Suboxone Talk Zone

I am going to move this question to a new post so that everyone can read it:

hi jeff-
i am in recoverery and was injured, was on percocets for about three months. i kinds detoxed with a lower dose of opiates but then took a few days worth again after a hard weekend. a few days later the wd symptoms came right back! oh, i couldn't take it so i asked my doctor for suboxone. he knew nothing about it and wanted to give me yet more opiates. after a lot of convincing he gave me 2 mg tabs/30 days worth. I want to be done with all this stuff asap- so what's your suggestion as to how to take this just to make it through the wd's from the opiates? thanks jeff

January 30, 2008 4:44 AM

This question illustrates a number of points. The first point is that opiate addiction is a life-long illness. Anonymous does not say how long he or she has been 'in recovery', but for the most part it does not matter; people who have been clean for years or even decades will find themselves brought instantly back to the mess they thought they left behind, after just a percocet or two. As addiction is a conditioned, or learned, process, it makes sense; If I take you back to your childhood neighborhood after twenty years away, you will likely be able to find your way around without difficulty. Unfortunately we cannot erase conditioned behavior any more than we can intentionally forget bad memories.

A second point concerns the nature of withdrawal. I am convinced that the intensity of withdrawal is more related to the intensity of prior withdrawals than to the amount of drug used. I have heard people describe very severe withdrawal after minimal relapse. There is a term in medicine-- 'kindling'-- which describes how CNS symptoms such as seizures become worse each time they occur. I have found that withdrawal is similar.

A third issue is the legality of prescribing opiates. It is illegal for anyone to prescribe a narcotic for the purpose of avoiding withdrawal, with the exception of certified methadone clinics or suboxone prescribers. It is illegal for a pain physician to taper a person off opiates to avoid withdrawal; it is illegal for a family practice doc to prescribe vicodin to avoid withdrawal. A family practice doc can prescribe suboxone for pain, but cannot prescribe suboxone for addiction UNLESS the doc is suboxone certified.

As for answers, My first question would be, what is/was the nature of your recovery? If you are involved in AA or NA, I recommend stopping the opiates and getting to a meeting, and then hitting as many meetings as you can for the next few months. If you hope to be opiate-free again, your best bet is to just stop using, and take the withdrawal.

If, on the other hand, your recovery was a bit 'shaky', or if you always had intense cravings, or if you just cannot stop using (God forbid that you have found a source of opiates), you may want to consider suboxone. Many people find that after years of being clean they still felt like an opiate addict just hanging on.... those people will often feel 'normal' for the first time when they take suboxone. In such a case, though, you would likely end up taking suboxone for a long time-- perhaps for the rest of your life.

Suboxone can be used to taper off of opiates, but it is most useful in this regard for coming off of high doses of methadone, which is extremely difficult to do. Suboxone (buprenorphine) is a very potent opiate-- much more potent than oxycodone-- and so it is probably as easy or even easier to come off oxycodone than to come off suboxone. The problem is that just coming off the opiate, as tough as it seems right now, is really the easy part. The hard part is staying off of opiates, as you found after your 'tough weekend'. If you do not have a good program going on in AA or NA, then you really may want to consider suboxone. It will prevent relapse and put your addiction into remission with a minimum of pain or discomfort. But again, this is a long term proposition-- just as opiate dependence is a long term illness.

Labels: recovery, relapse, withdrawal

I just changed the settings so that anyone can comment, not just people with gmail accounts. If you want permission to post NEW topics, send me an e-mail. I don't need your real name.

This new patient has been on suboxone for two weeks, and reports having low back pain and a runny nose. He also feels that the 16 mg dose of suboxone that he takes in the morning wears off by the end of the day. You can read my answer, and feel free to add your own experiences or suggestions:

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

Feel free to hit the 'comments' button to post follow-up questions to any post!

Nausea is not uncommon in patients starting suboxone. Please read what I wrote to this patient:

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

I know from my radio show that I will need to talk by myself for awhile... I often get letters from patients that ask specific questions that can be answered in general ways. I will include my responses, blocking any personal information, and maybe others will read my opinions and learn from them. Today I received an e-mail from a patient complaining that she takes one 8 mg dose in the AM, and by noon she thinks it has worn off. She uses the suboxone for pain control; before suboxone she was a bit out of control with narcotic pain pills--we all know how it goes-- running out early and withdrawing, or always needing more, or fearing that her lecturing doc would stop prescribing. Hear is my response:

Dear XXXX,

Yes, I did receive your message. Clarify for me a couple things—when you say ‘by mid day you feel the same’ I’m not sure what you mean. Feel the same to when? To before you took the dose? And what feelings are you talking about—pain? Or withdrawal?

Every day, another study comes out looking at the unique way that buprenorphine acts in the body (buprenorphine is the active substance in suboxone). We now know that the action of buprenorphine at different doses can be plotted out to form a bell-shaped curve. To visualize how this works, picture the liberty bell sitting on the ‘x’ (flat) axis, and the outline of the bell represents the opiate effect of the drug, as the dose is increased going from left to right. To translate what that mean for the patient, the effect increases as the dose goes up to 2 mg, and then levels out for awhile (the bell has a wide, flat top). Then at high doses the drug blocks itself, and the activity decreases again. In a patient, that means that you will get some pain control out of the drug up to about 2 mg per day, but then higher doses have no significantly higher effect. At much higher doses the drug actually blocks its own opiate activity and causes withdrawal.

The other thing we know is that the drug is extremely long acting. A single 8 mg dose will prevent withdrawal for 3-4 days. I can be certain that when you take 4 or 8 mg, the level of drug in your system will be virtually constant for 24 hours. The fact that you feel less after such a short period of time suggests that other factors are at play—the psychological effects of opiates in opiate users is almost as strong sometimes as the effects of the drugs themselves. I have noted that my patients' reactions are consistent with the pharmacodynamics of buprenorphine. For example, people who taper off suboxone find that it is very easy to go from 16 or 24 mg per day down to 4 mg per day—there is no significant withdrawal for that move. But going down that last bit, below 2-4 mg, causes withdrawal.

For you, you will not get any increase in pain control at higher doses. In fact, if you took doses higher than 32 mg you may start to get less pain control as the drug blocks itself. Likewise, increasing the dose from 8 to 16 mg will not make it last any longer, as it is already lasting several days. I can easily prove that to you—just stop taking the drug, and you will find that on day 3 or day 4 you will have withdrawal as it finally leaves your body. The main benefit from raising from 8 to 16 mg is the drop in cravings at the higher dose.

In your case, there is certainly a strong element of relief that is connected to just taking a pill. I would have no problem increasing you to 16 mg per day, but it would cost more, and I doubt it will reduce pain much more effectively. There are some points that are important for you to remember:

Opiate users derive a certain comfort from the drama of taking substances. I don’t know if it is the distraction, the placebo effect, or the feeling of being more in control from taking a medication. This 'comfort' sometimes becomes important enough that the patient thinks it is something they really need. But be aware of the limitations of the medication. For chronic pain, there never is a magic bullet that will do all that we need it to do. We have meds that can take the edge off of discomfort, but most of the improvement in function will come from non-med sources.

Examples of non-med sources include first and foremost, exercise. Low grade exercise, and just as importantly gentle stretching, are the primary healing function for fibromyalgia and other chronic pain conditions. Without exercise and stretching, the patient will not improve, and if on narcotics will likely do worse over time.

Ibuprofen and Tylenol are often helpful adjuncts to narcotics, and are not a problem when taking suboxone.

It is common for patients who have taken higher amounts of opiates to become quite focused on the effects of the drug. A person without addiction will take a pain pill for pain, and the resume activity without a second thought about the medication. At the end of the day he/she is likely hard pressed to remember if or when the med stopped working. People used to taking opiates are hyperaware of when the drug sets in, when it levels out, and when it decreases. They lose the opportunity to find pleasure in whatever it was that they were going to do on that particular day, because the whole day becomes about the medication. Ideally, suboxone will allow the patient to confidently know that the med is working, and that it will last all day—so there is no need to think about it and wait for it to wear off. Try to see the way that opiates grab your attention, and try to distract yourself by taking up some other activity that interest you or that you enjoy. Pain is always at its worst when one is highlighting it with attention.

Anwer my questions when you get a chance. Let me know if you think 16 mg will be helpful, as maybe you are craving opiates a bit. Finally, make sure that you are putting time aside for stretching and exercise—at least an hour or two per day.

JJ

I'm off to watch some football. Go Pack!! Oh-- and please, don't be shy. Add your questions or comments.

One of the comments I hear the most from suboxone piatients that they had their own group-- a place to talk about addiction issues, frustrations, inspirations, etc, without the need to hide their use of suboxone. Many suboxone patients attend AA or NA for the fellowship, but are held back from complete honesty for fear of being ostracized (a valid fear).

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.

Labels: addiction, buprenorphine, methadone, opiate, pain pill, suboxone, withdrawal