has several actions including increasing central serotonin and also activating non-mu opiate receptors (which are not blocked by buprenorphine). Two side effects are important– tramadol can cause seizures, and the combination of tramadol and antidepressants can cause ‘serotonin syndrome’, which I will let people look up.

Many times people confuse migraines with sinus headaches– which are treatable using local application of a strong decongestant and a med to break up mucous like guaifenesin. I mention this because of your mention of ‘pollen’ and other ‘air things’. If you are having visual scotomata then you are likely indeed having migraines. Have you tried all of the suppressive therapy– including the newer one, Topiramate (Topomax)? Have you tried the different abortive treatments for migraine? I hate ERs also, and would do anything to avoid them… but if you are there, ask if they have anything else that they use in such situations– I have heard of ERs using nitrous oxide, oxygen, IV toradol…

You mentioned ‘nerve inflammation’ in your face- I wasn’t sure if you were referring to the migraines or to something else. For ‘neuropathic’ pain, anticonvulsants sometimes help (like Neurontin, carbemazepine, etc).

I know I am grasping at straws here, and I wish there were better options.

Take care,

JJ

Regarding Suboxone, I am curious about the experiences out there.  What has your doc told you to do?  What do you plan to do?  In your part of the world is buprenorphine used for short-term, for long-term, or do you have a choice in the matter?

I invite people to reply to the poll, and to post if you have other thoughts on the topic– or about any other topic related to opiates or Suboxone.  You must register, but feel free to use an alias, and of course it is free.

Thanks– I will be in touch with the results!

JJ

http://suboxforum.com

http://suboxonetalkzone.com

http://wisconsinopiates.com

http://dsm-v.com

Comment:  Yes, methadone is a ‘pure’ agonist, but to claim no difference between it and morphine and other short acting agonists is really naive. The sole reason methadone is used is because of it’s different pharmacological profile. You claim that tolerance is as much an issue with methadone as with morphine/heroin, how is it then that patients stay on the same dose for decades?

Response:  There are several reasons that methadone is used for maintenance, not one sole reason.  First, it is easy to manufacture and so is dirt cheap.  Methadone clinics typically mark it up to $10-$15 per day, but when prescribed for pain treatment it is pennies per dose.  It does have some unique properties, and yes, those unique properties make it a good maintenance drug; for example it binds extensively to proteins and so has a long half-life when used for long-term maintenance treatment of addiction.  Interestingly though, when used for pain treatment it has a shorter ‘effective half-life’ and generally must be given every six hours or so.  In other words the half-life of the drug changes with chronic administration.  This somewhat unique property is one reason that SOME patients can be maintained on a stable dose for long periods of time.  A short exercise will help to understand this point:  Google ‘opiate conversion calculator’ and use it to find the dose of oxycodone that is equi-potent to 40 mg of methadone.  A good conversion program will ask you to differentiate between acute and chronic methadone.  You will see that with chronic use, methadone becomes more potent by a factor of 10 or more.  I see this as the main reason for the APPEARANCE of stability of dose with methadone maintenance.  Yes, some patients stay on the same dose for years.  But that same dose changes potency over time in ways unique to methadone, so that the patient is actually getting a constantly-increasing opiate potency at the receptor level—even as the oral dosage stays the same.   This does not occur with other agonists, and certainly does not occur with buprenorphine. 

Comment:  To claim that a methadone patient is still an active, using addict but someone on Suboxone is in recovery, that’s the biggest load of BS that I’ve seen in a long time. Sure, buprenorphine is only a partial agonist, but there’s still stimulation of opiate receptors going on. People without tolerance get just as high on buprenorphine as they do methadone, and tolerant users don’t get high with neither buprenorphine nor methadone.

Response:  People without tolerance are not the issue here, but for the record you are wrong—patients cannot get ‘just as high’ on buprenorphine as with methadone.  As an anesthesiologist I used buprenorphine for just that reason—for example, on the labor floor buprenorphine is a safer narcotic because medications given to the mother can cross the placenta and accumulate in the fetus, causing respiratory depression (and arrest) after the birth—a partial agonist like buprenorphine has a maximum effect that preserves respiration, at least as long as no other CNS depressants are present. Similarly a patient without tolerance will not be able to kill himself using only buprenorphine, as the effect will ‘max out’.  With methadone, on the other hand, it is quite easy to OD and die, simply from taking a few too many tablets.  In fact, a teenager experimenting with methadone for the first time can die from just two or three 10 mg tablets. 

As far as whether methadone users are ‘in recovery’ or are in ‘active addiction’, that is a matter of opinion.  I see a clear difference between taking methadone, a drug that causes progressive tolerance, and buprenorphine, a drug which allows tolerance to remain static.  The ‘shift of tolerance’ is at the heart of addiction—as it shifts upward the addict is high, and as it shifts downward the addict is in withdrawal.  Buprenorphine allows tolerance to increase to a level that eliminates the high, sedation, and other drug effects, but then the tolerance becomes fixed.  And for reasons not understood, doses higher than the ‘ceiling dose’ eliminate subjective cravings.  For people who consider being on methadone to be ‘in recovery’ I would just ask… why?  What is the difference between being on methadone and being on oxycodone, other than the dosing frequency?  I didn’t intend to take on the entire methadone system, but there are some very intrusive methadone ‘advocates’ out there—they pop into buprenorphine forums and spout opinions, using pseudo-scientific arguments and misquoting articles, causing nothing but confusion and ill will.  I suggest they get a blog of their own—maybe then they would feel less need to flame others.

Comment:  Having been on both substances myself, I can testify that the only difference I find between the two is that methadone has (for me) the ability to take away my cravings completely whereas buprenorphine didn’t quite do so.

Response:  Medication is only part of any recovery program.  In my opinion 16 mg of buprenorphine suppresses cravings sufficiently to allow any patient to remain clean.  Until a few years ago every single opiate addict in recovery (and not on methadone) was doing it without the help of a medication.  The real situation is that a person who uses from ‘cravings while on Suboxone’ is not ready to quit, and (sorry) in my opinion is looking for an excuse to use.  Nothing is perfect in life—people with opiate addiction must realize they have a fatal illness, for Pete’s sake!!  Cancer patients have to put up with the pain of surgery, severe nausea, hair loss, severe fatigue…  if an addict whines over a few ‘cravings’, I suggest they get real and take a good look at where they are at in life, and start being grateful for being alive. 

In my prison work I frequently come across patients who are intent on fine-tuning their subjective experience using every med they can get.  They think that medication should make them happy, relaxed, content, and filled with self esteem… but in reality medication will do none of those things.  Their expectations are completely out of line.  I get the same impression from patients who always need a bit more of this or that for cravings.  The whole process of that type of ‘treatment’—the focus on symptoms, the need to medicate one’s self, the self-centered demand to feel perfect–  is more consistent with addiction than with recovery!

Comment:  I got annoyed when you’ve written stuff that is twisting the truth, if not lying, about the treatment that has quite literally saved my life. And calling methadone patients active, using addicts (also something many many doctors would disagree with you on).

Response:  There are the ‘many doctors’ again… but seriously, if it works for you, that’s great.

Comment:  Why can’t you accept that our treatments are very similar to each other? I know that you in the US can perceive them to be oh so different, since one can be prescribed in an office-setting and the other can’t. I can see that it can lead to a them-and-us-thing, where suboxone can appear “better” or “more refined” or “less dirty” or whatever.

Response:  The treatments have similarities and differences.  I don’t think one is ‘less dirty’ or ‘more refined’.  But the molecular actions of the drugs differ from each other, and so the subjective effects differ.  Sorry—that is just a fact.

Comment:  I live in Sweden and here we don’t have ‘clinics’ per se, here both buprenorphine and methadone is prescribed in the hospital, and we have to go there to get our meds daily, for the first 6 months and then we get take homes at certain intervals (if we’re clean that is).

Response:  That stinks. You are missing out on one of the biggest advantages of Suboxone. 

Comment:  Here buprenorphine and methadone alike is looked upon with judgment by many many people, since the treatments are so misunderstood. Here buprenorphine (and methadone) patients are called addicts by people who don’t know better.

Response:  They ARE addicts– myself included– And will always be addicts.  Opiate addiction is not ‘curable’—it can only be managed.  I am an addict.  But I am not ashamed of that—although I am ashamed of some of my actions during active addiction.  It bothers me that the whole concept of ‘recovery’ is absent from methadone programs.  A methadone ‘advocate’ made silly remarks a few days ago that showed a complete absence of knowledge of 12 step groups— something that has been an incredible movement throughout the entire world, for almost 100 years! 

Comment:   You seem to have a little of the mentality that if I can do it, so can you. And I find that a bit strange since then you could easily have become sober without medication at all, since other people have been able to do so. Do you see what I mean? I’m just saying that while suboxone works for a lot of people, it doesn’t work for all, and it’s just naive to think so.

Response:  You know what?  A common thing said at NA meetings is that ‘if I can do it, so can you’.   Yes, I do have ‘that mentality’ as you put it… and I don’t get your objection to that mentality.  I don’t understand the rest of that paragraph either—I think we come from totally different perspectives.  I believe that EVERYBODY is capable of getting clean without the use of medication.  Unfortunately, many addicts will not choose to give up their addictions until they have lost everything.  I had to lose a career and a great deal of money before I ‘got it’.  I didn’t ‘get it’ with Suboxone; I went away to residential treatment for over three months.  I didn’t want to do that, but my back was against the wall and finally there was no other place to hide.  Suboxone was not available at that time—at least not in my area, and I had never heard of it (this was in 2001).  I had the ‘typical miracle’ of AA, NA, etc… I realized I was powerless, and the urge to use went away.  It really is that simple.  Unfortunately, addicts will not usually recognize their powerlessness until they have lost everything—buprenorphine allows people to find some peace without having to go that far.  But I do worry that their ‘recovery’ does not run as ‘deep’—see my articles on the topic here:  http://subox.info/index_files/recovery.htm .

The issue isn’t over who is ‘better’; the issue is whether the recovery will last, and whether the person ends up having a rewarding life.  Opiate addiction is a horrible, fatal illness—I have lost friends and patients to it and so the bottom line is that any way that a person keeps clean is OK with me.  And so I usually present the options to the patient and let him/her decide which path they will take.  Yes I have opinions about methadone—just as others have opinions about Suboxone.  From my perspective, it seems that there are ‘methadone people’ who can’t tolerate the opinions of others.  And I wonder… is that a ‘recovery’ issue?  Part of recovery is learning to accept things we cannot change… like the opinions held by others.  Part of recovery is acceptance—the idea of ‘living life on life’s terms’— including the fact that people are going to disagree on some issues.  And part of recovery is learning to know one’s self, and to know that one is OK regardless of how other people think… like not getting all flustered if some stranger in another state– who doesn’t even know the person– holds the opinion that his choice of medication isn’t the best.  These parts of recovery are what make many people grateful for being an addict.  If things are as I suspect, and methadone maintenance patients are not taught how to find these things… that would be a shame.

Suboxforum.com

Subox.info

suboxonetalkzone.com

I have been taken xanax for over half my life. initially for anxiety and insomnia. then like most was unable to function or handle the withdraw and remained on it. later because of an injury i was introduced to oxycontin. i became addicted and could not step off. one because of “real back pain” the other because of the withdrawl. i would have to go to rehab and or miss work. which is impossible for me because i am the sole provider for my children and i. also my family is very uneducated with these things and have a “zero” tolerance and would be disowned for sure. i no longer want to take opiates but i do feel i need xanax. will taking suboxone while taking xanax be fatal. or is it possible to combine the 2 until i am opiate free?

My Answer:

Thank you for writing;  I feel for you, and have been there.  It sounds like you recognize where things stand, which is miles ahead of many patients on Xanax who misinterpret the withdrawal as their own ‘anxiety disorder’.  I would first suggest that you never give up the courage to get off of the Xanax.  While it is a difficult thing to do, most people will eventually have less anxiety, less insomnia, less fatigue, and less depression if they can get away from benzos.  You CANNOT simply stop the Xanax, as you probably know, as the withdrawal from that class of medication can be fatal, and includes seizures that can just occur suddenly out of nowhere… while you are driving down a highway for example.

I must be cautious to avoid giving medical advice that has the potential to be dangerous; anyone reading my posts MUST make any treatment decisions along with their own physician.  But for the sake of education, yes, people have died from the combination of Suboxone and Xanax (alprazolam) and other benzos (like lorazepam, diazepam, clonazepam, etc.).   But two points deserve mention.  First, the deaths occur from respiratory depression when opiates and benzos are combined– the respiratory depression is ‘multiplied’, not just added together.  The danger is primarily restricted to people who are not tolerant to the medications.  If a person is used to both medications, the risk of having trouble is not all that significant.  So in your case, I would start the Suboxone and if you feel ‘buzzed’ from it I would have you take only half of your Xanax dose until you are tolerant to the Suboxone.  You could probably resume your regular Xanax dose after a couple days.

The second point is that the danger from Suboxone is much less significant than the danger of combining a full opiate agonist (like methadone, oxycodone, or hydrocodone) with a benzo.  The antagonist action of buprenorphine provides a significant measure of safety that is not present with opiate agonists.

One final comment–  the best way to get off the Xanax is to change to a very long acting benzo– clonazepam is usually the best choice– and then go on a slow taper.  If a person is motivated to get clean, and if the taper is done very slowly (over a period of 6 months) the withdrawal is minimal and can be tolerated without the need for inpatient detox.

Take care,

SuboxDoc

Knowing the lethality of opiate addiction, I frequently say that while there are some side effects, at least I know that people on Suboxone are safe.  Yes, there are exceptions; but for the most part a person who is on Suboxone and tolerant to it is not going to die of an overdose.

Thank you for a different perspective:

I thoroughly enjoyed reading this article. You offer a view seldom heard from both a professional stand point as well as personal experience. As a medical professional myself and advocate against methadone use I work to bring awareness to the potential lethal qualities of this drug. I have have spent two years actively researching both sides of it’s use from the clinical setting to pain managment. My findings were alarming which is why it has become a passion to alert the public to it’s dangers. Currently Methadone is the #1 killer of a prescription narcotic and you do not have to abuse it to die. These deaths come from clinics, pain management and the diversion from both sources. Many have lost their life while under a doctors care and monitoring.
In a clinical setting this drug has not been proven over all to produce drug free patrons but acts as a wonderful replacement drug to feed the addictive cravings sought. Methadone is a monster leaving a trail of devastation in it’s path. It has proven to be a gold mine for those owning and operating these methadone clinics preaching the their sales pitches with false promises.
Suboxone in european countries is showing abuse and diverted use but is far more safer to ingest then methadone and hopefully most using the replacement form of what they call treatment will no longer use methadone for long term. These clinics are opening all across this country and this practice is out of control as well. Instead of looking to be free of drugs we are only proviiding addicts with a legally controlled substitution station.

Mothers Against Medical Abuse. Org
Help Stop Rx, Methadone Deaths and Abuse

But in this case I am referring to methadone for addiction ‘maintenance therapy’, and the ‘methadone advocates’ that wrote to complain that I had ‘dissed’ methadone.  In an earlier post I noted the mention of ‘countless experts’ who supported methadone use, and I asked, which experts? Their replies contained references that I will eventually list in case anyone wants to look them up and read them in their entirety—as I did. I have the benefit of access to the online library and search functions of a major medical school—every time I use it I think about working on my thesis in 1986, reading science citation index each morning, writing down references, and then going up and down the back stairs in the ‘stacks’ of the medical library as I searched for the articles, sometimes needing to dig through bins of unshelved books and journals to find the right one… I can now do something at home in 30 minutes that used to take 4 hours at the med center. These efficiencies from the internet hopefully partially make up for the hours wasted on the internet by society… leaving me with some hope for the future of the human race. But I digress…

It is important to look up entire articles and read them from beginning to end; many times a sentence will be quoted by someone to make a point, but taken out of context in a way that completely changes the meaning of the sentence. Sometimes comments will get handed down from article to article like that old ‘telephone operator’ game, where a comment is passed from person to person around a large circle. Again, comments are changed a bit in each ‘generation’ of article until a whole new comment is generated. I would encourage ‘Arm-me’ to do this exercise with the comments that he/she provided; or just read on… I will get to the articles after responding to the more personal comments.

There was an accusation of a ‘financial motive to prescribe bupe’— I have been at the 100-patient max and closed to new patients for months; I recently re-opened for a few more but unfortunately there is no shortage of supply of addicts in my part of the country (although apparently not enough addicts to keep the methadone clinics open, as several have closed). As for ‘researching methadone for the benefit of my patients’, I explained in ridiculous detail in a prior post how my life has ended up devoted to opiate addiction— as both an addict and as a doc treating addicts—and I know methadone pretty well.

As for the scientific articles, here is a portion of one comment, out of several comments made by the methadone advocates: Here is one of the more extensive reviews of 24 clinical studies re: methadone vs. buprenorphine. In fact when they first started prescribing suboxone they told patients on methadone if they didn’t do well on 60-80mg of methadone they “most likely” weren’t going to do well on Suboxone.

I don’t know who Arm-me is referring to by ‘they’. He provided this reference: Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. – Mattick RP – Cochrane Database Syst Rev – 01-JAN-2008(2): CD002207. This references a ‘meta-analysis’; a meta-analysis is done by taking a number of separate studies which often have no significant findings, and adding them all together in order to create something statistically ‘significant’. This type of study is sometimes useful to summarize the findings of other studies, but one has to look at the nature of the collected studies—24 in this case—before drawing conclusions. This meta-analysis, for example, includes studies that predate DATA 2000 (the Act of Congress that legalized the Suboxone program), before which bupe was available only as a chemical dissolved in a liquid— and the use of the drug was very dissimilar to modern use of Suboxone. In the meta-analysis the author referred to ‘low, moderate, and high-dose’ buprenorphine; the ‘low-dose’ studies are irrelevant to current practice, as we now know that it takes 8-16 mg of bupe to suppress cravings. I know I am starting to bore all of you… The other reference was: Am Fam Physician 2006;73:1573–8, 1580: Managing Opioid Addiction with Buprenorphine—it was not a study at all, but rather a review article that is filled with the ‘telephone operator game’ quotes I mentioned earlier. Arm-me listed quotes from this review article, which the review article itself copied from other articles, which had also copied them… I tracked them back and found that they originated from two articles: one in 1997 (before Suboxone was patented) and the other in 2001—which was another garbage meta-analysis. Bottom line—there is nothing in those references that shows that methadone is preferential to bupe in any circumstance—UNLESS you compare methadone to a subclinical dose of bupe, which is where the quotes came from. Yes, it is true that in 1997, methadone in high doses was better than 2 mg of bupe. But no kidding—that is why nobody who knows what they are doing limits bupe to 2 mg. Another of the quotes referred to a study that measured ‘success’ as staying in the study—at a time when Subox was not available and the dosing had to be done at the study center using a liquid form of buprenorphine. Talk about apples and oranges… there is a big difference between going to a med center and waiting to have bupe squirted in your mouth vs dosing with Suboxone at home.

There are some other things about the latter reference supplied by Arm-me-the-methadone-guy that make me wonder about the bias of the article.  The article has a table with a cost-comparison of methadone vs Suboxone; in the comparison the author lists the price of Suboxone as ‘$100 for a 15-day supply of 2 mg’, and methadone as ‘$30 for a 30 day supply not including counseling’.  Suboxone is sold by Wal-Mart for a little over $5 for 8 mg; at the full daily dosage of 16 mg the cost is $300/month.  Why does the author use a 2 mg dose (that nobody uses for maintenance), which implies a much higher cost per mg?  And then the methadone price of $30 for 30 days– how many people out there have a clinic that charges one dollar per day?  In Wisconsin the charge ranges from $10- $15/day!  Either the author is being deceptive, or he doesn’t understand how things are– either case making his opinion a bit suspect a best.

I have to wrap this up… but there were a couple more things written that worked me up a bit.  Arm-me took issue with my comments about AA and NA, suggesting that there is not data to support the efficacy of that approach— but there are plenty of studies supporting the 12-step approach and so I am not sure where such an impression came from. I’ll provide one of the most recent ones and he can use the references in it to track back to others: Witbrodt J. Bond J. Kaskutas LA. Weisner C. Jaeger G. Pating D. Moore C. Day hospital and residential addiction treatment: randomized and nonrandomized managed care clients. Journal of Consulting & Clinical Psychology. 75(6):947-59, 2007.

Ironically my exchange with Arm-me only reinforced my opinion of methadone programs. He ended his message with this bizarre comment in reference to AA and NA: ‘if you can show me studies that prove that utilizing these support groups make your chances of sobriety better than hoping for a spontaneous remission, than I will gladly add the research to my “bookmarks” on mdconsult’. This a comment from a person who presents himself as knowledgeable about addiction—and as a ‘methadone advocate’. In contrast, the training for docs who want to prescribe Suboxone recognizes, teaches, and requires an understanding that medication is only a small part of recovery.

I have seen so many miracles in those who ‘get it’— those who ‘cling to AA as a drowning man seizes a life preserver’ (or something like that—taken from an AA reading)— as have other fortunate people who have been forced to make the tough changes that AA and NA require. That Arm-me would call them ‘support groups’, and then compare their value to ‘hoping for spontaneous remission’, tells me that he knows nothing of ‘recovery’ at all. And now I understand the whole problem here—the source of the tension. In talking to a person on methadone, I am talking to an active, using addict. Maybe the need for dope is temporarily filled—maybe he has even learned to repress the cravings into the unconscious. But the addict BS and loss of insight is still there. But of course, why wouldn’t it still be there?

After all, methadone is just another opiate agonist.

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!

I don’t want to whip out resumes and see who’s is larger, but I do want to establish my credentials and experiences. The posts make many references to ‘experts in the field of addiction’, and as that is exactly what I am, I am not sure who they are referring to. I assume they refer to people like Dr. Michael Miller, President of ASAP, the American Society of Addiction Medicine– down the highway from the city where I live, in Madison Wisconsin. Or the medical researchers who did the work that led to the approval of Suboxone. I would think those people are ‘expert’ enough. I know the work and the stated opinions of those experts– I have personally met and spoken with some of them, and have read editorial opinions and research papers written by others. I can honestly say that I have read pretty much every major study about opiate addiction over the past 8 years– certainly all of the ones that were in the peer-reviewed literature.

As for my own credentials, I am a Board Certified Psychiatrist; I am on the faculty of a major medical school where I teach mainly about addiction and addiction treatment; I am a trained Suboxone Treatment Advocate—I have been to meetings with the people who did the original (and later) research in Suboxone; I have met many, many opiate addicts over the years in my own recovery activities, as Medical Director of a 50-bed residential treatment center, through my own work treating over 150 patients with Suboxone, and through my work in the state prison system where I treat women and men who are incarcerated. I have worked in a methadone clinic, and have spoken with the VP of Med Services of the large company that has purchased many of the methadone clinics across the country– one of their ‘people’ few out to take me to dinner, to recruit me for a regional position as medical director of several individual methadone clinics.

The comments refer to the molecular actions of methadone; I completed my PhD in neurochemistry in 1986 before I went to med school, and my thesis involved work with brain receptors– characterizing how they bind to their ligands, localizing specific receptors, etc. While my thesis was not on opiate receptors (rather it was on receptors for vasopressin), several of the other scientists in the Center for Brain Research down the hall from my lab were doing the early work with opiate receptors, substance P, and ‘second messenger systems’. It was an exciting time, as that was when our knowledge base really expanded in those areas. Anyway, I have a pretty good understanding of the molecular issues.

Whew. I won’t repeat all of the things that got them so angry, as you can go back to my original post. I will comment on a couple specific things though. First, whenever you come across someone who is so worked up, you have to ask yourself, Why? What fuels the anger? Sometimes a person has their own issue with the topic that they are trying to avoid thinking about– you may have heard the phrase ‘thou doth protest too much’ from some Shakespearien source, in reference to a person who is denying something in an exaggerated manner. Maybe a person has a financial interest at stake; or maybe the person is afraid of losing access to something he/she needs… I don’t know. Maybe since I have a blog they see me as an ‘authority figure’ and that riles them up. Although it is pretty easy to have a blog these days.

Similarly, I am always a bit suspicious about a person who talks about ‘the experts’ without naming specifics. Zenith mentions a study about IV heroin users doing better with methadone– If I get the reference I will look it up and check it out. I have helped many IV heroin addicts with suboxone without any problem at all, so I am curious. If I don’t write about it, it will be because I was never given the reference and couldn’t find it in my own lit search (which I will do after this post).

There is no debate over the molecular actions of buprenorphine and methadone– anyone can find a Merck manual and read for themselves. Methadone is an opiate agonist, just like oxycodone, hydrocodone, hydromorphone, fentanyl, sufentanil, alfentanil, meperidine, morphine sulfate… In all cases the primary effect is at the mu class of opiate receptors (some drugs activate other classes of opiate receptors, like ketamine for example). Buprenorphine is a partial agonist, which gives it unique properties compared to agonists. Tolerance is universal and unavoidable with agonists. There were trials of ‘morphidex’ a couple years ago that gave hope for a way to limit tolerance… but it didn’t work in humans.

Methadone potency increases linearly with dose; buprenorphine levels off and becomes flat (I have read reports of antagonist actions in high doses, actually causing a ‘bell-shaped’ curve). Methadone is just another agonist– as any opiate addict knows. Buprenorphine is different. That is why a person who is using can take methadone to avoid withdrawal or to get a ‘buzz’, but taking buprenorphine will cause withdrawal if the person hasn’t abstained long enough to reduce the activity of agonists at the receptor– the bupe will displace the heroin, methadone, or oxycodone and block the opiate receptor.

Some of the other stuff gets a bit off-topic… yes, I realize that nothing is for ‘everybody’. If a person fails buprenorphine, they may have to go to methadone– including making the drive each morning to the nearest clinic and standing in line for their dose, knowing that if they miss it, it will be a long, long day. Fear of having to do THAT helps keep people taking their Suboxone! I also mentioned the problems with Suboxone and the need for surgery or intermittent narcotic pain treatment.

As far as my comments about the evils of opiates… thanks for reminding me that molecules aren’t people! (is it unprofessional to say ‘duh!’?). I was an anesthesiologist for 10 years– I loved the power of being able to instantly remove pain, in surgery, on the OB floor…. and in myself! Every opiate addict will likely have the need for narcotics at some point in life– but those who have learned to stay clean know that those times are very dangerous, and that pain medication must be feared. Anybody who wants to go the route of total sobriety from all substances– including methadone and buprenorphine– must learn to fear opiates if they are to stay clean. That is ‘recovery 101′– also the ‘first step’ of a 12 step approach. Powerlessness. And since we addicts are powerless over opiates, and since opiates will always destroy every good thing about us during active addiction, we had better fear them. I will talk about the twelve step approach sometime– it is the only approach that has ever worked to maintain total sobriety, and has certainly stood the test of time. Other things have come and gone over the years (google ‘moderation management’ and Audrey Kishline) as people try to find an ‘easier softer way’, but there is none…

As for my hatred of opiates, I lost a career and much more to opiates, and I have known a number of people who are now dead from opiates. So pardon me, but we are talking about ADDICTION here. And in that context, I HATE opiates– I hate them for the friends that they have killed, and for what they have done to my life and to the lives of those who I care about. That is what works for me– I am not into ‘euphoric recall’– talking about the good old days– or even thinking that ‘y’know, opiates THEMSELVES aren’t all that bad’. I will use them if I ever absolutely need to, but I will do my best to hate them the entire time.

Too much writing for a Sunday. I haven’t even taken a shower yet! Methadone users: chill out!

http:///suboxonetalkzone.com
http://subox.info
http://suboxforum.com
http://wisconsinopiates.com

I am not aware of the idea that a person’s choice of suboxone vs methadone should be dictated by their tolerance level, and I certainly do not agree with that idea.  I also do not see any advantages of methadone over suboxone when it comes to maintenance treatment of addiction, except for cases where suboxone is problematic– say in people who have frequent surgeries or frequent need to go on and off pain medications.  This may be the case in a person with a relapsing physical illness that causes severe pain, such as severe migraine or cluster headaches, or sickle cell anemia.  Buprenorphine takes forever to leave the body, and until it is mostly gone it is difficult to acheive analgesia even with very high doses of narcotics.  Patients with sickle cell crisis usually require potent narcotic pain medication, and it would be horrible to have to wait for three, four, or even five days in severe pain, waiting for the buprenorphine to dissociate from the receptors and get out of the way of the morphine, oxycodone, or fentanyl.

Methadone is just another opiate agonist.  Agonists are molecules that have a dose-related effect at the receptor, whereas antagonists block receptors without activating them (the classic opiate antagonists are naloxone and naltrexone).  Buprenorphine, the active drug in Suboxone, is a ‘partial agonist’, ‘mixed agonist’, or ‘agonist/antagonist’– it has both a blocking effect and an activating effect.  The dose/response curve for agonists would be a diagonal straight line going upward to the right; for a partial agonist like buprenorphine the graph is similar in low doses, but at about 4 mg or so the line comes off of the diagonal to flatten out– the ‘ceiling effect’. 

I do not see methadone as being better at filling that ‘hole’ that we were talking about (the ‘hole’ was in reference to the chronic empty feeling that many opiate addicts talk about having– sometimes for their entire life, even before opiate use).  Methadone has the same problem that all agonists have– tolerance.  At first, methadone will provide a euphoria… but then tolerance rises and the effect goes away, unless the dose is increased.  And that is how it goes… no matter how high the methadone goes, tolerance will ALWAYS catch up eventually.  That is why there is just no ‘future’ in opiate agonists– no future in using them for chronic pain, and no future in using them to fix ‘emptiness’.  In ALL cases, tolerance will take away any positive effect.  That is why people end up on ridiculously high doses of methadone or oxy if they use long enough.

Bupe is different.  The tolerance is ‘static’– it does not keep changing.  There is an initial change of tolerance– depending on the patient’s tolerance, the suboxone will pull the tolerance down, or push it up, so that it is set at about equal to the tolerance caused by 30 mg of methadone per day.  But once there, the tolerance stays the same even after months and months go by.  Moreover, because of the ‘ceiling effect’ the tolerance doesn’t change much even if the suboxone dose changes, as long as the suboxone dose is above 4 mg.  This is why there is little withdrawal when tapering suboxone until one gets to about 4 mg per day or less. 

We don’t know why cravings go away on suboxone.  The effect seems to be dose related, occurring more as doses increase beyond 8 mg per day.  Cravings are manifest by many different things– depression, irritability, or just plain old desire to use… and so many patients say that on Suboxone they feel happier, less moody, less irritable, etc.

I have treated over 150 people with buprenorphine over several years, and I am still learning more about the medication and about how people respond over time.  It is not a ‘sure thing’– people will still relapse if they don’t make changes in their lives.  The most important thing, in my opinion, is to remember the misery of being trapped by addiction.  People should be told that it is still there waiting for them– it will always be there.  People should also be aware that once they have used on Suboxone they are in deep trouble– the Suboxone seems to represent a commitment to a new life that helps keep people clean, and once a person crosses the line and uses, that commitment goes ‘poof’ and is gone.  Suddenly the person is back to trying to find the ‘will power’ to stop using… and will power simply does not work.  Even worse, residential treatment no longer works well either– residential treatment relies on the patient becoming so desperate that the mind opens to a new way of thinking.  Addicts who ‘know suboxone’ don’t get to that level of desperation– when they get anywhere close to desperation they say they have had enough, and they run from treatment. 

Opiate addiction is a fatal illness– a horrible, fatal illness.  It will wait, dormant, until the addict becomes complacent or thinks he/she is ‘cured’, then become active and take the addict’s career, money, house, family, freedom, and life.  It will change the addict’s thought process to allow rationalization of almost anything.  I encourage people to avoid complacency; use Suboxone as one tool of a recovery program, and make every day another step toward a better life.  Seek out positive experiences.  Take a daily inventory.  Find non-using friends.  Keep busy and always have at least one job.  Read something every day.

  And finally, fear opiates.  Always be afraid of opiates– see the substances for what they are, and what they have done to you.  Fear them and hate them.

If you have a minute check out my hobby of putting together web pages:  http://warmalglobing.com  is one; another is http://dsm-v.com .  And of course my home at http://wisconsinopiates.com .

In other words, my opinion is my opinion, but it is based on a great deal of education and experience.  I do my best to keep an open mind. 

The post:

I have heard often from Suboxone patients this same thing–that this “hole” seemed to be helped by subs at first, but then it slowly doesn’t work. This could be attributed to tolerance-however dose increase don’t appear to help.

\I have also heard the opposite-from a very dear friend who is thankful still, a year later, that her “hole” seems to have closed up because of her time on Suboxone.

I think R may find better luck with Methadone. See I don’t nessecarily believe as the “Experts” do that Suboxone is better for less tolerant and methadone better for “heavier” users of short acting opiates. I I I I believe that if you were a person who, while in active addiction, could take just enough to get high and be happy and content to save the rest you may do very well on Subs. However, if you were the type that was reaching for more before you even let the first pill, line or shot take effect–essentially you were the type of addict who loved to OVERFILL the “hole” then methadone might be for you.

If you look at this “hole”-lol- theory you could consider that suboxone has a ceiling effect and can only fill that hole to a certain point–which for the first group of people is just enough to be content, but for the second group is inadequate. Methadone seems to take up more “room” in the hole, therefore it fills past the point of Suboxone’s celing and there comes a point in treatment where you stop craving to OVER FILL the “hole”. That is a magical place to be when you’ve craved “filling the hole to the brim” most of your life.

Of course, this all might not make a whole lot of sense to anyone that hasn’t walked around feeling half whole their whole life.

Part 2 coming…

By the way, for those of you who enjoy reading my comments, please visit my practice, Fond du Lac Psychiatry, at http://fdlpsychiatry.com .  You will find links to my weekly radio show (send an e-mail to discuss on the air!) as well as things I have written about psychodynamic psychotherapy.

JJ

This is my, well, second day off opiates seeing it is 12:05am where I am. I had a 11 year on and off love affair with opiates. It got worse in the last 6-12 months or so. That feeling of euphoria really gets you and when you don’t have your pills you feel like you are going to die, literally!! I woke up this morning with no more pills. OH BOY was I sick… I found a list of docs who detoxed using subutex and/or suboxone… He did a patient and family history on me… He wrote me a script for six 2mg/0.5 suboxone. His instructions were take two under my tongue immediately… The taste was disguisting. I just took my second 2 and am cringing because of the taste… After 30-60 minutes, I felt wonderful… I was surprised he started me off at 2 and not 8mgs. The 2mgs do just fine. What is funny is that the euphoria you get from opiates, I am getting from this drug. I read up everything possible on the internet about this drug and it is supposed to be the best drug for opiate users. I have been posting a lot and hope you do not mind. I understand addiction and how hard it is so I want to help people. I am just starting my recovery and have a long road ahead, I know this but if more people know about SUB, there would be less addicts. I am making it clear to everyone that you absolutely cannot take any op’s while on Sub. Apparently you will get the worse side effects imaginable…

I deleted the parts that are identifiable or more specific to the individual than necessary here.

Some comments: As for the taste, there are some little tricks that will make suboxone more palatable; try chewing an altoid or another strong mint right before taking the suboxone, you can also try holding an ice cube in your mouth for 5 minutes first, spitting that out, and then taking the suboxone. Just be sure to start the suboxone dose without saliva or water in your mouth– you will produce saliva while you are dosing, and you want a high concentration of buprenorphine in the saliva, which means you want a low volume of liquid. Other people have used listerine strips. Finally, subutex has a different taste– it is bitter, but not ‘fruity’, and some people like it better. It is, though, significantly more expensive. Contrary to misconception out there, you do NOT need the naloxone to get the ‘blockade’ effect at opiate receptors. Subutex has an identical action in almost all patients– the exception being perhaps people who have had a gastric bypass or who have a (very unusual) allergy to naloxone.

For best results start with a ‘dry’ mouth, bite the suboxone with your front teeth to crush it and dissolve it immediately upon putting it in your mouth, then use your tongue to spread the the concentrated, dissolved medication over all surface areas inside your mouth. A couple points: the intact tablet is not doing anything, so holding it under the tongue takes needless time– get it dissolved right away. Second, there is nothing special about the area under your tongue; the medication will get absorbed from all surfaces inside the mouth, so use as much surface area as possible to increase absorption and speed the process. Third, after dosing for 5-10 minutes you can either swallow the saliva or spit it out– if the bitter taste really bothers you, perhaps spitting it out is the better option (also a better option for the rare individual who seems to get headaches from the naloxone in suboxone). Finally, do not drink anything or rinse your mouth with liquid for at least 15 minutes after dosing, as that will remove some of the buprenorphine that you are trying to absorb.

Euphoria… the initial effect of taking buprenorphine will depend to an extent on the individual’s degree of tolerance. A person taking over 80-100 mg of oxycodone per day who waits 24 hours to have moderate withdrawal, and then takes suboxone, will probably feel relief from the withdrawal, but will not feel much of an ‘opiate’ effect. On the other hand a person taking 5 vicodin per day (which contains hydrocodone, a weaker opiate) who waits 24 hours and then takes suboxone will likely have euphoria and other opiate effects– because the ‘opiate agonist’ activity of buprenorphine is stronger than what the person is used to or ‘tolerant’ to. In either case, the person’s opiate receptors will adjust fairly quickly to the potency of buprenorphine, and after a few days both patients will feel ‘normal’ after taking buprenorphine– no withdrawal, no euphoria. That is what makes it such a popular treatment– patients who take it regularly feel ‘normal’. In fact, many people experience life without the constant craving for opiates for the first time in years, and for the first time in years feel like a person who is not an opiate addict.

This leads to a much broader issue that I have talked about before– an issue that is more controversial: what other things should be required of patients taking suboxone? I have heard ‘second hand’ that Dr Miller, the President of ASAM, the American Society for Addiction Medicine, takes the approach that patients on Suboxone should be sober from all other intoxicants and attending group treatment and 12 step programs. I am in agreement on the ‘total sobriety’ issue but not with the second part, for a couple of reasons. Elsewhere in this blog I theorize a bit on the issue of Suboxone and 12-step attendance (I also discuss the issue here: http://fdlpsychiatry.com/subox.info/suboxandrecovery.pdf) but I have some practical concerns as well. First, ‘recovery’ is all about ‘rigorous honesty’, and yet if a person is honest about taking suboxone at an NA meeting he/she will end up being confronted and harassed– so patients are told to be honest about everything except suboxone use– and that is a problem because we are then reinforcing one of the things the addict has been doing for years– hiding the use of an opiate. Second, people on suboxone are different from people who are not on suboxone– they don’t have the constant awareness of the desire for opiates (or the unconscious drive for opiates manifest as irritability), and have an entirely different subjective experience. They don’t ‘feel’ like opiate addicts. Yes, they are still opiate addicts– don’t get me wrong on that. But they don’t feel the same way. And so I don’t know if a 12 step meeting will do anything for them. I know that to buy into recovery a person has to be desperate; not because there is anything wrong with the 12 step message as I think it is a great, universal approach to life that benefits everyone lucky enough to ‘get it’. But to adopt the 12-step way of living, of seeing the world, a person has to change. And change is very, very hard, and very rare. I remember my own first experience with the twelve steps: sick with withdrawal I wandered into a mall bookstore, found a book about AA, and read through the 12 steps. I concentrated for a few minutes, and considered what they said. Later that day, after using, I thought… ‘that didn’t work’. I’m trying to be a bit funny, but my point is that many people think that ‘recovery’ consists of intense education. Those people are eventually frustrated in treatment, as they think they are ‘getting it’ and yet their counselors and peers keep telling them that they are not getting it. In reality, treatment through a 12 step approach requires a deep change of attitude that is very difficult to come by. I like the saying ‘insight maketh a bloody entrance’. True change usually requires a significant period of distress– a rock bottom, a depression, a great deal of personal turmoil… another comment frequently heard in treatment is ‘crisis equals opportunity’, or ‘the Chinese symbol for crisis is the same as for opportunity’– something that I suspect is not actually true, but I could be wrong.

Wow. I talk too much. OK… practical problems to requiring 12 step attendance… My point (in case you zoned out) was that sitting through 12 step meetings, while not in the middle of a personal crisis at least at the start of 12 step exposure, may be a total waste of time. Ditto for attending ‘recovery group therapy’. Those things work for one type of treatment, and I see little reason why they would be helpful for people on Suboxone. An analogy… (wish me luck)… people with hyperthyroidism sometimes have the thyroid gland surgically removed; other times the thyroid is destroyed by taking radioactive iodine. If a person has had the entire thyroid removed, it makes little sense to then make them take radioactive iodine. Wow… that isn’t bad…

On the other hand… people with thyroid cancer have their thyroid surgically removed and then take radioactive iodine just in case some thyroid tumor cells were left behind. Given that opiate addiction is a fatal illness– at least as fatal as any cancer– maybe the more done, the better. I will say that anyone who is on Suboxone who is attending NA or AA or who wants to attend, and who can deal with the privacy issue of taking Suboxone, GREAT! If you can ‘get it’– if you can truly understand your powerlessness over substances and turn your life over to your ‘Higher Power’– you will be better off for doing so. You will also be in the position to get off of suboxone at some point.

I had better close, but will add one last thing. I will save the ‘dosing’ issue for another post, but please stay tuned because it comes up very often and there are some important concerns. But my last point today is that Suboxone does NOT cure opiate addiction, just as atenolol does NOT cure high blood pressure. To be honest, ‘cures’ are rare in medicine– we usually help the body heal itself or provide medication that ‘maintains’ a reduction in symptoms. We don’t fix the faulty blood pressure set point that is the core problem with hypertension– we give meds that artificially force the heart to pump with less force or at a lower rate, or that make the blood vessels open up wider, and that drops the blood pressure. Stop the medication and there often is a situation like ‘withdrawal’ where the blood pressure rebounds higher. Suboxone is an incredible medication– I know what it is like to be trapped by addiction before the days of Suboxone, and I understand why suicide is such a common outcome with addiction– if taken properly Suboxone will put addiction into complete remission, and that is a wonderful advance of science that saves many lives. BUT…. a person who becomes addicted to opiates has only three options: Buprenorphine maintenance for life, 12-step meetings for life, or prison and death.

DO NOT THINK THAT YOU CAN TAKE SUBOXONE FOR AWHILE, DO NO OTHER TYPE OF TREATMENT OR INSIGHT WORK, AND THEN STOP SUBOXONE.

In my next post I will try to talk about what a person on Suboxone CAN do to eventually stop taking the medication. I will also discuss the ever-important dosing question. The ‘sneak preview’ nutshell version is to follow the instructions of your prescribing doctor. Addicts take what they think they need to take– patients take what they are prescribed. You are not an addict anymore– are you?

I feel this big empty hole that I tried to fill with Opiates. Since on the Suboxone I’m not pulled towards the Opiates but I still have this hole that there is still a need to fill with something. It’s not there because I’m off the Opiates. It was there before the Opiates. They just happened to fill that hole to some degree. Does anyone know what I’m talking about or have the same experience?
Thanks
R.

My Response:

I understand what you are saying– at least I think I do. It is always hard to compare subjective experiences– for example, is my experience of ‘green’ the same as yours? But I do know that feeling of emptiness, darkness, loneliness, sadness, abandonment, despair… and like you, in my case it was present long before opiate addiction. I have heard many opiate addicts speak of the same thing as well– I wouldn’t say it is universal, but it certainly seems to be present in most people with opiate addiction who I have met over the years. I can tell you that most people found opiates to be the ‘perfect medication’ for that type of pain… at least until tolerance and the craziness of needing more and more took over and ruined everything.

I also often hear that the pain of that ‘hole’ is treated, at least partially, by suboxone. Again, I think that the main problem is tolerance– which is measured with suboxone (or more accurately with buprenorphine, the active drug), but which still occurs to some extent.

I think that the hole is often a manifestation of what we psychiatrists call ‘Borderline Personality Disorder’. Everybody has their own way of seeing the world– of seeing relationships, of seeing one’s own role in the grand scheme of things, of seeing their own traits as compared to others…. all of these views total up to form the ‘personality’ of the individual. The collection of views, perspectives, opinions, etc are a result of genetic influences, developmental influences, cultural and societal experiences, and life experiences, and for the most part the entire assembly is relatively ‘fixed’ at an early age– at least by our late teens. Ideally a person has a certain amount of flexibility built into their personality– the ability to change views and reactions to a wide range of situations. If a person has an inflexible way of seeing things they often run into recurrent problems in life– and in such a case may be considered to have a ‘personality disorder’.

Borderline PD likely forms in reaction to genetic factors to some extent, but a common environmental factor is the failure to form the intense bond with a parent (usually mom) at an early age– before age 2 for the most part. Many people will have the opinion that mom was perfect and so they didn’t have anything like I am describing– at least until I get to them and start talking about specifics. The point, of course, isn’t to blame our mothers, but rather to understand all of the factors that made us who we are, with the understanding that our mothers and fathers are products of their own upbringing just as we are. Anyway, mom may look ‘perfect’ when viewed through our adult eyes, but when we were babies she may have been unable to bond with us– perhaps she had her own addictions, or was depressed, or had an anxiety disorder… or perhaps she worked 80 hours per week and was just too tired to spend much time gazing into our eyes. Maybe she had 8 other kids to take care of. Or maybe we were born premature and we were so fragile that she was nervous every time she held us. Maybe we cried to much that she was often too angry to appreciate the quiet times. Who knows… but it is clear that the failure to bond is connected to BPD, and that BPD is not something restricted to single parents or to lower socioeconomic groups– it occurs in people who are CEO’s, doctors, electricians, teachers… and homeless people as well.

People with BPD have an ache that never goes away, and a ‘hole’ that can never be filled. I won’t go through all of the characteristics, as you can easily find them by googling ‘borderline personality symptoms’ or something similar. People with that basic personality often try to fill the emptiness with drugs, or more often with relationships– which are usually dysfunctional because the person tends to seek out traits that don’t make for healthy relationships. For example, people with BPD are attracted to very intense emotional connections, and for that reason they tend to attach to other people with BPD. People with such a personality tend to see people and the world in ‘black and white’– so people are either idealized and placed on a pedestal or hated and seen as completely without value. A partner may initially be seen as perfect, but over time the relationship is bound to disappoint, and then the partner is seen as horrible. Other problems include that fact that in healthy relationships, a person enters the relationship already ‘whole’ and complete, and brings assets to the relationship, but in BPD people enter the relationship looking for a person to MAKE them feel complete– and again, no person or relationship can be relied on to do that for very long.

Patients with BPD are often cutters; they often have intense mood swings that are misdiagnosed as bipolar (the mood swings in BPD are of much shorter duration and are ‘reactive’ to the environment); they often have periods of intense emotional pain– they ‘become’ depression rather than ‘have’ depression. They often feel entirely alone in the world. They often have a history of multiple suicide attempts, and are often treated with dozens of medications over their lifetime– none of which ever work very well.

There are many books about BPD that patients may find helpful– one such example is a book called ‘I hate you– don’t leave me’, reflecting the intense fear of abandonment that is classic in BPD. There is a type of therapy called ‘DBT’ or ‘dialectic behavioral therapy’ that reportedly has shown some success in reducing the behaviors that cause problems for patients, such as cutting or suicide attempts. My usual approach is to first do no harm– to try to avoid hurting the patient by either prescribing medication that is ultimately harmful (like benzodiazepines) or by forming professional relationships that are too intense and that make a patient dependent on their therapist.

I feel that I have a good understanding of suboxone…. With the exception of the pain issue. The reason for my lack of confidence in that area is because first, I have seen less-consistent results in pain patients, and second, some of the claims made by patients just don’t make sense!

Suboxone has several characteristics that make it different from opiate agonists (like oxycodone); the ‘ceiling effect’ combined with the long half-life results in a very stable subjective experience—there is no up and down, but rather there is a constant level of opiate effect over time. Tolerance occurs very rapidly—that is a good thing for addiction treatment, as the person taking suboxone feels ‘normal’ within a few days. But just as the person becomes tolerant to the sedation, respiratory depression, and other side effects of buprenorphine, 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.

In reality, though, patients will claim relief from suboxone for an indefinite period of time in many cases. I have no explanation for such an effect; perhaps it is all a placebo response, or perhaps (more likely probably) the pain control system is much more complex than we imagine. The other odd thing is that pain patients will often claim that the analgesic effect of buprenorphine increases linearly with dose, without reaching a ceiling and leveling off. That makes no sense to me either—the analgesic effect of opiates occurs at the mu receptor, which is the site where buprenorphine binds as a partial agonist, and so the ceiling effect should apply to the analgesic actions of buprenorphine. I suspect that in this case the placebo response is the reason for the patients’ perceptions.

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.

As far as the personality effects… many people have told me that suboxone seems to work as a ‘mood stabilizer’—they feel less labile, more regular, and generally a bit happier on the drug. There are case reports of opiates treating depression or precipitating mania, but buprenorphine doesn’t seem to push people to euphoria, but instead seems to ‘level’ their mood. Maybe that is what you have seen in your friends. I think that part of the effect relates to cravings; cravings can manifest as mood symptoms, and as suboxone eliminates cravings, it also eliminates some of the mood symptoms. This raises the issue of whether buprenorphine should be used to treat mood disorders… and for that I will leave the readers to do their own research. A couple years ago there was an article in Elle magazine by a woman describing her treatment of depression using suboxone. I do not know of any large clinical studies that support such use at this point.

Chronic pain is a very difficult issue, and I wish you the best. 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 am sure that at some point we will have ways to prevent tolerance, which would be quite a thing for people with chronic pain. On the other hand I can imagine many dangers associated with such a discovery. Thank you very much for your question; I am going to go ahead and post on my blog, http://suboxonetalkzone.com , and on the forum at http://suboxforum.com (without your real name).

J

Yesterday I visited a pain clinic in XXXX, XXXX that has an excellent reputation for both its medical staff and its interdisciplinary approach.  I won’t relate to you the entire, long story as to how my pain developed (I now have CRPS), but the upshot is that they suggested Suboxone treatment.  I have not been abusing any drugs, prescription or otherwise. I have, however, developed a very high tolerance to opiates.  I weigh only 105 lbs and can tolerate enough opiates to kill most average-weight adults. Really. That said, I had been on no opiate medication at the time of my visit because I had been benefiting from a SCS plus other conservative means. However, a few weeks ago the stimulator’s leads migrated and need to be replaced with a plate electrode.  In the mean time, my doctors recommended that I seek treatment at the pain center to cover the gap.

For the short term, they put me back on Percocet with the plan of reassessing after the surgery.  The doctor also said that if after the surgery the stimulator still isn’t functioning adequately, Suboxone would be a good choice for me.  I do understand the drug reasonably well, esp. its benefits over long-term nartcotic tx., but also have some significant concerns about it.  My main worry is whether Suboxone is likely to render my personality a dial tone.  I only know one person on the drug….    …She says it is very helpful for pain, but I have noticed that her affect has become much more dull since starting Suboxone treatment. I’ve noticed the same thing… …on the Durgesic patch, and have heard similar things about morphine pumps and Oxycontin; in other words, about other extended release analgesics.  I asked the nurse practitioner about this, who only said that she could not predict how a person’s other medicines might interact with Suboxone, but that such an outcome is possible. Would you mind sharing your opinion on the matter with me?

(name withheld)

I haven’t been to the other site (suboxforum.com) yet, so I don’t know if anyone has answered.  I have treated over 100 patients and have not yet had a person develop a rash.  That doesn’t mean it can’t happen, but it does suggest to me that it is uncommon.  The rash does not sound typical of drug reactions, which usually start on the face and chest and then spread from there.  The spots– what are they like?  a drug rash usually would have red spots that are small but that can eventually join together to make the whole area look red.  They often itch.  A drug rash would not look like pimples, or bumps with ‘white heads’ (which are from pus)– those are more consistent with impetigo, which is an infection.

Try using google images and search for ‘drug rash’ or ‘allergy’– I haven’t done it yet but I bet you will find pictures of typical allergic drug rashes.  If you do have a rash from suboxone the first thing to do would be to change to subutex.  There is a good possibility that you are actually allergic to naloxone, not buprenorphine.  If you change, I would give it a good month before drawing conclusions, as it sometimes takes a long time for an allergic rash to go away after the stimulus is gone.

If subutex doesn’t help, hopefully you have an understanding doc who is willing to give you methadone for awhile to see if the rash is in fact due to buprenorphine.

Cindy | mdyer78@yahoo.com | IP: 209.165.254.251

Ever since taking suboxone I have had a rash all over my pubic area which has now spread all over my body. Has anybody or know of anybody that has had this kind of reaction to suboxone? Please let me know if this is one of the side effects!

Very worried suboxone user,
Cindy

Mar 28, 12:01 AM

Here it is, with my answers inserted at the paragraph breaks:

Why is it wrong to take pain medications for pain?  Especially if you have INTRACTABLE CHRONIC PAIN, what is there because detox.

Medications for pain are not ‘evil’—the only way I approach the issue is from a quality of life position.  There are many problems with pain meds as they are now.  At some point I expect we will find a way to avoid tolerance to opiates—that will truly revolutionize pain treatment.  But as things are now, tolerance is the basis for the problems with chronic use of narcotics for pain.  Any person taking narcotics, either for pain or for ‘fun’ (although there is nothing fun about opiate dependence after the first few weeks), will become tolerant to the effects.  The medication will become less and less effective, requiring increases in dose to get the same pain relief.  The dose cannot be increased forever—eventually the patient would be chewing on pills every minute of the day—and so the doc must limit the pills.  If I give enough medication to satisfy a person who is 40 yrs old, what will I do when the person is 42 years old?  Tolerance develops very quickly—this leads to tension between doctor and patient, and eventually the patient takes too many and asks for early refills.  This annoys, angers, or frightens the doc, who therefore eventually stops the narcotics or quits seeing the patient.  The patient, meanwhile, thinks he is being deprived, and gets mad at the doc, mad at all docs, and mad at the world.  Finally, pain meds get inside the head of everyone who takes them, whether they are being taken legitimately or not.  The patient becomes more and more focused on the meds, getting the meds, the pain, and the withdrawal.  Relationships suffer.  Depression develops.  The patient eventually becomes a one-dimensional shadow of who they once were, where the biggest relationship in the patient’s life is the relationship with the pain pills.  I have seen this all happen many, many times, with every patient who takes narcotics.  I do treat with opiates, but I do tell the patient all of this, so they understand what they are taking on.  This is why opiates are always the last resort.  Any good pain doc will tell you that they have seen patients who complain of terrible back pain, who ask for narcotics repeatedly and think they need them…  who get detoxed for some reason and after getting past the withdrawal are surprised to find that the pain is gone, or very small.   I have seen it many times, and I cannot explain it, other than the body trying to trick the person into thinking he needs pain pills as part of an addictive process.

For cancer pain, by the way, none of this is relevant—with a limited life span the doc should just give what is needed to control pain.  But for non-malignant chronic pain, I have never seen opiates improve a person’s quality of life in the long term.  And I have seen many lives destroyed.  The patient may not see it—he may insist things are great on the pain pills, even as his marriage falls apart and his kids disappear.

Why would you want to withdraw, if the pain was being controlled and it lowered your blood pressure?

We have plenty of ways to lower blood pressure—narcotics should never be used for that purpose, except in the case of acute myocardial infarction, when morphine has a number of helpful effects including lowering blood pressure.

What if the patient was limited, and could not do alot of physical therapy to get the benefits of endorphins to work for them.

Patients can do much more than they think with physical therapy.  They need to be taught patience, and they need to work at it every day at home—not only at the therapy center.  Physical therapy is so valuable—but patients generally look for short term solutions.  That is unfortunate.  As far as endorphins go, I caution people against getting wrapped up in thinking about what their brain chemicals are doing.  It is much more complicated than magazines suggest–  endorphins, for example, do many things besides pain control—including things that have nothing to do with pain.  Yes, they have been shown to be released by exercise, but… so what?  We don’t know if that release actually does anything helpful for people.

Like you said, there is a difference between dependency and addiction.  My family members suffer from chronic pain due to chronic pain conditions, that we were either born with or developed.

There is a difference early on, but over time the differences go away.  A person who I see for a congenital pain condition who takes loads of narcotics has very few differences with a person who started pain pills ‘for fun’ and who takes tons of narcotics.  If anything, the addiction is worse in the pain patient, because they are convinced they need the pills, and cannot see the destruction they are causing.  A person who starts ‘recreationally’ is more likely to truly hate the pills, and is often willing to go to greater lengths to get off of them.  That person hates the pills, where the pain patient thinks he loves them.

So, intervention should come, if I am just lying around getting HIGH in a chair, like the rubbish I have been reading.

I don’t know what you mean by this sentence.  If you are referring to addicts as ‘rubbish’, you are off base.  Yes, some addicts have bad characters, just as some non-addicts have bad characters.  It sounds like you see a difference between ‘good people’ on pain pills and ‘bad people’ on pain pills.  That difference does not exist.  Over time, any person on pain pills becomes a slave to them, and desperately wants to be free from them.  For some people, it takes longer to seek freedom; some people never seek it.   I can assure you, though, that opiate addicts are not sitting around enjoying themselves—not after they have been doing it for a few months.  They are scrambling for money to get something to avoid being sick—stealing, prostituting, whatever.

OR should it be, I take the pain meds, and I can walk around in the house, function a little better than suffering in pain.

That is your decision.  But it is more complicated than you would like to believe.

I wish you the best, and hope things work out.

Jeffrey T Junig MD PhD

I treat XXXXXXX for opiate dependence. He and I have arrived at a taper schedule as you requested. I do feel obligated, however, to let you know that tapering off suboxone is not appropriate care for his opiate dependence.

I have no shortage of patients on suboxone– I am always at the 100-patient limit, and there are always people waiting in line if a patient leaves my care (The most common reason for stopping suboxone is pregnancy). I have no financial incentive to keep XXXX on suboxone; if anything I will be paid more for a new patient taking his place. I have a great deal of experience with addiction; I treat some patients with suboxone, and others by different techniques, depending on their personality, addiction/treatment history, and circumstances. I have treated about 150 patients with suboxone over the past two years; other patients were treated by myself in outpatient therapy, or referred to residential treatment.

I remain current with the standard of care for addiction. I am the Medical Director of XXXXXXXX, a residential and outpatient AODA treatment center in Wisconsin. I am Assistant Clinical Professor of Psychiatry at the Medical College of Wisconsin, where I teach medical students and psychiatry residents. I do the teaching of the addiction section of the mental health/behavior block for medical students. In the case that you do not accept my opinion on the matter, you can easily find ample support for the use of buprenorphine for long-term maintenance of remission of opiate dependence. I suggest starting at ASAM, the American Society for Addiction Medicine: http://asam.org. The president of the organization, Dr. Michael Miller, practices in Madison Wisconsin and is a strong advocate for the use of buprenorphine and Suboxone.Despite efforts to educate physicians and the public, there are a number of misconceptions and prejudices about Suboxone. The active ingredient of Suboxone, buprenorphine, has a distinct mechanism of action at the opiate receptor that is unlike the effect of oxycodone or methadone. After two-three days of use a patient on Suboxone feels no effect from the medication– no ‘high’, and no sedation. A patient on Suboxone cannot get an effect from any other opiate. The action of Suboxone that sets it apart is the effective relief of craving for opiates, which in effect induces full remission from active addiction. Patients on Suboxone are relieved of the terrible obsession that keeps them from moving forward in life. My patients include attorneys, physicians, nurses, prison guards, and factory workers, all grateful to have opiate dependence out of their lives.

There are certainly cases where total sobriety is favored over Suboxone. It is important to realize, however, that even with thorough, residential treatment, the relapse rate for opiate dependence remains well over 50%, much higher than that of other substances. Patients who maintain sobriety through 12-step meetings can expect to have cravings for the rest of their lives. I have had a number of patients tell me that traditional recovery kept them clean and feeling like a ‘recovering addict’, whereas suboxone made them feel like a person who was never addicted in the first place. The role of meetings and therapy for patients on suboxone is debatable, as the relief from the obsession to use allows good character to return. Most of my patients are working and doing well in life– as is XXXXXXXX.

The best way to understone Suboxone treatment is to compare it to treatment of hypertension. Like opiate dependence, high blood pressure is in part genetic, and in part caused by behavior (diet, smoking, lack of exercise, e.g.). We cannot ‘fix’ the defect in hypertension– which is a brain abnormality that causes a faulty ‘set-point’ for blood pressure. We instead artificially dilate blood vessels and weaken the pumping of the heart with medication, and the pressure drops. If we stop the medication, the high blood pressure is still there. The medication causes ‘remission’ of the high blood pressure– not a cure. Likewise, opiate dependence is in part familial and in part behavioral. We have no cure– no way to eliminate the obsession to use that characterizes addiction. But we now have a medication that will induce remission of that obsession. The comparison does not stop there– with both hypertension and addiction, we have non-medical ways to treat the diseases, using the power of the mind. For addiction, the person can work hard to drastically change their mind through hours and hours of treatment and life-long meetings. For hypertension, a person can use biofeedback and meditation to control their blood pressure– can you imagine how effective it would be if a patient put the same effort into it that an addict puts into meetings and treatment? Of course, we would never expect a person to go to that effort to control their blood pressure when medication is available… and yet we think of an addict very differently, and consider medication to be the easy way out. Yes, it is hard to get off suboxone…. Just as it is hard to get off some blood pressure medications, which cause ‘rebound hypertension’ when they are stopped.

As I said, XXXXX is prepared to taper off suboxone, as he has no choice. He will have life-long cravings that will at times occupy his mind and make him irritable. He will place himself at risk of relapse, which could land him in prison or even kill him. As his doctor, I have to wonder about the sense of that, particularly when he is being forced to deviate from the standard of care and face these risks because of someone else’s misconceptions and biases. I used to have similar misconceptions when I read the first studies about suboxone– after all, I treated my own opiate dependence by hours and hours of outpatient sessions and meetings, and then after ten years I treated my relapse by over three months away from my family, in residential treatment, followed by hours of groups and more meetings. The treatment was effective, but I lost my career as an anesthesiologist along the way, and almost lost my marriage and my life. And yet I was lucky– many people in the same position don’t survive. Thank goodness we have progressed to a point where almost everyone can be saved, treated to remission, and go on to live productive lives.

Sincerely,

Jeffrey T Junig MD PhD

Fond du Lac Psychiatry

Wisconsin Opiate Management Center

If I try to just take the oxycodone for a period of time prior to meeting with you would that eliminate some of the problems and complications associated with the transition from methadone to suboxone? If I took only oxycodone for 4 days or 6 days might I be able to go directly to suboxone without that withdrawal period?

Yes, it is helpful to change from methadone to oxycodone for a stretch of time. Methadone is highly protein-bound, and takes forever to leave the body– I like people to be off methadone for at least 4 days, whereas 24 hours off oxycodone is usually sufficient to avoid precipitating withdrawal with suboxone. There is no way to avoid withdrawal completely, however, as a person must be in a bit of withdrawal at the time of suboxone induction. Otherwise the person will get very sick.

Would I be feeling well enough by (specific date) to be physically comfortable enough to be a joy to be around or will I still be suffering? I believe I will need some help just with the driving alone…

Some people start suboxone and go to work later the same day– it depends on the person’s individual ability to handle the withdrawal, and on their tolerance to opiates. A person who takes less than 40 mg of methadone per day (or the equivalent dose of oxycodone) will generally have no problem adjusting to suboxone. I have done inductions on people taking well over 100 mg of methadone per day, and they do OK as long as they have gone without methadone for a few days. If you can change completely to oxycodone and avoid methadone for a few weeks before suboxone, you will do better.

In addition to the methadone I have also been prescribed Clonazopam (a benzodiazepine) that I take with the methadone. I take 3 to 4 mg a day. Can Dr. Junig prescribe me that or a different one and get me tapered off the benzo’s? I really want to be clean and sober as I once was… I stopped going to meetings and I had gone to over a thousand during that time and was pretty darn healthy in all ways; but after I stopped I picked up a drink and eventually narcotics again.

Clonazepam is a dangerous med for anyone with a history of addiction. The tolerance that develops makes the drug helpful only for short-term use, for the most part. I will prescribe it sometimes for a person who is taking the proper medication for anxiety (like prozac or effexor) but who still has breakthrough anxiety, as long as the dose remains stable. 3-4 mg is a high dose, and I would want to try to taper that down a bit if possible.

The part about the meetings is typical. Opiate dependence is a long-term affliction—life-long for most people. People contemplating suboxone have two choices: life-long medication, or life-long meeting attendance. At this point there is no cure. Addicts who stop going to meetings eventually go back to opiates, for the most part. Likewise, it is important for people who stay sober through the 12-steps to avoid all intoxicants. Use of a different drug often results in ‘cross-addiction’ to the different substance, which then often leads back to using the drug of choice.

More Suboxone Information at subox.info.

I have been taking Suboxone for 2 months now and it has changed my life! I finally feel a freedom I haven’t felt in over 30 years! I am a nurse and am able to work around and administer narcotics with absolutely no thoughts, urges, or cravings…a miracle for me. BUT, the hospital I work for has just informed me I cannot be taking suboxone while employed there.

I am just in shock. Is there any recourse for me? Are there any laws protecting my disease/disability medical management?

I feel it’s like being told I can’t take my insulin if I were diabetic.

Any suggestions?!

Ouch!

I have been watching to see what position the various Licensing Boards take on suboxone. I did not expect to hear of such a silly demand by an employer– particularly an employer that supposedly has an interest in keeping people healthy.

If you read some of the forums out there you will come across this statement: “We need our doctors and nurses to be 100% on their toes– would you want your surgeon to be on suboxone?” My answer, of course, is YES– particularly if he/she has any history of opiate dependence. I want his/her mind 100% on my surgery… not on the last meeting they went to, not on the meeting that they need at the end of the day, and not on the narcotic prescription that they will write after the surgery If they are taking suboxone, then I know that they are essentially ‘normal’– they are not having cravings, they are not sedated, they are not ‘high’– they are the person that they would be, if they were able to dissect out their opiate addiction.

For our nice nurse, I wish that you could go and hire the best employee-rights attorney in the country, and sue the hospital for wrongful termination. In fact, as I think about it, I wonder if they can even make such demands. Can a hospital threaten to fire a patient for taking antidepressants? If not, how can they threaten to fire you for taking suboxone? They would have to claim that it somehow impairs you from your job– and how could they do that? As anyone taking suboxone knows, once you are used to the medication there is no significant effect from taking it.

I actually DO have a great attorney for this type of work. The problem is that lawsuits cost money. I will send him an e-mail and see if he has come across this issue before. In the meantime, don’t do anything drastic. You may want to consider drafting a letter that threatens to go the the EEOC over the issue. They cannot fire a person for having a protected disability, including addiction (they can fire a person for behavior, or even risk of behavior, related to the addiction– but if the addiction is only a ‘past’ issue they can’t hold it against you).

Stay tuned…

More Suboxone Information at subox.info.

Suboxone has really worked for me in getting off vicodin. But I have been unable to stop taking suboxone. It occurred to me recently that this may turn into a lifelong dependency. If so, what are the long-term side effects of suxone?

Thanks so much,

A

My Answer:

Hi ‘A’–

Suboxone really is best thought of as a long-term, perhaps life-long medication. Your attachment to pain pills will in all likelihood be life-long as well; most people who stop suboxone are surprised at the cravings for opiates that they have. I don’t think suboxone increases the cravings at all, but rather it is just so effective at eliminating them that people forget how attached to opiates they once were. I generally recommend that people stay on suboxone ‘forever’, or until something better comes around– they are much safer on suboxone, as it helps them avoid an impulsive relapse that can put them in jail, kill them, etc…

We do not know of many long term effects from suboxone. Long term opiate use in general can lower testosterone levels in men and cause things from that, like reduced sex drive and I suppose even infertility. I assume that buprenorphine will do the same. There are the other short-term side effects that over time become long-term side effects– dry mouth (which long-term can cause an increase in tooth decay), constipation (which could lead to hemorrhoids, diverticulitis, anal fissures or perirectal abscess), sweating (which could lead to… problems dating?). The opiate antagonist naltrexone can cause liver damage, and it is related to naloxone, which is a component of suboxone– in general the naloxone does not get absorbed, and so the chance of liver damage is likely minimal. It may be a good idea to check a set of labs once per year, though, to check the liver, kidneys, thyroid, and blood cell system, just for safety’s sake.

Probably the worst thing about long-term use is that some docs insist upon keeping everyone on suboxone in endless therapy. I do not think that therapy is generally required, and I do not think that ‘forced therapy’ is very helpful. But it is hard to find a doc who will treat with suboxone as they would treat with any other treatment for a chronic condition– that is, to prescribe the medication without placing a number of other requirements on the person.

I hope that answers your questions–

Take care,

J

More Suboxone Information at subox.info.

Hi and thx for getting back to me. I have never tried anything to get off of these pills. I am not your stereotypical addict. Truth be told I have never been addicted in my life. I feel like such a loser for letting myself get out of control and if it was not for being sick I would have licked this a long time ago! I am not off them right now because I cant. I work hard all day to support my family and there is no time to be down and out. I have also suffered an incredible string of losses over the past two years. What a predicament huh? I lost my wife two years ago, and the story goes on. I have chronic back pain from degenerative discs, but I will deal with that. Will suboxone do anything for me?

My response:

I have a couple things to say that may come across as ‘brutally honest’—don’t take it personally, but rather understand that EVERY person who gets stuck on opiates has a unique story, and we all were reluctant to see ourselves as ‘stereotypical addicts’. There is a term in addiction—‘terminal uniqueness’—that refers to a state of mind that is common with addiction, and which keeps people sick. A frequent refrain by a person new to a treatment center is ‘I’m not like those people’. The fact of the matter is that one rarely sees a ‘stereotypical addict’ at treatment. What one sees are teachers, dentists, single and married moms, college students, high school students, people with back problems or fibromyalgia, people who have been through terrible tragedies… So try to avoid seeing the things that make you unique. Instead, try to see the things that make you like everyone else—the horrible feeling of being trapped by something, when you have always handled things well up until now. That is how most people who are stuck on opiates feel—trapped, embarrassed, ashamed, angry… and afraid. Others don’t feel anything because they repress all of their feelings and put up a fake, cocky exterior. That is what denial is all about.As an aside, I own the domain name ‘terminaluniqueness.com’– I will be advertising a book through there eventually… I hope…. But if you search under ‘terminal uniqueness’ you will find a number of things written by recovering people.

J

More Suboxone Information at subox.info.

By now almost every opiate addict has heard of suboxone, the amazing medication for opiate dependence that has taken the using world by storm. I will admit to mixed feelings about suboxone based on what I have seen and heard while treating well over 100 patients over the past two years. I also acknowledge that my opinions are likely influenced by my own experiences as an addict in traditional recovery. While suboxone has opened a new frontier of treatment for opiate addiction, it also threatens to split the recovering and treatment communities along opposing battle lines. Such and outcome would be a huge missed opportunity to improve the lives of opiate addicts.

An amazing medication.

For clarification, the active ingredient in Suboxone is buprenorphine, a partial agonist at the mu opiate receptor. Suboxone contains naloxone to prevent intravenous use; another form of the medication, Subutex, consists of buprenorphine without naloxone. In this article I will use the name ‘Suboxone’ because of the common reference to the drug, but in all cases I am referring to the use and actions of buprenorphine in either form. The unique effects of buprenorphine can be attributed to the drug’s unique molecular properties. First, the partial agonist effect at the receptor level results in a ‘ceiling effect’ to dosing after about 4 mg, so that increased dosing does not result in increased opiate effect beyond that dose. Second, the high binding affinity and partial agonist effect cause the elimination of drug cravings, dispelling the destructive obsession with use that destroys the personality of the user. Third, the high protein binding and long half-life of buprenorphine allows once per day dosing, allowing the addict to break the conditioned pattern of withdrawal (stimulus)-use (response)- relief (reward) which is the backbone of addictive behavior. Fourth, the partial agonist effect and long half life cause rapid tolerance to the drug, allowing the patient to feel ‘normal’ within a few days of starting treatment. Finally, the withdrawal from buprenorphine provides a disincentive to stop taking the drug, and so the drug is always there to assure the person that any attempt to get high would be futile, dispelling any lingering thoughts about using an opiate.

Different treatment approaches.

At the present time there are significant differences between the treatment approaches of those who use suboxone versus those who use a non-medicated 12-step-based approach. People who stay sober with the help of AA, NA, or CA, as well as those who treat by this approach tend to look down on patients taking suboxone as having an ’inferior’ form of recovery, or no recovery at all. This leaves suboxone patients to go to Narcotics Anonymous and hide their use of suboxone. On one hand, good boundaries include the right to keeping one’s private medical information so one’s self. But on the other hand, a general recovery principle is that ’secrets keep us sick’, and hiding the use of suboxone is a bit at odds with the idea of ’rigorous honesty’. People new to recovery also struggle with low self esteem before they learn to overcome the shame society places on ‘drug addicts’; they are not in a good position to deal with even more shame coming from other addicts themselves!

An ideal program will combine the benefits of 12-step programs with the benefits of the use of suboxone. The time for such an approach is at hand, as it is likely that more and more medications will be brought forward for treatment of addiction now that suboxone has proved profitable. If we already had excellent treatments for opiate addiction there would be less need for the two treatment approaches to learn to live with each other. But the sad fact is that opiate addiction remains stubbornly difficult to treat by traditional methods. Success rates for long-term sobriety are lower for opiates than for other substances. This may be because the ‘high’ from opiate use is different from the effects of other substances—users of cocaine, methamphetamine, and alcohol take the substances to feel up, loose, or energetic—ready to go out and take on the town. The ‘high’ of opiate use feels content and ‘normal’— users feel at home, as if they are getting back a part of themselves that was always missing. The experience of using rapidly becomes a part of who the person IS, rather than something the patient DOES. The term ‘denial’ fits nobody better than the active opiate user, particularly when seen as the mnemonic: Don’t Even Notice I Am Lying.

The challenges for practitioners lie at the juncture between traditional recovery and the use of medication, in finding ways to bring the recovering community together to use all available tools in the struggle against active opiate addiction.

Drug obsession and character defects.

Suboxone has given us a new paradigm for treatment which I refer to as the ‘remission model’. This model takes into account that addiction is a dynamic process— far more dynamic than previously assumed. To explain, the traditional view from recovery circles is that the addict has a number of character defects that were either present before the addiction started, or that grew out of addictive behavior over time. Opiate addicts have a number of such ‘defects.’ The dishonesty that occurs during active opiate addiction, for example, far surpasses similar defects from other substances, in my opinion. Other defects are common to all substance users; the addict represses awareness of his/her trapped condition and creates an artificial ‘self’ that comes off as cocky and self-assured, when deep inside the addict is frightened and lonely. The obsession with using takes more and more energy and time, pushing aside interests in family, self-care, and career. The addict becomes more and more self-centered, and the opiate addict often becomes very ‘somatic’, convinced that every uncomfortable feeling is an unbearable component of withdrawal. The opiate addict becomes obsessed with comfort, avoiding activities that cause one to perspire or exert one’s self. The active addict learns to blame others for his/her own misery, and eventually their irritability results in loss of jobs and relationships.

The traditional view holds that these character defects do not simply go away when the addict stops using. People in AA know that simply remaining sober will cause a ‘dry drunk’—a nondrinker with all of the alcoholic character defects– when there is no active recovery program in place. I had such an expectation when I first began treating opiate addicts with suboxone—that without involvement in a 12-step group the person would remain just as miserable and dishonest as the active user. I realize now that I was making the assumption that character defects were relatively static—that they developed slowly over time, and so could only be removed through a great deal of time and hard work. The most surprising part of my experience in treating people with suboxone has been that the defects in fact are not ‘static’, but rather they are quite dynamic. I have come to believe that the difference between suboxone treatment and a patient in a ‘dry drunk’ is that the suboxone-treated patient has been freed from the obsession to use. A patient in a ‘dry drunk’ is not drinking, but in the absence of a recovery program they continue to suffer the conscious and unconscious obsession with drinking. People in AA will often say that it isn’t the alcohol that is the problem; it is the ‘ism’ that causes the damage. Such is the case with opiates as well—the opiate is not the issue, but rather it is the obsession with opiates that causes the misery and despair. With this in mind, I now view character defects as features that develop in response to the obsession to use a substance. When the obsession is removed the character defects will go way, whether slowly, through working the 12 steps, or rapidly, by the remission of addiction with suboxone.

In traditional step-based treatment the addict is in a constant battle with the obsession to use. Some addicts will have rapid relief from their obsession when they suddenly experience a ‘shift of thinking’ that allows them to see their powerlessness with their drug of choice. For other addicts the new thought requires a great deal of addition-induced misery before their mind opens in response to a ‘rock bottom’. But whether fast or slow, the shift of thinking is effective because the new thought approaches addiction where it lives—in the brain’s limbic system. The ineffectiveness of higher-order thinking has been proven by addicts many times over, as they make promises over pictures of their loved ones or try to summon the will power to stay clean. While these approaches almost always fail, the addict will find success in surrender and recognition of the futility of the struggle. The successful addict will view the substance with fear—a primitive emotion from the old brain. When the substance is viewed as a poison that will always lead to misery and death, the obsession to use will be lifted. Unfortunately it is man’s nature to strive for power, and over time the recognition of powerlessness will fade. For that reason, addicts must continue to attend meetings where newcomers arrive with stories of misery and pain, which reinforce and remind addicts of their powerlessness.

The dynamic nature of personality.

My experiences with Suboxone have challenged my old perceptions, and led me to believe that the character defects of addiction are much more dynamic. Suboxone removes the obsession to use almost immediately. The addict does not then enter into a ‘dry drunk’, but instead the absence of the obsession to use allows the return of positive character traits that had been pushed aside. The elimination of negative character traits does not always require rigorous step work— in many cases the negative traits simply disappear as the obsession to use is relieved. I base this opinion on my experiences with scores of suboxone patients, and more importantly with the spouses, parents, and children of suboxone patients. I have seen multiple instances of improved communication and new-found humility. I have heard families talk about ‘having dad back’, and husbands talk about getting back the women they married. I sometimes miss my old days as an anesthesiologist placing labor epidurals, as the patients were so grateful—and so I am happy to have found Suboxone treatment, for it is one of the rare areas in psychiatry where patients quickly get better and express gratitude for their care.

A natural question is why character defects would simply disappear when the obsession to use is lifted? Why wouldn’t it require a great deal of work? The answer, I believe, is because the character defects are not the natural personality state of the addict, but rather are traits that are produced by the obsession, and dynamically maintained by the obsession.

Combining suboxone treatment and traditional recovery.

Once the dynamic relationship between use obsession and character defects is understood, the proper relationship between suboxone and traditional recovery becomes clear. Should people taking suboxone attend NA or AA? Yes, if they want to. A 12-step program has much to offer an addict, or anyone for that matter. But I see little use in forced or coerced attendance at meetings. The recovery message requires a level of acceptance that comes about during desperate times, and people on suboxone do not feel desperate. In fact, people on suboxone often report that ‘they feel normal for the first time in their lives’. A person in this state of mind is not going to do the difficult personal inventories of AA unless otherwise motivated by his/her own internal desire to change.

The role of ‘desperation’ should be addressed at this time: In traditional treatment desperation is the most important prerequisite to making progress, as it takes the desperation of being at ‘rock bottom’ to open the mind to see one’s powerlessness. But when recovery from addiction is viewed through the remission model, the lack of desperation is a good thing, as it allows the reinstatement of the addict’s own positive character. Such a view is consistent with the ‘hierarchy of needs’ put forward by Abraham Maslow in 1943; there can be little interest in higher order traits when one is fighting for one’s life.

Other Questions (and answers):

-Should suboxone patients be in a recovery group?

I have similar reservations about forced attendance, but there is something to be gained from the sense of support that a good group can provide.

-What is the value of the 4^th through 6^th steps of a 12-step program, where the addict specifically addresses his/her character defects and asks for their removal by a higher power? Are these steps critical to the resolution of character defects?

These steps are necessary for addicts in ‘sober recovery’, as the obsession to use will come and go to varying degrees over time depending on the individual and his/her stress level. But for a person taking suboxone I see the steps as valuable, but not essential.

-Where does methadone fit in?

Methadone is just another opiate agonist. A newly-raised dosage will prevent cravings temporarily, but as tolerance inevitably rises, cravings will return. With cravings comes the obsession to use and the associated character defects. This explains the profound difference in the subjective experiences of addicts maintained on suboxone versus methadone, and explains why in my practice I have many patients who have switched to suboxone, but none in the other direction.

The downside of suboxone.

Practitioners in traditional AODA treatment programs will see suboxone as at best a mixed blessing. Desperation is often required to open the addict’s mind to change, and desperation is harder to achieve when an addict has the option to leave treatment and find a practitioner who will prescribe suboxone. Suboxone is sometimes used ‘on the street’ by addicts who want to take time off from addiction without committing to long term sobriety. Suboxone itself can be abused for short periods of time, until tolerance develops to the drug. Snorting suboxone reportedly results in a faster time of onset, without allowing the absorption of the naloxone that prevents intravenous use. Finally, the remission model of suboxone use implies long term use of the drug. Chronic use of any opiate, including suboxone, has the potential for negative effects on testosterone levels and sexual function, and the use of suboxone is complicated when surgery is necessary. Short- or moderate-term use of suboxone raises a host of additional questions, including how to convert from drug-induced remission, without desperation, to sober recovery, which often requires desperation.The beginning of the future.Time will tell whether or not suboxone will work with traditional recovery, or whether there will continue to be two distinct options that are in some ways at odds with each other. The good news is that treatment of opiate addiction has proven to be profitable for at least one pharmaceutical company, and such success will surely invite a great deal of research into addiction treatment. At one time we had two or three treatment options for hypertension, including a drug called reserpine that would never be used for similar indications today. Some day we will likely look back on suboxone as the beginning of new age of addiction treatment. But for now, the treatment community would be best served by recognizing each other’s strengths, rather than pointing out weaknesses.

This article can be reproduced freely as long as the following attribution is included:

The author, Jeffrey T. Junig MD PhD is a psychiatrist in solo practice in Wisconsin, and is Asst Clinical Professor of Psychiatry at the Medical College of Wisconsin. Read more articles about suboxone at http://subox.info or at Suboxone Talk Zone: http://subox.info/blog.html . He can be contacted at Fond du Lac Psychiatry or at the Wisconsin Opiate Management Center.

Hi XXXXXXX,

I received your message. A couple thoughts… As far as pain goes, the suboxone has the analgesic potency of about 30 mg of methadone or about 50-60 mg of oxycodone. Your best bet, with or without suboxone, is to avoid treating back pain with opiates– that is a dead end street with a pile of messed up lives at the end of it. It may be that you were treating aches and pains that you didn’t know that you had– often people on opiates will hurt their backs, knees, whatever, without knowing it, and continue to do more and more damage without the usual warning that our bodies give us (as pain). If you try to treat back pain with opiates long term, the tolerance requires higher and higher doses of meds, and the patients gets more and more messed up by the obsession for opiates. So… the treatment for your back should include 1) rehabilitation either through physical therapy or by your own exercise and stretching routine, 2) anti-inflammatory medication like ibuprofen or naprosyn (over the counter as aleve), 3) avoid re-injury by learning correct lifting technique and avoiding certain things that you know will aggravate it, 4) ice after over-use, heat to loosen muscles at night, 5) getting enough sleep, and avoiding things that cause muscle spasm like caffeine, opiates, and alcohol.

Runny nose… that is sometimes a symptoms of withdrawal. That along with your other questions suggests that your tolerance is higher than the opiate effect of suboxone. Give it time, and it will go away– if it is still there after a couple weeks I would start to think it is something else, like a virus.As far as the meds ‘wearing off’, I have had the benefit of seeing the pharmacologic data on the drug buprenorphine when I was doing my ‘treatment advocate’ training with the company. The drug lasts forever in us humans– when a person stops taking subox the ‘real withdrawal’ doesn’t hit for 3-5 days. In your case, you are likely feeling a combination of things. First, as I said in the prior paragraph, you are having mild withdrawal from ‘mismatch’ between your tolerance and the suboxone– this will resolve soon. Second, it is not uncommon for people to have full- blown withdrawal symptoms that come from our brains ‘replaying’ our earlier withdrawals. Usually the more we focus on them, the worse they become. They will fade away as your tolerance adjusts– by the time I see you again they should be gone. In the meantime try to keep busy and distract yourself as soon as you sense them coming, or if they come at a certain time each day try to keep busy at that time. More subox will not help, because of the ceiling effect of the drug– your receptors are all bound up at 8-16 mg/day.

Call Nancy to set up an appointment soon, because we do fill up!

Take care,J

Nausea usually comes about if the opiate effect of the suboxone is stronger than what you were used to. Reduce the dose to half a pill per day– that will be enough to prevent withdrawal (even a quarter of a pill per day will prevent withdrawal), but hopefully won’t be so much that you get sick. Once you tolerate that dose, you can slowly increase every few days to the full amount.

Sometimes the nausea comes from the naloxone, and we have to go with subutex– but subutex is more expensive and less available. Usually reducing the dose does the trick. The nausea is almost always gone after 4-5 days. I could prescribe a med to reduce nausea– send me the phone number of a pharmacy if you want me to call in compazine. That med will make you sleepy, though, and has other potential side effects. For example, it can make your muscles twitch without your ability to control them (the symptoms go away after the drug wears off, in about 6 hours).

Again, send me a pharmacy phone number if you like, or otherwise give it a couple days at the reduced dose.

J

More Suboxone Information at subox.info.

My hope is that suboxone patients will use this site to discuss their experiences, hopes, and frustrations in a positive way. This is not a forum to debate whether or not suboxone is a wonder drug or the work of the devil, as there are already plenty of sites dedicated to particularly the latter opinion. But for those patients who are taking suboxone to induce remission of opiate addiction, who prefer the stability and normal mind that comes from suboxone maintenance over the chains of active opiate addiction, please use this space to tell your story, to ask questions, to post answers, or to just say ‘hello’.

To comment on a topic, click on the word ‘comments’. At the present time I do not plan to moderate what is written. If you would like to author your own articles or topics, send me an e-mail at blog@subox.info and I will give you permission.

More Suboxone Information at subox.info.