trafn

Hi,

I've been sober since 1992 and am now a physican who works with people suffering from opioid dependency. Specifically, I work with suboxone as part of a treatment triad: 1. motivated patient, 2. medication to control cravings and withrawal symptoms (suxboxone), so that the person can focus on, 3. counseling (the cure is in the counseling).

I would like to discuss individual experiences poeple have had during recovery and the positive and/or negative experiences they had with suboxone. I am hoping this will give me a greater understanding for those I am trying to help.

While nothing works for everyone, I have been very impressed with the results people get with this medication. But, it is NOT a cure. The cure is in the counseling and I refer everyone I work with to NA or AA. Yet, it is almost impossible to pursue counseling when you have cravings banging away in your head 24/7, or you're facing recurring withdrawals.

What are your thoughts?

kj0975

U should post this in the substance abuse forum as there are a few who use sub on that forum might get more feedback.

Tazman53

trafn I am a recovering alcoholic so I can not help with your query, but I would like to congradulate you on your sobriety.

I was medically detoxed and had some councilling and now maintain my sobriety using AA, I am not familiar with suboxone, I pray that it does not come with all the BS I have heard about methadone. If it doesn't, it sounds like a good path for one with an opiate problem to follow.

GvngIn

I started Suboxone 2 weeks ago and I am so happy this medication is available for addicts. I was taking about 200mg of hydrocodone a day, and had ZERO withdrawl symptoms due to the Suboxone. I am now on 24mg a day, and the only side effect I have experienced is loss of appetite.

The psychiatrist who prescribes this for me also mandates recipients of Suboxone participate in group meetings once a week in his office, and submit to twice weekly random urines. He also strongly suggests participation in AA or NA. Like you said, counseling is the key, and I feel that anyone who uses this medication as a quick fix, and does not work on their program, is really cheating themselves out of a wonderful sober life.

Best of luck to you,
Erinn

NoelleR

I'm a recovered alcoholic, and also a recovered addict.....no overall DOC, but a lot of opiods the last three-five years.....

I did not use sub or any other med to aid in my recovery, so I can't be of much help to u, but there are lots here who have used, and are using sub; they should be around soon.....

.....and kj0975....."U should post this in the substance abuse forum as there are a few who use sub on that forum might get more feedback."

This IS the Substance Abuse Forum, rightcheer..... (o:


NoelleR

kj0975

LOL I thought it was in the newcomers section. Sorry.

bval

Sweet, I've been hoping someone like you would come along!

Welcome to SR.com, and congrats on your 18 years of clean time. That is awesome stuff!

***** IMPORTANT: The content of this message is directed at the POSTER, a medical professional who's asking for 'medical advice', so everyone else, do NOT ACT on anything I've posted, please CONSULT YOUR DOCTOR instead *****

I got clean off (15 months now!) of a 240-400mg/day habit of OC's using buprenorphine, and I'm a pretty huge proponent of this medication, but after hanging out around here for over a year and hearing a lot of stories, I'm frankly pretty dismayed about the medical profession's practices around this medication. I'll outline some of these issues for you.

1) Doctors don't really seem to be able to gauge how much of the stuff people actually need, like AT ALL. All you have to do is look on this very thread to see an example of what I'm talking about (and I see this ALL the time on this board). Someone with a 200mg/day hydro habit does not *need* anywhere NEAR 24mg/day of bupe, especially not after two weeks. I experimented with this stuff a lot in my day, went on and off of it for a couple of years, truth told, before I finally got serious about getting clean, and I've advised people on this board (and gotten lots of feedback) about their dosages (despite our rules here ) many times, so I know something about whence I speak.

What I'm saying is, there doesn't seem to be meaningful dosage guidelines being distributed to prescribing doctors, either that, or they ignore them. So I'm going to give you *my* guidelines, based on personal experience, and that of many others. I'm going to base this on oxycodone dosages, since that's what I'm most experienced with. Obviously, hydrocodone is a bit weaker, mg/mg, and oral morphine is considerably weaker, mg/mg, since it's not nearly as well absorbed by that route vs. the opioids.

I think that roughly for every 100mg of OC that an addict is taking on a daily basis, they should START on 8mg of subs/day per 100mg/OC (up to a limit of 24mg/day). I think this dosage should then be halved after one week, then quartered after two weeks. That's basically what I did, (not because of my doctors advice, I might add) and I experienced no w/d's at any time.

I see WAY too many people on these boards who've been on 100mg/day (or even less) of hydrocodone that have been prescribed 16mg of subs a day, and frankly, that is just WAY WAY WAY more than they actually need to avoid w/d's, and will effectively make the process of getting clean much more lengthy and difficult than it would have been had they gotten a proper dosage from the beginning.

I also believe pretty strongly that this medicine works best when you break your daily dose up into 3-4 separate dosages over the course of the day, rather then slamming your body with all of it at once in the morning, which some doctors seem to prescribe. I think that has a tendency to make people not feel very good, causes more side-effects, and will actually prolong the length of time it will take them to get OFF the medication.

So seeing this corrected would be my A1 priority as far 'advice to doctors' goes.

***** IMPORTANT: The content of this message is directed at the POSTER, a medical professional who's asking for 'medical advice', so everyone else, do NOT ACT on anything I've posted, please CONSULT YOUR DOCTOR instead *****

2. People are not well enough advised about this drug by their doctors from the beginning. For example, I see many people here don't know really basic stuff about it. For example, I've seen ALL the following expressed by people here:

* They don't know it's a substitute opioid.
* They don't know it's an addictive drug.
* They don't know they will need to wean down to a *very* low dose before they stop it in order to avoid significant withdrawals.
* They don't know that by quitting short-acting opiates via bupe, they are making a tradeoff between short but intense withdrawals vs. longer but less intense withdrawals when they get off bupe.
* They don't know that when they first start taking it, they should prepare for the possibility that they are going to feel like utter crap for at least 24 hours (and sometimes longer) afterwards.
* They don't know that the nature of this drug is such that taking more will often make you feel WORSE, as opposed to better (unlike short-acting opioids, in general).
* They don't understand what the naloxone in Suboxone is supposed to do (which is NOTHING, provided the drug is taken as prescribed).
* They don't know that the sub/saliva mixture should be held in one's mouth for at least 20 minutes, otherwise they are just wasting money on a very expensive pill. It takes at least that long to absorb the majority of the bupe contained in these pills.
* They don't know whether should be spitting or swallowing the resultant mix. Many seem to experience stomach upset if they swallow, and it's frankly not necessary, so patients should be told they can spit it out.

I could go on and on, but you get the idea. Doctors should prepare handouts for people that explain all these things, and there should be a place on the handout where the doctor writes out a reasonable weaning schedule for the patient, along with spelling out ALL their other 'requirements' (drug tests, etc) so that the patient can see (and sign off on) what they are really 'signing up for' with regards to their bupe treatment so they can make a more informed choice about this course.

***** IMPORTANT: The content of this message is directed at the POSTER, a medical professional who's asking for 'medical advice', so everyone else, do NOT ACT on anything I've posted, please CONSULT YOUR DOCTOR instead *****

3. Doctors don't seem to know how fast to wean people, nor do they seem to know how low people need to get, dosage-wise, before stepping off. My guideline would be as follows: Most people can handle halving their dosage every month.

As you probably know, the reason it's so much easier to wean on this drug than methadone is a combination of the VERY long half-life (hence there is considerable buildup of blood concentration above and beyond what the person takes each day), and the fact that just being on bupe (and no dope) actually affects some measure of 'healing' of the receptors, and thus acts to literally reduce opioid tolerance over time.

As far as where to 'step off' at, I recommend this be at no more than 2mg/day, and at that dose for at least two weeks. That's what I stepped off at, and when I did so I was: completely broke, under my mom's lock and key, and under threat of ending up 'on the street' if I was to fail. Having never been 'on the street', and a pretty proud guy, that was a pretty huge motviation.

And honestly, I *just barely* pulled it off. The upside of stepping off at that dosage was that I basically got my ass kicked by withdrawals, and that has some measure of 'deterrent value' for the future. I can tell you, though, that many people wouldn't be able to pull off stepping off at 2mg, let alone more than that. As the physician, you should really try to judge the conditions/situation that the patient is going to be trying to do their final 'kick' under, and their general state of mental health/motivation, before deciding what dosage to have the patient step off at.

If you determine that a patient really needs to avoid any significant w/d's, for whatever reason (job situation, fear, whatever), they should be taken down to a dosage of about .5mg every OTHER day for about a month. Yes, you pretty much need to be down to that low a dose if you want to more or less avoid withdrawals.

***** IMPORTANT: The content of this message is directed at the POSTER, a medical professional who's asking for 'medical advice', so everyone else, do NOT ACT on anything I've posted, please CONSULT YOUR DOCTOR instead *****

4. I think setting up draconian 'conditions' that patients *must* follow in order to get their bupe in a doctor's office setting is TOTALLY inappropriate.

In other words, the 'drug testing' nonsense that some docs impose should be *optional*, at the request of the patient *only*. If someone is dependent on opioids, and they come to you to get bupe to combat their dependency, that DOES NOT give you license to *insist* that they 'quit taking drugs and get sober'.

The reality is, the nature of bupe makes it MUCH less dangerous to mix with other substances than most other drugs out there. Do you insist that everyone you give a prescription of vicodin to because they broke their arm submit to a drug screening? I didn't think so. Yet as far as interactions go, vicodin is considerably more dangerous than bupe. So that particular 'justification' that some doctors use in imposing drug-testing is mostly a smokescreen, and I believe it costs people their lives a long more often than it saves anyone.

Bottom-line, I say leave the drug tests to the state-sponsored clinic and detox environment, I think it has no place in an office setting. In fact, I think it should be virtually impossible for the patient to create a situation where they cut-off from their supply of bupe unless the doctor has good reason to suspect utterly bad faith on the part of the patient and/or diversion is taking place.

It's just think it's TOO IMPORTANT that people, once they are on bupe, STAY ON bupe and don't go back to shooting heroin or snorting oxys or whatever, cause they've been cut off due to some arbitrary 'rules' set by their doctor that are not LEGALLY REQUIRED to be enforced by said doctors. If you, as a physician, simply adhere to the law/your insurance regs, and don't go trying to make up a bunch of your own rules, you are likely to 'save' a lot more people than you otherwise would, in my own humble opinion.

I could write on for days about this stuff (as you may have guessed), but I gotta get to work.

***** IMPORTANT: The content of this message is directed at the POSTER, a medical professional who's asking for 'medical advice', so everyone else, do NOT ACT on anything I've posted, please CONSULT YOUR DOCTOR instead *****

kj3880

I agree to everything BV said, pretty much. As always, he's a wealth of exerience.

I will say that in my case, and a few others that my doc encountered (a 30 year-experienced addictionologist with special advanced training in drug replacement therapy) that it took longer than 2 weeks to go from the 4 mg to the 2 mg dose without really awful cravings and depression. I and several others had to go back to 4 mg for a couple of months before going back to 3mg, then to 2mg.

That might be because some people (like me) are dealing with the body's depleted ability to produce endorphins that's caused by long-term opiate use coupled with clinical depression (quite common pre-existing condition in opiate/opioid addicted patients).

The most helpful things about my doctor have been:
1. He takes his time listening to each patient in monthly counseling sessions to really hear what our needs are before writing the new prescription.
2. He treats me like a patient who needs care, not like a junkie who needs a drug test. Because of his positive attitude with me, for the first time in my adult life, I can tell the whole truth to this doctor.
3. This doctor understands that just because a patient relapses, doesn't mean he's finished working towards recovery. He encourages honesty about this by keeping the patients even if they do relapse, as long as keep making an effort to get back on track.
4. Doctor allows patients to give input and feedback on the correct dosage individually rather than relying on a model or preconceived tapering schedule. He understands that people recover at different rates and are not the same.

Hope this helps.
KJ

Timebuster

Doctor…

I don’t have the experience as the posters above have, but I have a question. This is from my own experience. In the late Nineties, I had a ten bag a day heroin addiction. My job medical coverage referred me to a sub specialist. At that time I never heard of this now miracle drug to help addicts with addiction. It was administered through a syringe without the needle under my tongue. I was never told of the dose, so I have no idea how much they were giving me.

I was told that they would wean me down until I no longer needed it. I was on suds for three months. Also in those three months I received intense consulting at the doctor office three times a week in a group setting with other recovery addicts.

The last week of them giving me my last dose of subs I felt a little uncomfortable. When I completed the sub program I had no withdrawal symptoms and I felt great. The first two weeks without drugs or subs and my drug addict mentality I relapse. I was back doing dope.

My personal experience, I can tell you why I relapse. I did not work a program and the sub experience was to easy. My drug addict mentality said, I now have my ace in the hole. I can go out and shoot dope and when the you know what hit’s the fan I can go back on the subs.

So my question to you is. Do you have the same experience in your practice with addicts who are looking to recover from addiction but play the addict game.

Thanks in advance.

Ivan

CarolD

Oops! I did move this from Newcomers
and forgot to PM you tho I did trafn.

Thanks for your suggestion. ..

PeachyClean

What happened to bvaljalo's post?? It was very informative and interesting.

Hello trafn,

I am a recovered addict. I didn't use any type of medication to help with my addiction.

I just wanted to say welcome and congradulations of your accomplishments.

Lily

I haven't used Suboxone, but after detoxing off opiates and being sick for almost a week, I haven't ever used more than 5 days in a row out of fear. I also have almost 8 months clean and this is after having 8 yrs prevoiusly w/ a prior meth addiction, no painful withdrawal there, just sleep for probably 2 weeks.

however, I have got to work an NA program. I have to be around other addicts and work my steps. It is when I am off on my own my mind starts thinking....just a little bit.

Make sure you impress meetings on your patients!

blessings, Sheila

NoelleR

Thx Carol.....heck, I often haven't got a clue where I am...

One of the ministers in my church loves the verse in Deut. where it says that God will bless us in our coming in and our going out...we love to take that to mean that He'll bless us even if we don't know whether we're coming or going....good thing, too.....lol


NoelleR

jane_668

Hi,

I'm a recovering addict.MY DOC is Tramadol.I had a hard time staying off it. I was always motivated and each time I was convinced that this time I'll make but I was never clean more than a month in five years.It almost destroyed evry precious thing in my life.So I decided too give Subutex a try.It was the best thing that evr happened to me.i got my life back together.I'm finally able to work and have alife

bval

I should say I also agree with KJ, that whilst the estimations I gave above worked pretty well for me, they are just estimations, and that doctors shouldn't necessarily 'religiously' rely on any set schedule of weaning, but rather should take the patients input into account. Especially when the dosages start to really get down lower towards the end of the taper, and *especially* if the patient is trying to hold down a job and/or tend to a family at the same time they're tapering.

I also think doctors should be open to the idea that some people may really need to stay on a low maintenance dose literally for *years*. Whatever it takes to keep a person off the regular, life-destroying dope ...

Thanks for putting my post back up Peter

windysan

I kicked in a psych unit. Went to rehab 28 days. Went to meetings for a couple of years until I realized I was too stupid to understand all the religious stuff and that I disagreed with most of it. I've been off dope 5 1/2 years. No cravings, no desires.

Fishing is great therapy. Take your patients fishing.

bval

I totally know what you're saying Ivan, and that's a legit concern anytime you're dealing with anything that makes going through withdrawals easier for a person. But if you think about it from another angle, there's a lot of drugs out there that people get hooked on that really don't have any appreciable withdrawals (snorted coke or speed, for example, don't have anywhere near the kind of withdrawals associated with them that heavy opioid usage does), yet people still struggle for years with quitting (and staying off) these drugs as well. The point is, getting clean and *staying* clean will *always* be more about the addicts level of desire for a clean life than anything else.

Something I should point out about bupe that makes it sort of 'ideal' for the purpose it's used for is that switching back and forth going from bupe to regular dope is really pretty arduous. You apparently only used it one time to help you get off dope, so you haven't really experienced what I'm talking about.

Had you continued to try to go back and forth multiple times, you'd have quickly discovered that it's not nearly the 'ace in the hole' you imagined it to be. It's more like pocket 8's. Basically, every time you try to get back ONTO bupe, it gets harder and harder. In other words, it takes longer to stabilize and start feeling well on it again, especially if your dope habit has gotten worse, which it typically WILL each time you relapse.

Plus, nowadays, you're not going to be getting bupe shots under the tongue directly from the doctor, you're going to have to manage your dosages yourself over the course of a month between doctor visits. It's a lot trickier (and harder) to manage a proper weaning schedule under these conditions, when it's left more up to you than the doctor directly.

Also, you may not get a doctor who'll wean you down as low as you'd need to go in order to totally avoid withdrawals, some docs *want* you to go through some measure of withdrawals after bupe, for just the reason you've described above.

Also, especially during the weaning period, you can easily end up running out of meds early, and end up getting sick. Sometimes docs will suddenly take days off when you're supposed to be going in to get your script.

Sh*t happens, in other words, and being on bupe, while much better than being on dope, is not always quite as convenient a proposition as it may seem at first blush, and it's certainly no guarantee that you won't at some point end up in withdrawals.

The most important thing about it is ... most people cannot handle the withdrawals from a large habit, and thus end up with the monkey chained to their backs, destroying their lives, cause they see no other option. With bupe, there is now another option, and life is simply a lot better on bupe than it is in the grips of oxys or heroin or even methadone (IMHO). I think it's a life-saver, despite the fact that, yeah, as you say, it may *seem* like a means by which one could perpetuate a cycle of relapse/getting clean ... in practice, that 'cycle' turns out to be not nearly as practical as it might seem to you based on your personal experience.

Bottom-line, bupe DOES have withdrawals, and they are significant, and they are hard to avoid unless you have someone else FORCING you to wean down to a proper dose. You were lucky enough (or ... not) to have bupe in that situation timebuster, but most people ... are not going to have that luxury. By far the vast majority of people nowadays who get off of dope using bupe ... are going to have to tough out some real withdrawals eventually.

I should add ... bupe w/d's are NOT as bad as regular dope, as long as you step off at a reasonably low dose, though. And weaning down is actually relatively easy compared to how it is trying to wean off of dope. So ...

windysan

I'm sure glad I ain't gotta kick dope no more.

bval

WORD, Windy.

The only thing I know of that sucks anywhere near as bad is the death of a close relative. I'd imagine suffering through terminal cancer, or dying from starvation, would probably be worse, too, but I've not 'been there'.

There ain't a *whole lot* in this life that's worse, that's for sure.

ccgirl2

I tried sub once and spent most of my inpatient detox puking. Somehow I don't think its a typical reaction.