Sick When Starting Suboxone: Abres Los Ojos!

An interesting case from a reader:
Thanks Doc for your efforts. I appreciate you.
I am a four year hydrocodone addict 55 years old. I became addicted when I used the drug for an injured cervical disc.
A couple of years ago I found out about suboxone and got in touch with a Dr. in Tulsa who prescribed it for me. I waited until I thought I was in withdrawl..about twenty hours and took my first dose. I became dizzy, nausiated, numb and all I could do was make it to the bedroom where my nausea eased a bit…I never vomited. I lay there for ten hours in a numbed state half in and out of sleep. The next day I was fine.
The Dr. said I took it too early. So, I waited a week without any hydros and took another pill and got the same results. The Dr. said to flush them and I did.

Two years later I am still an addict. Do you think I should try again? Could I take small slivers of the pill without the negative effects? What do you think?
I am desperate to get clean.
I have also heard about subutex but have never tried it. Could it be that subutex is what I should try for?
Respectfully,
John in Oklahoma
My Response:

High on opiates
High on opiates

How much hydrocodone were you taking in the days leading up to taking Suboxone? Your reaction sound more like a person overdosing on buprenorphine than precipitated withdrawal– do you remember, at the time you were nauseated, were your pupils very large, or very small? If you were in withdrawal your pupils would be huge; if you were overdosing they would be ‘pinpoint’, and if you were having an allergic reaction of some type, they would be about normal.
20 hours should be plenty long for hydrocodone, and your second attempt could not have been precipitated withdrawal, providing you weren’t on some other opiate. Nausea and vomiting are not the main features of withdrawal; more typical would be lower abdominal cramps and diarrhea. Nausea is a big part of overdose, on the other hand. The potency of Suboxone (any dose above 4 mg) is equal to about 30 mg of methadone, or about 60 mg of oxycodone, or about 100 mg of hydrocodone… if you were taking the 5 mg tabs, that would mean that a tablet of Suboxone would equal the potency of about 20 tablets of vicodin. Since vicodin lasts only a few hours, to have an equal tolerance you would need to be taking about 20 times 6 = 120 tabs of vicodin per day. That is a lot of vicodin– enough to kill you by destroying your liver, so you were probably taking significantly less.
Out of junk
Out of junk

I think the Suboxone was just too strong. Yes, you could try working your way up with tiny pieces, but it is
hard to titrate at the low doses because of the unusual dose/response curve. I think a better way, if you are not on a huge dose of vicodin, would be to use clonidine, immodium, and maybe some other things to help with the withdrawal, and use the steps to stay clean… otherwise you will be moving up the tolerance ladder.
Subutex would be another option if I am wrong with my assumptions about your dosing– some rare people do have bad reactions to the naloxone, even though little gets into the system. One other hypothesis… if you were taking tons of vicodin, and your liver was in bad shape, your liver might not have been able to destroy the naloxone (first pass metabolism at the liver is what keeps the naloxone in Suboxone from working), and so the naloxone in Suboxone precipitated withdrawal.
Good luck!
John Writes Back:
Yes, Dr. you may be right. My dose was relatively low, I was taking at or about four or five lortab 10 tablets a day.
I wasn’t aware of the potency of the suboxone. I seem to remember I took the four or five mg. tabs, the small orange hex shaped one.
I did not check my pupils, but if I take it again I will be sure to do that.
I know my dosage is not that of others and that Vicodin addiction is not that of Oxycontin or heroin. That said, I still feel hoplessly addicted to them and have tried the twelve steps twice. That is why I am interested in the suboxone, but like you say it would be stepping up the tolerance ladder, I suppose. Since my willpower is nonexistant at this point, I think I am going to give the suboxone one more try the way I suggested and I will let you know how it works.
Half-wasted?
Half-wasted?

Thanks for your timely reply, and I think you hit the nail on the head.
God bless you
John in Oklahoma
And Me Again:
You might want try a bit of a medication called ‘hydroxyzine’, which is used to reduce nausea from opiates– although it also can be quite sedating, so don’t drive on the combination. A non-sedating alternative would be odantreson (zofran), which is what is given post-op for nausea. In fact, forget the hydroxyzine– premedicate yourself with a dose of zofran, about 4 hours before the induction, and you should do much better.

Waiting for Suboxone after Heroin

How long do you have to wait before taking Suboxone, if one had been using heroin for almost a year? What can one take to ease the withdrawal symptoms in the meantime while waiting? Are treatment centers effective places to go to as a start or just start out with a qualified Suboxone doctor? Any feedback would be great! Thank You.
Hi, and thanks for writing.  Once a person has been on something for a couple months it doesn’t matter if it is three months or three years– the tolerance and risk of precipitated withdrawal are more a function of dose and type of drug than of time.  For example, methadone and high-dose fentanyl have long elimination half-lives and therefore take longer to leave the body before starting Suboxone, whereas low-dose fentanyl or crushed oxycodone have short half-lives and leave more quickly.  Heroin is somewhere in between, longer acting than oxycodone but shorter than methadone.
As soon as you start withdrawing, your tolerance will start to fall.  It falls the fastest initially and then slows down a bit after the first couple days.  For heroin, people who go three days without using will do great– that is more than enough time.  If your daily dose is on the low side 24 hours is sufficient to avoid precipitated withdrawal;  if your dose is real high you might want to try to go a bit longer, say 36-48 hours or so. Treat withdrawal symptoms by treating the individual symptoms.  First, take clonidine– that will reduce all of the symptoms by about half.  It requires a prescription but most docs will prescribe it, as it is pretty safe.  You can take the skin patch, but i prefer the pills because they can be controlled more easily to increase or decrease the dose.  I give 0.1-0.3 mg every six hours or so; stop it if you get light-headed when standing up quickly.  It is a $4 med at Wal-Mart. For the diarrhea and cramps, take immodium, sold over the counter.  For body aches take ibuprofen and tylenol (both if your liver and stomach are in good shape– avoid the tylenol if you have hep C).  A small dose of ativan or valium goes a long way in the evening;  the clonidine helps with sleep as well.  If you don’t have either you can take some benadryl– it will make you sleepy and might reduce your anxiety a bit.  Keep warm by soaking in a hot bath as much as possible– that will also relax your muscles.
Some detox centers use Suboxone, but some don’t– be sure to check.  Likewise different providers have different styles.  The local hospital by me makes Suboxone patients spend the night before induction!  Not sure how the insurance companies let them get away with that.  But some docs around here make people wait longer before starting Suboxone– I have heard some descriptions of other places that sound a bit silly, like ‘just don’t take anything for a week’.  Hmmm. Reminds me of that old joke where the guy goes into the pharmacy and asks for talcum powder and the woman says ‘sure– walk this way’.  As she walks away the guy says ‘if I could walk like that I wouldn’t need the talcum powder!’   (sorry– working on a Sunday does that to me…)
SD

Induction, Relapse, Benzo Questions

Some questions about the induction process and my answers:

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.