Tapering off Buprenorphine or Suboxone, Pt 2

In the last post we discussed some of the misconceptions about tapering off opioids.  Today we will discuss a couple basic principles, and then describe the approach I recommend for my patients tapering off buprenorphine.
Opioids act at receptors that normally bind endorphins, which are released by neurons in response to a range of stimuli including trauma and rewarding behaviors such as eating a good meal or using addictive drugs.  Endorphin pathways elevate mood, reduce sensation of pain, and impact urine production, immune function, intestinal motility, and other bodily functions.  Endorphin pathways have a certain baseline activity or ‘opioid tone’ that is directly related to opioid tolerance.   When opioid stimulation is greater than one’s tolerance, opioid tone is increased.  When opioid stimulation drops below one’s tolerance, opioid tone is reduced, causing withdrawal symptoms.
The goal of any taper off opioids is to recover original or native opioid tolerance.  Some people focus on getting rid of the opioid, and even use substances or behaviors to ‘flush buprenorphine from the body’.   Products marketed as detox agents have minimal impact on the clearance of buprenorphine or other substances.  And even if they could increase the rate of clearance,  they would only make detox harder by increasing the severity of withdrawal symptoms.  The relatively slow metabolism and clearance of buprenorphine provides a cushion by slowing the loss of opioid tone.
Prolonged use of any opioid changes opioid receptors.   The changes are not fully understood but include a decrease in number of receptors and changes in binding properties that reduce receptor sensitivity to opioids, including endogenous opioids (endorphins).  Recovery from a state of tolerance takes 2-3 months, and is initiated by reduced opioid tone.  Withdrawal symptoms reflect the reduced opioid tone that provokes eventual recovery of native tolerance.
Recovery of native tolerance is the rate-limiting step when tapering off any opioid, including buprenorphine.  When the dose of buprenorphine is reduced, the amount of buprenorphine at opioid receptors decreases over the next 5 days and then stabilizes at a lower level.  In response, opioid tone (the summation of current flow through opioid receptors) drops below normal.   If the dose of buprenorphine is maintained at that level, opioid tone will recover to normal in about 2-3 months.  If buprenorphine is suddenly and completely discontinued, opioid tone will decrease to very low levels and cause severe withdrawal that lasts for 2-3 months.  If buprenorphine dose decreases more slowly, opioid tone will decrease more slowly, lessening the severity of withdrawal.  But it still takes 2-3 months for opioid tone to return to normal.  So for any taper, patients must decide whether to decrease their dose quickly and be done in 2-3 months, at the cost of greater withdrawal, or instead to taper more slowly to reduce the severity of withdrawal.
The relationship between buprenorphine dose and opioid activity is linear up to about 2-6 mg.  Beyond that point further increases in dose have less impact on opioid tone.   The reverse occurs when tapering, so that opioid tone decreases only slightly as dose is reduced from 16 mg per day to 4 mg per day.  The non-linear dose/response relationship allows for rapid decreases in dose early in the taper process with limited or no physical withdrawal symptoms. Since the early challenge is mostly psychological, I use the early part of a taper to help assess whether a patient is truly ready to take on the tapering process.
I like to have patients lead the way in tapering off buprenorphine.  I’ve found that if I lead and reduce the amount of prescribed buprenorphine for the next month, patients often fail to make reductions and end up out of medication before the end of the month.  So instead I ask patients to tell me when they are certain that they are ready to stay at the lower dose.
During a taper, I recommend dosing buprenorphine twice per day.  Patients start by removing 2 mg from the evening dose.    After at least two weeks 2 mg can be removed from the morning dose.  This sequence is repeated at intervals of at least 2 weeks until the total dose is 4 mg per day. In my experience patients who get to that point are usually in a good mental position to begin the second, more difficult part of the taper.
Most people will be able to continue working when opioid dose is reduced by 5% or less every 2 weeks, or 10% every month.  That number is a good general guideline when deciding how fast to taper.  Suboxone film makes tapering relatively easy.  Patients purchase a weekly med organizer, and start the week by opening and stacking 7 films.  A scissors or razor is used to cut a millimeter from the end of the stack, and one film is placed in each compartment of the organizer for that day’s dose.  When the patient is comfortable with that dose, slightly more is removed for the next week.  The process continues every 2-4 weeks, eventually changing to the 2 mg films.  I recommend that patients continue tapering until the dose is 300 micrograms (0.3 mg) per day or less before stopping buprenorphine completely.  It is fairly easy to guesstimate where to cut the film in order to reduce by 10%;  just measure half, then half of that, then half of that.
Buprenorphine tablets, of course, are much harder to divide.  Zubsolv did people a favor by coming out with a range of doses, and hopefully other brand and generic manufacturers will eventually follow suit. For now I usually have patients use the tablets to taper as far as possible, using the 2 mg tablets in the lower dose range, and then pay the extra cost for the film for the final month or so.   A 12 mg film can be divided into 24 half-milligram pieces without too much effort, so the cost doesn’t have to be prohibitive.
I have had many patients taper successfully off buprenorphine.  Fear is common and normal for a number of reasons, but the fear usually gives way to a sense of confidence and optimism when a taper is done correctly.
Things to keep in mind:

  • Be patient.  Tapering by too much, or too quickly, causes withdrawal symptoms that lead to ‘yo-yos’ in dose.
  • Buprenorphine products are very potent.  A sliver of Suboxone Film may contain enough buprenorphine to harm or kill an animal or small child.  Take care to divide the medication in a well-lit setting, and clean up very carefully.
  • Buprenorphine is used to treat pain in microgram doses.  If you jump from 1 mg, you will have considerable withdrawal symptoms.
  • If you are still running out of medication early, it is not time to taper off the medication.
  • People on buprenorphine for a year or less have rates of relapse over 90%.  In my experience patients are more successful tapering off buprenorphine if they have been on the medication for 2-5 years or more.
  • If you struggle in tapering down to 8 mg, consider going back to your stable dose, waiting 6 months, and trying again.
  • People addicted to opioids often substitute other drugs for their drug of choice.  Do not start a new addictive substance in order to get off buprenorphine.

Good luck!

Tapering Off Buprenorphine or Suboxone pt. 1

Many patients taking buprenorphine live in fear of a dark world around the corner where they will have to taper off the medication.  They see horror stories on YouTube posted by people who, for some reason, abruptly stopped the medication and kept a video log of their experiences.   My own patients sometimes ask, nervously, if I plan to retire some day.  Some have asked what they should do if I ever, say, drop dead.
It needn’t be all that bad.  Yes, sudden discontinuation of a typical dose of buprenorphine will result in withdrawal symptoms.  But if you taper correctly, your body will slowly reset your tolerance without putting you through the wringer.   In this post I’ll describe my typical approach to helping a person through that process.  But first we should correct some of the misconceptions about buprenorphine and opioid dependence.
It does NOT get harder and harder to stop buprenorphine the longer you take the medication.  I have heard that idea over and over in one form or another, and I presume it comes from the experience people have with active addiction where use tends to grow with time, and other facets of life gradually fade away.   But the opposite occurs in patients treated with maintenance agents like buprenorphine or methadone, where use of the medication does not trigger a reward or relieve the ‘punishment’ of withdrawal.   The conditioning that occurred during active addiction is slowly extinguished, and most people gradually lose the desire to use opioids.   I’ve witnessed this process literally hundreds of times over the past 12 years in patients on buprenorphine or methadone. Patients of successful treatment also develop interests and accomplishments that help them avoid returning to opioids.  And after a few years away from ‘using friends’, people no longer see themselves as part of the using scene.  Patients get to a point where they have too much to lose to get close to that world again.
Opioid withdrawal has physical and psychological dimensions.  During short-term detoxes, minor physical symptoms trigger fears that magnify the perception of those symptoms.  A bead of sweat on the neck signals that hot flashes, diarrhea, and depression are on the way.  Patients who have been away from the cycle of using and withdrawal don’t seem to have as many emotions about their physical symptoms.  I see the change very clearly in methadone-assisted treatment, where the minor withdrawal at the end of the day is a big deal to people starting treatment, but a minor inconvenience in patients tapering off methadone after several years of treatment.
Does buprenorphine ‘get in your bones’?  YES, of course!  Bones are living tissue, so anything in the bloodstream gets in the bones.  Glucose gets in your bones.  Aspirin gets in your bones.  But so what? When you taper off buprenorphine, the buprenorphine in your body will be metabolized and removed.  It does not accumulate or stay in bones or other tissues beyond what occurs with other fat-soluble molecules.
Is buprenorphine or Suboxone ‘the hardest opioid to stop’?  No.  The brain keeps no record of the molecules that pushed opioid tolerance higher.   The challenge during a taper is that opioid receptors have become down-regulated by opioid stimulation, resulting in reduced endorphin tone as the opioid is removed.   Opioids that leave the body quickly tend to have more-intense discontinuation effects than those that leave more slowly because the latter mimics a taper, where opioid activity decreases over time.  The longer half-life of buprenorphine also slightly extends the total period of withdrawal by a few days.
I’ve heard people claim that ‘heroin was much easier to stop’, and rather than tell people what they should think I’ll let them have their opinions on the issue.  But that opinion is not supported by studies comparing withdrawal from different opioids.  Usually the claim is followed by the comment that ‘with heroin I was fine after 4 days’ or something along that line.  But it takes longer for tolerance to reset, after ANY opioid.  I suspect that perception comes from the severity of early heroin withdrawal, making subsequent weeks easier by comparison.  Again, the brain doesn’t care which opioid you used to take;  it only cares that the opioid stimulation that was there is now gone.
In a few days I’ll share the approach I recommend to patients tapering off buprenorphine.

How and When to Stop Buprenorphine or Suboxone

First Posted 12/15/2013
People know my bias—that buprenorphine is best-considered a chronic, perhaps life-long treatment for a chronic, life-long disease.  That said, I am aware of how many people out there are convinced that they need to be ‘off everything,’ no matter the misery opioids have caused in their lives.  I don’t get it; my perspective over the years has been seeing obituaries of patients who were doing great on buprenorphine or Suboxone for years, until well-intentioned relatives convinced them that they weren’t really clean.
But I’ve written all of this before.  For those of you who are still intent on stopping buprenorphine, I’ll share my observations after watching hundreds of people stop the medication—some intentionally, and some before going back to H for some crazy reason.
First off—there is NO truth to the idea that ‘the longer you take it, the harder it is to stop.’  The idiots who peddle that line are the same people who are on and off buprenorphine, or perhaps who have run out of doctors willing to see them and now hoping that company will join their misery.   The opposite is true.  The patients who have done the best are the people who stayed on buprenorphine or Suboxone for at least 2-3 years, and came to a point where they just knew it was time to stop.  The ones that have done well—stayed clean—are the ones who made gains during their time on buprenorphine.  They got educated.  They got promoted.  They started families in a responsible manner (i.e fell in love first, and then had the family).
I’ve seen so many people stop Suboxone after 3 months, 8 months, or a year—and what I’ve seen mirrors the studies that show 90% relapse rates within one year of stopping buprenorphine.
I’ve developed a set of indicators that are associated with maintaining abstinence after buprenorphine.  In very-rough order of importance, they are:

  1. Taking buprenorphine once per day or at MOST twice per day, not in response to depression, fatigue, emptiness, insomnia, or urge, but completely ‘by the clock’—as they would take blood pressure medication.
  2. Having month after month with no extra calls reporting lost or stolen buprenorphine, having no ‘very bad weeks where everything went wrong that forced them to take a little extra’.
  3. No use of intoxicants, especially for treating mood or anxiety—i.e. the ability to live ‘life on life’s terms.’
  4. Age over 30.  Not sure why—but I have my theories.  Age brings wisdom, persistence of intent, insight into emotions, and the realization that life is temporary and precious.
  5. No history of depression or anxiety.  Not always controllable, unfortunately.
  6. Stable job, stable finances, and stable relationship, and preferably one or two hobbies.
  7. Complete loss of using contacts, and NO immediate access to opioids (no spouse on pain pills or Xanax;  no dealer calling every few days).
  8. Absence of a chronic pain condition- or acceptance that one will have to tolerate one’s pain.
  9. Being on a regular exercise schedule.
  10. The recognition that opioids kicked the snot out of them, multiple times—and a strong fear of relapse.

People who lack one or more of these items should strongly re-evaluate a decision to stop buprenorphine.  There are other factors—but it is late, so cut me some slack.
When someone wants to stop taking buprenorphine and I’ve educated that person about the numbers and risks, my next step is to ask the person to cut from 16 mg of buprenorphine (if on that much) to 8 mg.  That change done correctly will cause no physical withdrawal, but creates enough mental pressure to separate those who are ready from those who are not.
Remember at this point that all of these things are used in my own practice;  they are not intended to direct people who are not my patients, but rather to stimulate discussion with your OWN doctor(!)
 
The method I usually recommend is for the person to go to twice per day dosing—8 mg AM and 8 mg PM, and then change to 8 mg AM and 6 mg PM for two weeks, then to 6 mg/6 mg for two weeks, then 6 mg/4 mg for two weeks, then 4mg/4 mg.  If the person can do that without any problems, I am willing to help with the taper.
I usually have patients to make small reductions at their own pace every few weeks.  The goal is to move slowly; one common misstep is to make a reduction before arriving at a stable blood level from the last reduction.  A dose should be maintained for at least a couple weeks before dropping lower.
Most people benefit from more-frequent dosing during tapering, since the effective half-life of buprenorphine is shortened when blood levels drop below the ‘ceiling level.’  I’ve had some patients claim to do better dosing 3 times per day during tapers. My only concern about dosing that frequently is the risk of returning to conditioned addictive behavior. I suppose the other issue is that more-frequent dosing requires smaller doses, that are more difficult to keep consistent.  The 2 mg film is very helpful for tapering at lower levels, can with a razor or hobby-knife.
Patients on buprenorphine for pain treatment can avoid violating the Hamilton Act and progress down a series of Butrans patches—a process that is technically illegal for non-pain patients.    The biggest patch releases about 0.5 mg of buprenorphine per day, which seems like a big step from 2 mg of oral buprenorphine until you remember that only 30% of an oral dose is absorbed.  So 2 mg of oral buprenorphine yields about 0.7 mg of buprenorphine in the bloodstream—close to the amount delivered by the largest Butrans patch.
It is illegal to taper opioid addicts using Butrans, according to the Harrison Act.  I realize that the situation is not fair… but sometimes Presidents create laws, even put their names on them, thinking the law is a good idea… and then the future ends up showing what a bad, bad idea the law was. Just speaking of Harrison, of course…
When patients fail a taper by using opioid agonists or returning to a higher dose of buprenorphine, I suggest they go back to a comfortable dose, and try again in a year.  The hardest part of tapering is mental, but the physical symptoms are nothing to sneeze at.  When tapered slowly, the physical withdrawal from buprenorphine isn’t all that much worse than having a bad cold.  The goal is to stay in the game, hour after hour (after hour).
I recently met with a patient who stopped ‘cold turkey’ from 16 mg, who shared his experience in detail.  He worked every day in a factory job, and managed to stay at work throughout the entire process. He swore by the 5-hr energy drinks, and said that they kept him working on the worst of days.  His symptoms peaked at 11 days, and at 3 months he felt fully recovered.  He carried pictures of his kids, and looked at them every time he felt a hot flash or was stuck on the commode.
I believe that he will do well because he knows that addiction is truly cunning, baffling, and powerful, and understands that he must always be alert for some crazy, cocky idea to enter his thought process.   One interesting thing in this particular patient was that the entire time he went through withdrawal, he never experienced cravings.  He had been on buprenorphine for a number of years, and just felt ‘done.’
Finally… most of us were brought to addiction by our best ideas.  Sobriety requires CHANGE, and change is not comfortable or pleasant.  Nobody wants to attend his/her first meeting.  And everyone who loves meetings has many, many days when meetings are the last thing they want to do… but they go anyway.  THAT is what change is all about.

A New Way to Stop Suboxone?

Originally Posted 10/27/2013
I usually have my wife/business partner review my posts and provide her opinion whether my arguments are sound.  For the record, she tells me that this post is technical and boring.  I disagree, but we aren’t planning to separate over the issue.  A valid criticism, I think, is that I’m doing a lot of guessing and wondering in this post.  This post is an example of the things I waste time wondering about.   I try to avoid writing things that are somewhat speculative, but I wanted to give it a shot for two reasons.  First, because there may actually be something to the idea I am about to describe.  But more important, I wish to point out some of the many ideas in the addiction world worth exploring…. And I hope that pharma continues to search for answers (i.e. spend money) in this area of medicine.
So I’ve been thinking more about ALKS 5461, the Alkermes pipeline medication that is a combination of buprenorphine and ALKS 33, which is a mu opioid antagonist also called Samidorphan with the structure shown at the left. ALKS 5461 is being developed by Alkermes for the treatment of major depression.  I don’t know much about the clinical actions of ALKS 33, (a proprietary molecule), except that it comes from a family of drugs that bind with high affinity and specificity to mu or other opioid receptors.  Samidorphan, a mu receptor antagonist, allows investigation of buprenorphine’s potential therapeutic effects at kappa and delta opioid receptors by blocking effects at the mu receptor.  Drugs with actions at other opioid receptors have be developed, and in some case patented.Until recently, theories about depression revolved around abnormalities in brain monoamine pathways or deficiencies of monoamine neurotransmitters.  Monoamines include serotonin, melatonin, and the catecholamines (noradrenaline, dopamine, and adrenaline). Most modern antidepressants act at serotonin or catecholamine receptors or reuptake sites. The new Alkermes medication ALKS 5461 is the first serious effort that I am aware of to treat depression from the opioid perspective.
Our brains contain natural opioids called endorphins and enkephalins.  Endorphins and enkephalins are neurotransmitters in pathways with a wide range of actions, including blocking pain and raising mood during injury or sexual activity. Pain pills such as oxycodone displace endorphins and hijack the natural endorphin pathways, providing euphoria without the trouble of buying flowers.  Of course, a relationship with self-administered opioids always becomes more destructive than even the most codependent partnership!
As an aside, when I presented for addiction treatment 13 years ago I told the addictionologist about my background in neurochemistry, and went on to explain that I was fairly certain that I suffered from a deficiency of natural opioids.  That doctor got a kick out of my story, and I would enjoy a sense of justification if my hypothesis someday proved to be correct.
When one considers using treating depression with buprenorphine, the obvious deal-breaker is the same issue that has prevented every other serious consideration of treating depression with opioids, namely the development of tolerance at the mu opioid receptor.  Because of tolerance, anyone who finds relief from depression with buprenorphine would be cursed by the need for eventual withdrawal, as well as other consequences of opioid dependence. I assume that Samidorphan is added to ALKS 5461 to prevent mu activation and tolerance.  Beyond partial agonist effects at the mu receptor, buprenorphine antagonizes (blocks) delta and kappa opioid receptors.  These blocking actions are not subject to tolerance, and may provide avenues for treating pain and/or depression.
Depression causes significant morbidity throughout the world, so there are huge profit incentives for new antidepressant medications. Addiction creates a large market as well, but companies rarely go as far out on a limb for addiction products as they do for other diseases. The need for new antidepressants is acute, but in an alternate universe where pain and addiction treatment take priority, Samidorphan and related opioid molecules might have a number of benefits. I’ve posted, for example, about my experience treating severe chronic pain by combining buprenorphine with an opioid agonist.  I expect the combination to be exploited eventually given the need for effective pain treatments, perhaps using an analog of Samidorphan.
Doctors use buprenorphine to treat opioid dependence.  The goal of buprenorphine treatment is to block the cycle of use and reward for some period of time, and to allow patients to create support systems, establish self-sufficiency, regain self-esteem, and practice living ‘life on life’s terms.’  The amount of time that it takes to accomplish these goals likely varies depending on the individual’s premorbid function, life experiences, insight, genetics, and other factors, but studies suggest that a year is not long enough to make meaningful headway.   It is possible that for some people, opioid dependence is a relatively permanent condition that is best controlled with life-long maintenance treatment.   But for those who would like to try to maintain sobriety off buprenorphine, the tapering process reignites the circuits that were set up by the initial addiction, causing cravings, withdrawal, and the constant obsession to delay the taper and resume the prior day’s dose of opioid.
If ALKS 33 has a long half-life and blocks buprenorphine in a dose-dependent manner, I could picture an alternate strategy for stopping buprenorphine where the antagonist (ALKS 33) is introduced to buprenorphine patients at a gradually-increasing dose.  The goal would be to eventually have the person on a daily dose of Samidorphan sufficient to block all of buprenorphine’s effects at the mu receptor, at which point the person could discontinue buprenorphine without withdrawal.  I suspect that the patient would experience withdrawal in response to each increase in dose of Samidorphan, although withdrawal would be reduced by introducing the drug at a measured pace.
What is the value in tapering in such a ‘reversed’ way?  Why would adding an antagonist be preferable to the current process, i.e. simply reducing the dose of buprenorphine over time?  The answer comes from an understanding of the nature of addiction.  A person stopping buprenorphine by gradually adding Samidorphan would face the decision once per day, whether to take the next dose of Samidorphan.  Compare that once-per-day decision to the current method of tapering buprenorphine, where the person must decide, thousands of times per day, to NOT take more buprenorphine.  I would expect that deciding to take an antagonist once per day would be more likely to succeed then CONSTANTLY deciding NOT to take buprenorphine all day long, throughout all of life’s ups and downs—times when the patient was conditioned to take opioids.
We will learn more about Alkermes new medication in coming months. I hope that someone in a power position will consider some of the other diseases that might respond to these interesting chemicals, including opioid dependence.

Making People Stop

Below is an e-mail that I changed just enough to hide the person’s identity.  Every week, I receive messages that describe similar situations.
My husband has struggled GREATLY with substance abuse since in his 20’s; he is now in his mid-40’s. He is the kindest sweetest man and he is the BEST husband and father. When he is using he becomes someone he is not. We have run the gamut from jail to overdose.  Six years ago a friend introduced him to Suboxone and it LITERALLY gave him his life back. He bought it off the friend for years, where it was very expensive. Finally I brought him to a doctor a bit over a year ago. She is pretty adamant about weaning him off of Suboxone.
From experience, I know that 2-3 months after he stops Suboxone he will relapse. I strongly believe it IS a MIRACLE drug! I agree in the sense that if a diabetic needs insulin to save his life, you give it for a lifetime. My husband over the last 6 years has been the man of my dreams, the man I always knew he was. I have extreme anxiety because I know this doctor is just doing her job and trying to follow guidelines however my husband’s LIFE is at stake!  It’s not like if he stops this med he could ‘just’ have depression;  he could end up in jail, or worse. He has his life back. He is enjoying his family life as he should.
If this is what it takes for him to live a normal life then why not?  When we ask his doctor about staying on Suboxone, she says her concern is that we don’t know the long-term effects. She doesn’t want to keep anyone on any med without knowing what it could do. She says it hasn’t been on the market long enough. 
My husband had a SEVERE opioid addiction. He was taking 10-15 Oxycontin 80mgs a day and then ended up switching to 400mgs of methadone before he switched to Suboxone. He has found that he is comfortable with 4 of the 8mg pills per day. I believe it is because he was used to taking such high doses of opioids. He has tried really hard to decrease Suboxone for his doctor but I see the anxiety build in him. She says no one in her practice is on that dose. To be honest he was taking more when he was buying them from a friend but brought himself to a stable 4 pills per day when he started with the doctor. He and I both REALLY like her and would like to continue treatment with her. I wish I had a DVD of little clips of our life from before and after Suboxone. I am positive she would be floored. I am positive she would understand my concern. In my eyes my husband is back. He is such a beautiful soul and I hate to see that taken away from him yet again.
Doctor I read up at the top of this blog that you agree with a lifetime use. He currently has no noted side effects. Do you have any suggestions that I may present to his doctor? I dream of the day that she says it is alright for him to continue on this until maybe he chooses to wean if he so chooses to do so. That would alleviate SO MUCH stress on both of us. Please let me know what you think.
Anyone who reads this blog knows that I agree with most of the opinions expressed in the email.  I know how horrible things are for active opioid addicts—and for the families of active opioid addicts.
More and more physicians pay lip service to ‘addiction as a disease,’ but most do not yet treat addiction as a disease.  The comments about diabetes are ‘right on.’ One could substitute a number of diseases to demonstrate the same point.  We physicians have few illnesses that we cure; rather we manage illness over a person’s lifetime— and opioid dependence is clearly a life-long illness.
To address a couple points in the message:  the active ingredient in Suboxone, buprenorphine, has been in clinical use for over three decades, and has established a clean safety profile.  Buprenorphine has not been used at the high doses employed for treating opioid dependence for quite as long, but even that track record is significant, i.e. 8 years in this country, and longer in Europe.  Most physicians would not consider an 8-yr-old medication to be a ‘new drug!’
The situation described in the message is, in my opinion, the result of several factors.   First and foremost, the reluctance to prescribe buprenorphine is a consequence of stigma.  Doctors prescribe new antidepressants, pain relievers, blood pressure treatments, and cholesterol-lowering agents with much less concern over ‘safety.’     I wonder, frankly, if safety is the concern—or whether there is an unconscious sense that patients addicted to opioids, or to other substances, don’t deserve an ‘easy way out’ of their problem; that sitting through a miserable detox is  a more fitting ‘treatment’ than a pill that makes things better.
I come to this cynical conclusion only because the alternative—that buprenorphine is ‘dangerous’—doesn’t make sense.  The risk of any medication must be compared against the risk of not using that medication.  As the message states, we know the risk of ‘not treating’ the woman’s husband!  Similar comparisons are used to justify the use of chemotherapeutic agents that have severe toxic effects, including the risk of killing the patient.  As I’ve written in prior posts, the fatality rate from untreated opioid dependence is as high as for many cancers.  So does it make any sense to withhold buprenorphine out of safety concerns?!
There are other reasons for doctors’ reluctance to prescribe buprenorphine. Many fear they will do something wrong, and run afoul of the DEA during an audit—a process that all buprenorphine-certified prescribers are subject to.   Some doctors feel pressure from friends and family members of patients, who often blame the doctor for keeping the patient ‘stuck on Suboxone.’  Some doctors want to maintain high patient turnover in order to keep money  coming in, since practices are ‘capped’ at 100 patients per certified physician.
Finally, I think many doctors see ongoing treatment as less satisfying than a ‘cure.’  They consider residential treatment the gold standard, and buprenorphine as a less-intensive alternative.  They buy into the idea that the addict can be returned to ‘normal’—whatever that is—if he/she works at recovery hard enough.  I understand the thought, as that is the type of treatment experience that I went through.  But on the other hand, the relapse rate for opioid dependence, after residential treatment, is very high. I myself relapsed after seven years of recovery, losing my career, and almost my life.  During my years as medical director of a large residential treatment center, patients discharged as ‘successfully treated’ often became repeat customers, at least until they lost their job and health insurance.  Some of them– too many of them–died.
I won’t get into the specifics of treatment;  I’ll leave that to her husband’s doctor to work out.  But I do hope that the doctor will give some thought to whether stopping this life-saving treatment is truly in the patient’s best interest.
To the patient’s wife– I encourage you to continue as an advocate, and I hope your doctor will understand your perspective.

Stopping Suboxone

Liquefied Suboxone taper methodI recently received a question about stopping Suboxone (buprenorphine)…. I deleted the message but I remember the bulk of it, and I have a copy of my response. I thought that someone else out there may find it useful, so here it is:
The question:
I have decided to go off Suboxone after that was recommended to me by almost everybody. My doctor told me to taper off by going down to 2 mg per day, and then take 2 mg every other day, then every third day, and stopping after I get to every 4th day. I followed those instructions and I am taking it every other day, but I am now getting sick every other day. Is this a good way to stop Suboxone, or do you recommend another way?
My response:

I’m not certain who is giving you advice. More and more, the standard of care is to keep people on buprenorphine for at least a year, and many people stay on ‘remission treatment’ indefinitely– just as we do for other chronic illnesses. There is no evidence or truth to the idea that ‘it is harder to stop buprenorphine the longer you take it’; tolerance does not increase after reaching a plateau, usually in a month or so, and I have found that patients are more successful at stopping buprenorphine the further they get from the period of active use. There is no significant toxicity from the medication when it is taken properly; it is far safer than medications used to treat other illnesses, such as hypertension, elevated cholesterol, asthma, diabetes, or arthritis– let alone other potentially fatal illnesses like cancer.
If you DO go off buprenorphine, the method you described won’t generally work because of the pharmacokinetics of the drug. The plasma half-life of buprenorphine is 2-5 hours, but the elimination half life is over 30 hours. The volume of distribution of the drug increases with dose because of dose-dependent protein binding. Finally, the ceiling effect creates a non-linear relationship between blood level and pharmacologic effect. The practical result of these factors is that larger doses of buprenorphine produce opioid effects that last longer than smaller doses. A typical buprenorphine pain dose of 50-100 micrograms lasts for 6-8 hours, but in the super high doses used for addiction (8 mg equals 8000 micrograms), the opioid effects last much longer- allowing for once per day dosing.
As the dose is lowered, the effects of buprenorphine become shorter in duration. So the person tapering buprenorphine need to not only take smaller amounts each day, but must also divide that daily amount into two, then three, then maybe even four doses to avoid withdrawal symptoms at the end of the dosing interval.
On my forum, SuboxForum, people discuss the ‘liquefied taper method’– a method that I believe I was the first to describe, where a tablet of Suboxone is dissolved in a small amount of water, and doses are administered by drop from a medicine dropper or TB syringe. Any small medicine bottle and the included dropper can be used. I would suggest taking the time to calculate the microgram per milliliter concentration, and using the dropper to dose known amounts.  A TB syringe is more accurate, as it has the amounts marked on the side. For this purpose, a ‘cc’ is the same as an ‘ml’. There are 1000 micrograms per milligram (mg). I’ll leave the rest of the calculations to you!
Another option might be to use ‘Butrans’, a buprenorphine skin patch, after tapering to a low sublingual dose. The biggest patch releases 500 micrograms (or 0.5 mg) per day, and there are a couple smaller sizes with the smallest patch releasing 0.1 mg per day or 100 micrograms. One could taper down to a quarter of an 8 mg tab per day, and then change to the 0.5 mg patch. That sounds like a big drop, but only a small percentage of the sublingual dose of buprenorphine is absorbed– some estimates as low as 15% of the dose. By that estimate, a 2 mg sublingual dose of buprenorphine would be comparable to 0.5 mg of transdermal buprenorphine.
I wrote Butrans might be used because under current law, doctors cannot prescribe Butrans to treat addiction—and I assume that includes tapering off buprenorphine. Federal law that allows for use of controlled substances to treat opioid dependence (DATA 2000)—an exception to the Harrison Act— only allows use of medications that are indicated for opioid dependence. At the present time, Butrans is indicated for treating pain, and not for treating addiction. By my understanding of the law, doctors can use Butrans to taper patients off buprenorphine only if the indicated use for the buprenorphine is any condition other than addiction.
But again, do give some thought to whether you should be stopping buprenorphine, as the relapse rate for opioid dependence is, unfortunately, very high.

Is She Still Using?

I have been involved in Q and A with a person in another part of the country, and will share some of our exchange after removing the identifying info. BTW, I receive many e-mails from people and I just don’t have time to answer most of them; I DO provide ‘educational consultation’ (not a ‘medical’ relationship) at a rate of $100 per 30 minutes, and anyone is welcome to set that up by writing to appointments@fdlpsychiatry.com.
The person below consulted me over her daughter, who is addicted to opiates and on buprenorphine but not doing well. The grown daughter receives some level of support from her parents, who are in that horrible position of trying to pull back to avoid enabling while at the same time fearing that pulling back will cause relapse or worse. The mother has had the impression that her daughter is sedated from buprenorphine, and that the buprenorphine may be making things worse. Mom considered helping daughter pay for ‘rapid opiate detox’ to ‘get off Suboxone’ at one point; I was not a big fan of that idea, as I have seen people do poorly after that approach (in my opinion, GETTING clean is much easier than STAYING clean).
Our exchange:
She is still on suboxone but we are paying for it. her weekly appt last week was on wednesday and she did not bring us her prescription to have it filled until saturday which means she did not have any meds for 3-4 days.
She was like a wild animal when we saw her and told us she has filled it herself. Then finally Saturday she gave us the prescription and told us to fill it for her.
Number one: why would she have waited so long, would this be a sign of a relapse? Number two: can you stop for 4 days and then start up again? Wouldn’t this make you high from it? She is on 16 mg.
She is NOT doing well with Suboxone, could she be using it to subsidize the in-between times or something?
Just can’t figure out why a medicine that is supposed to make her better is making her worse?
Hi XXXX,
I find myself in the position of defending Suboxone– and wish I had something else to suggest. People taking buprenorphine comprise about 20% of my psychiatry practice, and I have not taken a new patient for buprenoprhine treatment for over a year, so I want to make it clear that I am not a ‘Suboxone zealot’. I’m just trying to be frank about what I see with addiction.
I often end up saying things like ‘it isn’t fair to Suboxone.’ When I say that, I am not concerned about ‘fairness’ toward a business plan or marketing strategy; I am speaking of ‘fairness’ in an intellectual sense. Maybe instead of ‘fair’ I should say ‘proper’—I will try that below and see if it helps clarify my point.
Your last comment is an example of why I have the forum and blog, as I hear similar comments frequently— i.e ‘why a drug that is supposed to help making her worse?’ That is NOT an intellectually honest question. SOMETHING ELSE is making your daughter worse, and buprenorphine is keeping her alive. I lived as an addict for 10 years BEFORE Suboxone, and I saw what things were like with only methadone as an option. While there has always been residential treatment, the results of treating opiate dependence with residential treatment have always been poor.
In the past six years, 1200 people died in Milwaukee from overdose. There is nothing special about Milwaukee; recent stories in Time, Newsweek, and elsewhere have highlighted the dramatic increase in overdose deaths from ‘prescription medications,’ largely opiates and benzodiazepines. We do not know what would have happened in your daughter’s case, had she not gone on buprenorphine. She very well might have died by now. She might be in prison. We don’t know—but at any rate it is not PROPER to ‘blame’ buprenorphine, when in fact the medication may have saved her life. The fact that she is still sick is most likely because addiction has many factors and consequences that are impossible to define, let alone treat. I have seen the outcome of untreated opiate dependence too many times. That outcome consists of either death or incarceration. The deaths have been mostly ignored until recently, and I imagine that after this ‘news cycle’ we will return to ignoring them. But the deaths are still there, every day. One result of being a physician who treats opiate dependence is that I now read the obituary section of the newspaper; I sometimes get ‘follow-up’ there on people who had at one time sought help, but for whatever reason had stopped coming to appointments.
To answer the other questions, it is very unusual for a person who is doing things right to forget to fill a prescription for buprenorphine. At first, people in treatment may wait until the last minute, then call in a panic saying they will run out the next day. One of my jobs is to get them living like ‘normal’ people, i.e. planning ahead of time and respecting boundaries, including not expecting me to drop everything because THEY forgot to schedule an appointment. Your daughter should learn to take care of the basics herself, and suffer some degree of consequences should she ‘forget’ to plan ahead. Every addict, of course, has many excuses for not being able to make appointments, call in requests for refills ahead of time, etc… even if the addict is doing nothing all day, and the caretaker is working three jobs! That dynamic must change so that the addict is responsible for herself.
Yes, stopping buprenorphine for 4 days and then restarting it will result in the person ‘feeling’ opiate effects. It is difficult to sort out whether the person is feeling ‘high,’ or just feeling the loss of withdrawal—but there would definitely be relief associated with taking the buprenorphine after 4 days. The goal with buprenorphine is to avoid that cycle of ‘sickness’ and ‘relief’ and to instead feel normal all the time. And ‘normal’ is what the vast majority of my buprenorphine patients describe; they say that they feel nothing with each dose, and that they don’t feel ‘high’ at all. Feeling ‘normal’ is consistent with the chemistry of taking buprenorphine; the person becomes completely tolerant to the effects of the medication and as long as the blood level remains above a certain threshold, there is no sense of something wearing off.
In the case of your daughter, I agree with you—something is not right. She is either using opiate agonists intermittently or she is still very much wrapped up in wanting to ‘feel’ something—or both. There are deficiencies to all testing methods, but she should have a ‘state of the art’ urinalysis at some point when things are irregular. By ‘state of the art,’ I mean a test that is witnessed (most labs can provide this service), that has a chain of custody, and that is analyzed at a certified medical laboratory.
In a case like that of your daughter, it is important now and then to return to basics– does she WANT to live a clean life? What is motivating her to do well, and what is motivating her to do poorly? Are there sufficient consequences for bad behavior? Is SHE the one working the HARDEST on her sobriety? She SHOULD be, by the way… when I see a situation where everyone else is working to help a person stay clean, I know that bad things are coming.
I realize that it is simply horrible, what is happening to you and to your daughter. You are being forced to distance yourself from her so that she will take on more responsibility for herself, and so that you are protected to a small degree from the horror of the current situation and the fear of what could come at any time. That distance is just like any other significant loss. Understand that it isn’t your fault, and you are not alone. I often compare opiate dependence to cancer; both illnesses have consequences far beyond the risk of death. The loss that you are experiencing is similar in some ways to what cancer patients go through, when they see close friends back away out of fear of death and dying.
The one consolation is that for most people, age brings insight. I have many people on buprenorphine who do very well—they take a daily medication as they would for any other chronic illness, and lead happy and productive lives. But I also have a few younger patients who do not do as well—particularly those under age 20. In those cases, the course of illness includes a constant battle to prevent the addiction from going ‘underground,’ i.e. where the addict keeps secrets from the physician, and there are periods of stability and relapse. In such cases I hope that buprenorphine at least allows me to keep the person alive and out of prison (and hopefully employed or in school as well). The addict’s life may still be chaotic, but each day the person is a little closer to age 30—an approximate age when insight seems to have a better chance of taking hold. Hopefully your daughter will gain insight as well as time passes. If she only loses a decade of her life, she still has much to live for.
As always, I’m sorry for what you are going through. Protect yourself first; make sure you are doing all that you can to keep your own sanity intact.
JJ

How Long to Take That Stuff?

I ended the ‘85% off’ sale of the recordings listed to the right of the blog;  they are also listed at the web page ‘Sober After Suboxone,’ along with some other useful recordings about opiate dependence.  I have received good feedback about the recordings, and I think that the ‘how long’ one is the most useful for the people reading this blog;  people at other stages of opiate dependence may find other recordings more useful, such as the one that discusses opiate dependence treatment options.  The treatment options are NOT just a list of the different options available;  they are a list of the options from the perspective of someone (i.e. me) who has dealt with my own opiate addiction for 16 years.  They take into consideration the fact that few people will commit to residential treatment, and more importantly they take into account the relapsing nature of opiate dependence in SPITE of residential treatment options.
The ‘how long are you going to take that stuff’ recording is for the people who are always on your case about Suboxone– the people who think you are still getting high, or the people who say you have ‘substituted one addiction for another’ (you haven’t, by the way).   I take on these and other issues, such as the fantasy about being ‘clean of all substances’ that comes from NA programs from time to time.  I haven’t fully decided on the title of the book I am almost done with, but I like ‘dying to be clean’, as it captures the folly of going off life-sustaining medication to chase after a shame-based goal to be ‘completely clean.’  For parents who keep harping on their children to stop Suboxone, will you feel better when your son or daughter has died from an overdose while trying to avoid the Suboxone that would have kept him or her alive?  DROP THE IDEA OF BEING OFF EVERYTHING.   Opiate dependence is a horribly fatal illness;  if Suboxone is working, count your blessings and appreciate life.  Finally, addiction is not the ‘use’, it is the ‘obsession’.  Suboxone is unique among opiates in that it addresses the obsession.  THAT is what gives you your son or daughter back.
As I said I stopped the 85% off sale, but I did keep a 50% off sale– not actually a sale, but more a permanent 50% price reduction.  I hope you will continue to use the recording, either to arm yourself with knowledge or to share the information with others.
As I have said before, consider the $10 purchase as a donation to the cause.  I really appreciate those of you who have already purchased one or several of the recordings.
Thanks!

A Common Mistake

I brought a note from the ‘comments’ section up here because it presents a topic that comes up over and over with opiate dependence and Suboxone.  I am the expert on MedHelp.org’s addiction forum;  I get questions and comments like this one quite frequently on that site– although I have addressed the issue so many times that I think people there know what my opinion will be on the subject.  I will post the comment, and then write my own comments afterward.
I started on the Suboxone in Feb 08 to get off the opiates. It worked very well for me, I lost 20 pounds while on it, got very active, and above all was the happiest I had been in a long time. After 7 months of taking 32 mgs a day I had to wean off it b/c I had no more insurance and it was very expensive. I tried to wean the best I could and the end of Oct was it for me. I was down to taking 2 mgs a day then completely stopped b/c I ran out of Suboxone. About 3 days after I stopped taking it completely I started withdrawing from the Suboxone. I was getting the chills, I felt weak, I had this nervous feeling in my stomach which was very annoying and caused me to not be able to sleep. Once that began I started doing research on Suboxone withdrawals and people were basically saying that depending how long you were taking the drug that would depend on how long you withdraw b/c Suboxone stays in your system for a long time. So what did I do.. to get rid of the withdrawal feeling I was getting I started taking the opiates again. Then eventually I  got addicted to those again. What I have noticed works with the suboxone is if you take it for about 10-14 days long enough for the opiates to get out of your system and stop taking the Suboxone you wont get sick and you will be successfully detoxed from opiates. Now the hardest part is staying away from the opiates. I am now on my 3rd day of the Suboxone treatment again, I am only taking 1 pill a day and by the 10th day I am going to take 1/2 a day. I will stop at 14 days and stay completely away from the opiates by keeping busy, working out, and most of all living a NORMAL life. I am also planning on attending NA classes for support. I will keep you all posted and to everyone else doing the same.. GOOD LUCK TO ALL OF YOU!!
I have written about the natural progression of opiate dependence before, but I will review things again for newcomers.  Early in addiction, the addict believes that if he can only get past the physical withdrawal, everything will be fine.  During the first third of an addicts ‘using life’ he is always fighting for that first piece of sobriety– you see these people on message boards all over the internet, comparing tapering plans and different cocktails of amino acids or other worthless regimens to find the one that ‘works’– that gets them through a taper or withdrawal to become opiate-free.  They usually are not interested in meetings or rehab at this point;  they don’t consider themselves to be ‘THAT kind of addict’ who needs that much help– just the right pill to get through the worst of things.  These are the people who often insist that Suboxone be used only short-term, as a bridge to sobriety.  They have no interest in the idea that they have a life-long illness, and will argue that point until blue in the face, even as they continue to use opiates on a daily basis.  Denial is huge during this stage of addiction;  the addict minimizes the impact opiates are having on his relationships, work, and health status.  It is easy to discount all of those things because he considers all of the messes to be temporary and ‘easily corrected’– once he just stops the darn opiates.  He assumes– sometimes for a long time– that the ‘right method’ will come along… eventually.  Hooked?  Not him!
A person enters the second stage of addiction when he has been able to successfully taper of opiates.  From my vantage point of seeing many, many addicts over time, this point is not associated with any particular taper method or amino acid formula, but rather occurs when the person has enough consequences to motivate him through the withdrawal.  More and more bad things pile up until they cannot be repressed and ignored;  job(s) lost, friendships damaged or destroyed, finances in shambles, legal problems, and marital difficulties are some examples of these consequences.  During the first stage, the addict would get to a certain level of withdrawal and say ‘screw this!’ and resume using, but during the second stage the problems are remembered even during bad withdrawal, and the addict stays motivated to be free of opiates.  The taper that eventually works is often the worst one;  the addict just says ‘enough!’ and stops without any plan or preparation.  Or perhaps the consequences lead to a jail cell or being completely broke– again, resulting in sudden and absolute sobriety without the luxury of a taper or meds to reduce the severity of withdrawal.
That’s great, right?  He is finally there– free of those opiates… or so he thinks.  But unfortunately he is about to enter the third and worst stage of opiate addiction– the stage that can last for years and years and that totally demoralizes the individual.  This stage begins with relapse, and it can happen after a week, or it can happen after a year.  The bottom line is that it almost always happens– and that NOBODY thinks it will happen to him.  I hear the comment over and over– ‘no doc– I don’t plan to relapse!’  or ‘I know what you are saying– but you don’t understand the way I am!’  Everyone considers himself too smart for relapse, but I see the AA adage come true over and over:  nobody is too dumb for Recovery but some are too smart for it!  The meaning is that every now and then a person will avoid relapse– and it tends to be a person who has a ‘simple’ outlook on life who didn’t really ‘shine’ in other, more competitive areas.  Someone who is well aware of his own limitations, and who never got in the habit of trusting his own opinions or his own abilities.  That person can sometimes simply stop using because he easily accepts the idea that he has lost the fight– that opiates are much stronger than he is, and that he will never figure out how to take them without disaster.
Most people, though, are way too smart for this situation;  as soon as things start going well their minds take off again…  and at some point they return to using.  I’m not going to spend time on all of the triggers for relapse, but maybe I will discuss that another time–  but there are things common to all relapses, including   rationalization, denial, grandiosity, and the feeling of ‘terminal uniqueness’ that I mentioned above, where all of the warnings are an issue for OTHER people.  During this third stage, the addict will have repeated episodes of relapse and sobriety;  there is little joy in using since consequences occur much more rapidly now, so more and more time is spent being sick from withdrawal.  This is the stage that most long-time addicts remember, and fear, the most.  In my case, I could stop using every weekend;  I was away from the operating room and away from the drugs, and I would start the weekend determined that ‘this was the LAST TIME–  come Monday I won’t touch ANYTHING!’  And so I was always sick;  the kids would be playing outside and I would be in my bedroom curled up on the bed, hating myself for not being there for them.  And of course, on Monday I would be right back at it again, telling myself that THIS weekend didn’t work because I needed just one more day… or because I had (insert incident here) to deal with.   As I mentioned earlier, during this stage the addict becomes truly ‘sick and tired’.  This is a dangerous period of time for the addict for a number of reasons;  when the addict uses he feels a great deal of shame, which fuels more using– making use more impulsive and reckless and more likely to cause a fatal overdose.  The addict also becomes depressed– sometimes extremely depressed– and commits suicide, either actively or through just not caring anymore about the risks of taking too much.  The addict sometimes feels such a wave of hopelessness or shame that he needs to do ANYTHING to change how he feels– so he swallows any pill he finds, or shoots up something that he doesn’t even know the actions of–  he just needs SOMETHING!  Even a hammer to the head looks good at this point!
This is the time when traditional treatment has been effective;  the addict is at rock bottom, and he no longer feels confident about any of his own abilities.  He is ready to follow ANYONE or ANYTHING– after all, what does he have to lose?  Life is over anyway– so why not listen?  If the addict can keep this attitude throughout one to three months of residential treatment and then keep it into an aftercare program, he has a genuine shot at some meaningful sobriety.  If, though, he gets into treatment and quickly makes a girlfriend, or he can tell jokes and be the funniest, most popular guy in the facility, or if the counselors are in awe of his wealth, education, or power and tell him how cool he is…  there is a strong chance that the treatment will prove worthless.  He needs to hold on to the attitude that he knows nothing, for only that attitude will allow true learning and change to occur.
This is why, in my opinion, young people have lower success rates in treatment.  Young people often feel way too invincible for treatment to take hold.  They also have short memories for painful events;  consequences are quickly forgotten and dangerous self-reliance returns.  The true wonder of AA is that the program designers understood all of this;  the program is all about humility and powerlessness, and consists of a series of steps that, if practiced completely, will take a person to the right frame of mind and keep him there– provided he continues to work the program.  The reason treatment tends to work better for older people is because first, more are at the later stage of addiction when they are truly ‘sick and tired’,  and second, self confidence tends to return a bit more slowly.  Us older folks tend to remember the bad things because we know that some friendships can be lost forever.  Plus it is difficult to feel immortal when one’s body aches each morning!
I’m sorry to pick on the writer of the comment above;  I could do this with many of the comments that I receive from those who plan ‘short term’ use of Suboxone.  In light of what you have read, go back and read the comment again;  see if you can tell the stage of addiction that the person is experiencing.  Again, I get these types of comments over and over, both here and at the other site that I mentioned.  I have watched, over the past 16 years, as addicts (including myself) have gone through the same process.  Every person is convinced that HE is different– only to eventually find that in regard to addiction he is the same as everyone else.  This is why I recommend seeing Suboxone as a long-term medication… or seeing AA or NA as a life-long program.
One final comment… the three stages that I use to describe opiate dependence are ‘mine’;  I have noticed them over the years and they continue to be retold in my patients’ stories, and so they appear entirely obvious to me.  I have not seen the stages spelled out in this way by others, so if at some point others agree with me, let’s name them the ‘junig stages of addiction’.  I accomplished one more of the ‘goals of my life’ a few weeks ago when a guy met me at the airport with my name on a piece of cardboard;  having something named after me would scratch one more thing off the list!

Micrograms, Tapering, and the Ubiquitous Nature of Addiction

One thing I enjoy so much about the blog is that I receive comments from people around the world… hello to my new friend in Holland, and California, and New York… I have also mentioned before how the miserable disease of opiate dependence affects people from all jobs and socioeconomic groups. I receive messages from members of the underground world of opiate dependence, and so often I think about how surprised people would be to know what a huge problem this is!  Writers, stockbrokers, artists, businessmen, doctors, lawyers, factory workers, photographers, teachers, students, IT professionals, waitresses, realtors, landlords, welders, professors, home-makers, mothers and dads… I have talked to opiate addicts from all of these occupations, and more.  And in all of them, the stories are the same…  the initial use, the loss of control, the assumption that the control will come back, the feeling of being ‘different’, so that the stuff that happens to ‘other’ people won’t happen to ME, the repeated failures to control use, the repeated episodes of withdrawal,  the occasional fear deep in the gut that maybe I am REALLY in trouble after all… the deep feeling of shame, that ‘I should have known better’, often with some weak effort to blame someone else, which even the addict doesn’t fully believe but which is still used as an excuse, since the alternative– accepting all the blame one’s self– seems intolerable.  The personality effects are identicle;  everyone has done things that he/she never though he would do– women reduced to prostitution, men to burglaries or robberies, and in one person I have met (outside of the prisons) even murder over drugs. He now says that his constant guilt keeps him from getting clean, but I see that as just another excuse; he could just as well say that taking a person’s life is what made him get clean.  You see, there are ALWAYS excuses to use…  the family is too distant… or too close.  The weather is too horrible, or too nice.  My house is too empty or too full;  my wife is too attractive and flirty, or too unattractive and boring.  Always an excuse… which means that there is really never an excuse.  In fact, one of the only times I tend to cut people off from telling their stories is when they get to the excuses;  I have heard them all, and none of them mean anything.  And yes, I have used many of them myself as well.
In all cases the addict started out feeling great;  often he was stressed from a good job and the opiates allowed some extra energy at home, and the wife and kids were happy about the changes.  But the addict starts to feel miserable inside eventually– it is only a matter of time.  And once that happens, the addict retreats further and further inside, getting smaller and smaller, while putting up a facade that he thinks is fooling everyone… but the kids are probably the first to notice that something isn’t right.  This is a classic set-up for borderline personality in the kids;  later when they talk to their therapists they aren’t sure what happened, because everything seemed OK– there were no beatings, and dad was always happy…  but normal child development doesn’t do well with ‘fake’ personalities.  Spouses often don’t notice at first because they engage in the same denial that the addict engages in.  But the kids don’t know how to do ‘denial’, and so they internalize the growing distance from the addict, from dad or mom, as somehow related to them.  To kids, everything relates to to themselves… so the distance becomes part of low self esteem, mood swings, cutting, and impulsive behavior that is really borderline personality but that some idiot will misdiagnose as ‘bipolar’…  the kid will be put on depakote or seroquel or zyprexa, and will gain 100 pounds…
Is anyone still reading?  What a pathetic story!  The good news is that eventually the addict will get miserable enough to take action.  The bad news is that all of the damage will last a lifetime– not just the addict’s lifetime, but the kids’ lifetimes as well.  But with effort, there is still good news, at least in my twisted opinion.  I see all the people out there who have ‘normal’ lives as the real unfortunates.  If it is through hard times and being tested that we grow, and learn about ourselves, what does that say about the people who never have any problems?  Maybe that is part of the meaning behind the Chinese proverb, ‘may you live in interesting times’.  As another aside, I have a feeling that the whole country will therefore be lots smarter after the next few years…
OK.. Micrograms.  This simply refers to the new info that was sent to me by a nice gentleman who I cannot mention by name…  and a topic that I referred to a couple posts ago.  I mentioned that in order to taper off Suboxone, you must think in terms of micrograms, not milligrams.  When you take an 8 mg pill of Suboxone, you are taking a supra-maximal dose of buprenorphine– a dose that is off the scale.  The ‘ceiling’ is way up high, far above the doses that are used clinically for treatment of acute pain.  As I have said, 24 mg, or 4 mg, of Suboxone are both as potent as 30 mg of methadone!  So your taper off Suboxone doesn’t really start until you get below 2000 micrograms per day– or 2 mg, which is a quarter of a pill.  To do a proper taper, you want to think in terms of tapering down from 2000 micrograms to zero, in small steps.
I had an idea of how to do this at about the same time I received the message from the nameless contributor who had done his own tapering studies.  He did what I had finally figured out;  take an 8 mg tablet and dissolve it in a small amount of liquid– water would probably be fine.  You want a small enough volume so that when you put it in your mouth it is concentrated enough to cause absorption of the drug through mucous membranes, but a large enough volume so that it can be measured accurately.  I suggest using a vial that childrens’ medicine comes in– one with a measured eye dropper.  calculate out the concentration of buprenorphine, and then use the dropper to take a measured dose of the liquid each day.  At some point– if you start getting withdrawal by the end of the 24 hour period– you might want to change to dosing every 12 hours (cut each dose in half, of course).  I recommend making a reduction in dose every one or two weeks– if you are still feeling sick from the step a week earlier, don’t make another change until you feel better.  In general, each drop in dose should be a drop of about 10%.  Be sure to keep the mixture refrigerated, and toss it if it develops a foul odor!
If you taper very slowly, you should be able to avoid the vast majority of the withdrawal.  It will take a long time though, so be prepared to keep at it for months.  If, on the other hand, you need clean urine very quickly…. you have little choice but to simply stop, and tell everyone that you have mono again.  (gee… seems like you are ALWAYS getting mono!), 
Maybe you can get away with saying ‘yes, I know… but I have a real good feeling that I’ll probably never get it again’.
As always, I wish you all the best.  Opiate dependence stinks… do what you all can to stay alive, and pat yourselves on the back every now and then.  You probably deserve it– and nobody else is going to!
SD
If you