Monday Morning Anti-Suboxone Quarterback

I spend some time on this post at the forum so I will share it here as well.  First, a post from a person who uses the name ‘Suboxone7yrs’:
I was addicted to vicodin for 10 years popping 50 pills a day of Vicodin ES or NORCO, I then decided enough is enough, went to the ER and they gave me a list of doctors who deal with addiction. I went to see this female doctor who gave me the 3 hour consultation thing, then put me on 32mg of SUBOXONE, she sold me the suboxone out of her office for $5 per pill, rather then paying $8 a pill at a Walgreens I thought ok why not?…Well 5 years later this doctor STILL had me on 32mg of SUBOXONE! She then must have gotten caught because she was no longer in practice, so I found another doctor who was commited to getting me off, it took 2 years and my last dose of 2mg was March 2, 2009. I looked up all over the internet “How long will W/D’s be for this” some said 3 to 5 days some said longer. I am here to tell you I went through withdrawals for 31 LONG A** days and when I tell you this is the hardest thing in life I have ever ever done I an NOT kidding you. I was at the ER 8 times for the CLONODINE patch, I know every one is different but my god, I laid in bed crying…begging for god to take me, it was PURE HELL people PURE HELL!!! Leg twitches AND arm twitches for 31 days straight! Skin crawling, lost 40 pounds from going to the bathroom, weak, vomiting, sweating, depressed like I have never been I couldnt wash my hair for weeks, my best friend had to drive over and wash my hair and do my laundry, your useless!!! I will NEVER EVER recommend to anyone that they go on SUBOXONE even if it’s for 2 dam days. This is just MY STORY and MY OPINION. I am sure it had worked miracles for tons and tons of people but even the doctor couldnt understand why I was withdrawling for SO LONG! 17 years of putting a pill or several pills in my mouth took a blow to my body and I just wish I NEVER EVER would have gotten on SUBOXONE. It was the worst experience of my dam life. I just think about Suboxone and I feel like vomiting. Now I feel all the under lying problems I have that I never felt because I was on Suboxone, like 2 bulging disks in my back that are killing me and I need something, I cant even take a 15 minute walk and I am only 37 years old! I am stuck…dont know what to do? This is ny story and Im stickng to it. I hope others out there have a better road of recovery getting off suboxoxe, all I have to say to them is good luck and hold on tight for the roller coaster road to come!! Piece
Below is my response:
I’m a little disappointed in all you folks, after all the lecturing I do!! I’m kidding– sort of, anyway! I agree that the dose of 32 mg was too high– but the 7 year part is not ‘too long’. ‘Suboxone7years’ is doing what many people do; blaming Suboxone rather than blaming his opiate addiction. We don’t know what would have happened, had the person NOT had Suboxone, but read the history. The person was addicted to opiates for 10 years! My active addiction lasted only 6 months– and that was enough to give me cravings even after 7 years of being totally off medications or substances (i.e. not on Suboxone or anything else– just tons of meetings). So a person who has been on opiates for ten years is SERIOUSLY ADDICTED. After my 6 months of use, I went through treatment that consisted of 3 1/2 months residential (after a week of horrible detox), and then 6 years of aftercare (group twice per week for a few years, then once per week).
I must admit to a bit of skepticism over 7yrs report, just because Suboxone was not available in the US until 2003– so I don’t know how he/she got to 7 yrs of use followed by the time in withdrawal between 2003 and 2009. Yes, DATA2000 was the act that allowed ‘treatment of opiate dependence using opiates on schedule III through V’, but Suboxone was not approved or sold until mid 2003. Maybe ‘7yrs’ means ‘6yrs’– no biggie, as I tend to exaggerate as well.
‘7years’ had 10 years to quit opiates– and then thanks to Suboxone was finally able to get free. And after 7 years of freedom, she complains about 20 or 30 days of withdrawal?! She also blames that on the Suboxone– but you also have to blame it on the 10 years of using before Suboxone! What makes 7 years think that all the withdrawal is just Suboxone’s fault? 7years, let me point out to you that you COULDN’T quit the other drugs– but you COULD quit the Suboxone. What does that tell a logical person about which one is harder to get off?
I have detoxed more than I ever wanted to… and I have seen many, many people go off many things (I’m medical director of a large residential center in addition to my practice). As I have pointed out, I couldn’t walk during my detox! People going off Suboxone tend to go to work and complain about how sick they feel– people going off agonists tend to like in a bed in a detox ward or at home, and they don’t complain– because they are too weak to talk! I’m sorry you felt miserable, 7years, but have you ever ‘jumped’ from 30 mg of methadone? Or come off heroin? You must have at least seen the movies– they call it ‘kickin” because the legs kick constantly. That was MY detox– I lost 30 pounds, and for days I was up around the clock, legs kicking, body shaking and shivering, sweating like crazy, nausea and diarrhea at the same time– after a month I could walk about 50 feet without needing to sit down and rest– and that was a huge improvement!
But none of this even gets to the real issue. 7years, how do you plan to stay clean going forward? Given the time factors I mentioned above, you couldn’t have been clean for more than a couple months so far– opiate dependence is a relapsing condition. Everyone is certain it won’t happen to them, but… it happens to even those who are working a very intensive recovery program. That is why the recommendation, more and more, is to STAY on Suboxone! Yes, if you are a masochist who wants to watch your family get destroyed, go out on the quest for ‘pure sobriety’. But I recommend against it. My own relapse occurred after 7 years of very good recovery– I was ‘all AA and NA’ for years before my relapse. If anyone thought I would return to that life, I’d say they were crazy fools. But you know what? People DID say I was flirting with disaster when I stopped meetings… and they were right.
Now we have Suboxone, so people like 7yrs can enjoy freedom without the work of 90 meetings in 90 days followed by years of aftercare. That is fine– but it isn’t really fair, after enjoying the freedom the medication gave you, to claim that you didn’t really need it, and wish you hadn’t taken it. You very well might be dead or in prison had it not been there. In light of that, a month of feeling sick is a good deal– better than the work I put into my freedom. But your work is just starting, if you are so convinced you will never take Suboxone. Feel free to stop back in a year and boast, if you are still clean– and I hope for your sake that you are. But I often point out that the people who complain about Suboxone are usually people with a few clean months, as those people have themselves fooled into thinking they are all done with addiction… I have put offers out on some of the Subox-hater sites asking for someone with 5 years clean to talk to me– and so far, I haven’t found a soul.
SD

Stopping Suboxone– A Bit More Information about a POTENT Drug

I received some feedback after writing about tapering Suboxone here and on my site Sober after Suboxone (soberaftersub.com), and I would like to share the information and suggest a new way to think about buprenorphine during the tapering process.
First… it has already become clear to me that Zofran, or odantreson, is not the big answer for opiate withdrawal that everyone is hoping for.  Oh well…  maybe some day.  As I have said a number of times, some day there will be a medication that prevents tolerance, and I would expect such a medication to affect withdrawal as well, as the two processes are closely related.  On the other hand it is possible that such a medication would actually prolong withdrawal, by preventing the plasticity required for the receptors to return to normal.
The other thing… buprenorphine is a very potent drug.  This is the essential problem when tapering Suboxone;  there is not a low-dose formulation available to taper in the lower dose ranges.  The best way to understand the problem is to realize that buprenorphine is a ‘microgram’ medication– not a ‘milligram’ medication like oxycodone.  When I worked as an anesthesiologist I would give a woman in labor 50 micrograms of buprenorphine intravenously– or 0.05 mg.   Buprenorphine taken orally (trans-mucosally) has a ‘ceiling’ potency at a dose of 2 mg or 2000 micrograms.  If you are taking a quarter of an 8-mg tablet, you are still at the maximum effective dose of buprenorphine!! Whether taking16 mg, 32 mg, or 2 mg of buprenorphine, your tolerance is very high; as high as it would be if you were taking 30 mg of methadone per day.
The standard way to taper a long-acting opiate like methadone is to reduce the dose by 10 % every month.  So if you wanted to do things that way that reduces the amount of withdrawal, you would go from 2 mg or 2000 micrograms of buprenorphine once per day to 1.8 mg (1800 micrograms) per day, and then a month later change to about 1.6 mg (1600 micrograms) per day.  Note that the reduction amount does not stay constant;  each month the dose is reduced by 10 % of the current dose.  So after about 4 months you will be at 1 mg per day, and from there you would reduce to 900 micrograms per day.  The problem?  This 900 micrograms would be 9/10ths of an eighth of a Suboxone tablet!  How do you measure THAT out every morning?


Things get worse;  remember that buprenorphine is very potent. You don’t want to ‘jump’ from that 900 microgram dose, as it is still represents significant opiate tolerance and will result in significant withdrawal.  So you keep tapering… down to 500 micrograms per day… keep going down each month, past 100 micrograms, eventually to 50 micrograms and lower.  Ten micrograms of Suboxone would still have some opiate potency;  this would equal 1/800th of an 8 mg tablet!  Beyond the logistics of working with such small pieces of Suboxone it should be obvious that tapering off Suboxone is best considered a long-term process.
I am going to see what is available in other formulations of buprenorphine and look into the legalities of dispensing buprenorphine from the office.  I should mention that I do not have something like that now, and that any medications in our office are kept in a safe, and that we have security measures that include lethal and non-lethal deterrents, video recording devices… I go a bit overboard with security measures, as I am aware of the motivational power that withdrawal has on some people to do horrible things they would not otherwise do.  When I worked in the prisons I met a number of people who were average students, wives, dads, or moms, before finding opiates and eventually forging checks– or holding up pharmacies using a finger in a paper bag, not realizing that threatening a gun is as bad as having a gun from the law’s perspective.  Nothing like 5 years in prison to help one find a ‘rock bottom’!
One more important point that will help you undertand the withdrawal from opiate medications… the body generally reacts to change in a ‘logarithmic’ fashion, not in a ‘linear’ fashion.  And when responding to change, the relative amount of the change is a more accurate predictor of symptoms than is an absolute value.  To explain my point using opiate effects, the withdrawal experienced by a person is probably similar when changing his daily dose of methadone from 300 mg per day to 100 mg per day– a change of 200 mg–  to the withdrawal experienced when changing from 30 mg to 10 mg — a change of 20 mg.  So at the end of your taper off buprenorphine, even though the numbers of milligrams or even micrograms seem tiny, and you are taking a piece of Suboxone the size of a speck of dust for your daily dose, you may still have a bit of withdrawal when you stop!
Finally, yesterday I had my third patient who stopped Suboxone abruptly and had no withdrawal.  She was taking 16 mg per day–correctly– when her parole was revoked, forcing her into jail where she had to stop Suboxone without any taper.  Like two other patients of mine, she claims she had no withdrawal!  I do not know why that would be the case– I have a couple ideas but will spare us all that discussion at 10 PM on a Saturday night!
As always, thank you for stopping by and reading;  thanks more for subscribing, thanks even more for referring something you like to Stumble upon, digg, or the other services to help keep my ‘page rank’ up there.  If you are a publisher or have access to a book agent, please consider helping me get a collection of my posts into paperback book form.  Finally, drop a 20 in the ‘donation’ box and you will buy yourself an e-mail consult–  I try to answer without the 20 as well, but I get more and more questions and never get to all of them.
Opiate dependence stinks.  I hope Suboxone is helping you deal with it;  if you are struggling, please consider asking for help.  All of us addicts want to do everything for ourselves, and call our own shots.  Look how well that has worked!
You all take care.
SD

It (gasp!) IS Hard to Stop Suboxone. Here is why.

Yes, you heard it here fir…. fourth…  it is hard to stop Suboxone.  As anyone pausing at this web site knows, it is hard to stop ANY opiate.  There are many forces at work against you when you are tapering off opiates; physical withdrawal, mental withdrawal, cravings for opiates, and the unconscious mental effects of addiction– the conditioning of your mind to see opiates as the solution to all of those uncomfortable feelings.  With all of that going on, it is no wonder that most ‘opiate tapers’ end unsuccessfully, leaving the addict more discouraged than he was before.

Suboxone is clearly different than other opiates, and the differences profoundly influence the tapering process.  I will mention my good friend Brian over at suboxonetaper.com, where he walks through his own experiences and helps a person know what to expect during the taper of Suboxone.  I have mentioned a number of times how the ceiling effect of the drug affects the tapering process;  there is minimal withdrawal going from 16 to 12 to 8 to 4 mg, but then the withdrawal kicks in during the last part of the taper.  This is probably why people leave messages here and there on internet health boards about Suboxone being ‘the worst thing to stop’;  the early stages are a cake-walk, and then the person tapering the drug gets hit with a brick at the end of the process.

What we really could use, to help people taper off Suboxone, is a tablet that is as large as the 8 mg tablet, but that contains less buprenorphine.  It would be helpful to be able to dose people with 1 mg, then 0.5 mg, then 0.25 mg, then 0.125 mg, then off.  Buprenorphine is a very potent drug;  when used for pain relief it came in solution for IV administration in microgram doses, and a dose of 50 micrograms was a potent dose;  the smallest pill form available is 2000 micrograms!  So tapering requires the use of tiny chips of a tablet during the final stages, making accuracy impossible.  In fact, if you wanted to do a proper taper with the drug you would want doses of about 50 micrograms each… and that amount is in one fortieth of one quarter of an eight mg tab.  Do you know anyone with tiny tiny fingers and macroscopic vision?

Since we don’t have a formulation that allows slow, accurate reduction in dose, we are left with doing the best that we can under the circumstances.  I think it is useful, knowing what to expect, so you don’t become too discouraged when hit with the withdrawal at the end.  One thing that seems to be different about Suboxone is that people seem to have less ‘pull’ to take more during the taper.  I don’t know if that is a real difference in the drug, or if it is just that people coming off Suboxone in my practice have taken it long enough for the conditioning that is so prevalent during active use has faded at least to a large extent.  I believe in medicating the taper off Suboxone;  I was criticized on one site for suggesting the medication Vyvanse to deal with the horrible fatigue.  But there is a ‘balance of risks’, and I believe that it is safer to use everything we can to get a person through the taper without re-igniting all of those thoughts and memories of using, even if it means using a stimulant or benzo for a week.

People need to understand that the issue with addiction, and with all of these things related to addiction, is NOT THE DRUG… THE ISSUE IS THE RELATIONSHIP WITH THE DRUG.  Some people hear the word ‘amphetamine’ and they go crazy– ‘that’s addictive!’ they say.  Yes, it is.  So is clonidine, when used in the prison environment.  There are safe ways to use addictive medications;  unfortunately modern medicine demands ten minute appointments, where safe prescribing is an impossibility.  Why do patients keep putting up with it?  Shouldn’t it take longer to figure out your problem and educate you, than it takes to make a hamburger?

The problem with any opiate taper, including Suboxone, is the loss of motivation after a few days of pain, weakness, and depression.  You all tell me– would motivational tapes help?  I have mentioned my web site sober after Sub, where I have tapes describing the state of mind you want to be in…  you can get in that state of mind in a few ways that I know of, including going to meetings.  I am eventually going to have tapes that will hopefully help a person feel support during the four or five days at the end of the taper…  the days when everything appears hopeless and the clock moves in half-time, or even slower.

As for medications, I have been surprised at the effectiveness of gabapentin in relieving the ‘hot flashes’ that are such a pain during withdrawal.  Clonidine is helpful, but it is such a drain on energy that it is sometimes hard to decide if a person is better with or without it.  I tend to recommend it for nighttime use only.  And then there is Vyvanse, an interesting molecule consisting of lysine bound to amphetamine…  it is impossible to abuse, and a short course can really help a person keep working.

For those people who have a problem with the use of a stimulant, picture my patient in the final few days of tapering off Suboxone.  He is tired and discouraged, and despite my encouragements I know that the ‘addict inside’ is now awake, and about to use the self-pity to turn the person away from his good intentions.  That is what happens, by the way– the addict inside the person waits for these opportunities, and once active the addict inside will actually change a person’s insight!  And once it changes, it is impossible to change it back… at least not until there is some negative consequence that wakes the ‘real’ person.  Crazy description, I know…. but addicts will recognize what I am saying.  I strongly recommend all addicts learn to recognize their own ‘addict inside’.  One value of twelve step groups is that you get to hear about everyone’s addict inside, and you learn that the addict inside everyone is the SAME PERSON– the SAME ADDICT.  Watch it in others, and learn about it in yourself.

Where was I…. this patient of mine is on the fence, and I am in danger of losing him.  He won’t go off and relapse, but he will go back to the full dose of Suboxone for another six months before trying again.  So if instead of all that, I can give a week of a stimulant to get his energy and mood up a bit, and help him kick through those last few days… where is the harm?  As it turns out, many opiate addicts have ADD as well;  they were in that common path of poor student identified by the school and the parents, leading to anger, shame, discouragement, and drug use.  And so I have seen a number of patients start reading for enjoyment for the first time in their lives…  pretty cool.

I think I’ve covered the major points:
Yes, it is hard to stop Suboxone… just like anything else.  The ceiling effect results in the withdrawal symptoms being ‘back loaded’– all at the very end of a tapering process.  It is very hard to taper because of the potency of buprenorphine;  a tiny fragment of a tablet of Suboxone contains a very potent amount of buprenorphine, which is usually dosed in micrograms when used to treat pain.  Remember when tapering that stopping 16 mg of buprenorphine is like stopping 30 mg of methadone… and stopping 2 mg of buprenorphine is like stopping… 30 mg of methadone!  THAT is the ceiling effect in action– great for holding addiction in remission, but a pain when it comes to eventually tapering off Suboxone.

One last comment:  tapering off the opiate is the EASY part;  the hard part is not picking back up again.  And that takes a great deal of work over the rest of your life.  Before Suboxone, getting clean literally required changing one’s personality.  I honestly don’t know if people going through a year on Suboxone, learning some things, then tapering the drug will be able to stay clean long term.  I try to offer things that I believe will help, things I picked up through a long residential treatment and years of twelve step immersion.  I really hope I am helping at least some people- not only helping them feel ‘not alone’, but also helping them keep opiates from destroying their lives.  BUT… if you are not doing well, don’t rely on my blog to turn it around.  Do what I did, and open your mind and ask for help at a treatment center.  I will say this again, because if you hear it I will save you tons of money you would otherwise waste:  open your mind before stepping in the door.  Treatment is NOT education– it requires you to change, and to do that you must drop all of your resistance to change.  Avoid thinking that you have the answers; after all, it was your own best thinking that got you to where you are today.

Darn That Suboxone!

This guy doesn’t like Suboxone– or the horse it rode in on.  He has been trying to write angry posts under my youtube videos, but I have been blocking them– His feelings about Suboxone popped up on one of the health sites out there this morning, catching my attention through ‘Google alerts’ for Suboxone.  It must be the same guy, because the complaints are the same, the language is the same, and in both cases the screen names are related to frogs(!).  I will go ahead and post his comments, and then my response, so that he can relax– knowing that he has done his part in the epic struggle over Suboxone.
His Post:
Ive looked all over the internet and still have not found more then 5 people who have quit suboxone like i have. I took it for 12 months tapered down to

2 mg and quit 5 days ago..Basicly i am writing this due to the fact that i am really pissed at the fraud i feel is being commited by the drug maker of suboxone. I was taking 15 10 mg a day of percocet and 10 mg a day of norco a day b4 i got on sub. Anyways the reason i am so pissed is that these last 5 days have been the worse 5 days ive ever had.My Dr says oh youll just feel little tired for a few days is all.. ya right… 5 days of not being able to move,anxiety,depression you name it.. and no i am not crazy i took pills for shoulder injury so i have an idea where these feelings come from and its the

good ole subs that all these Drs are making a fortune off. You must remember

that out of all My drs patients i am like the only one whos quit totaly and can actually sit here and tell you what its like.. Its terrible and after considerable thought

i think people need to know this sub is just another opiate and what gets me is the withdrawls are even worse then reg opiates. I CLOSE WITH ONE LAST COMMENT: ITS ALL ABOUT THE MONEY WHEN IT COMES TO SUBS: Think twice before some slick talking Dr wants you on it.. its far from a magic pill. Just ask the few of us out of 1000000,0000 people who quit the phoney stuff.

There is no magic pill for addiction to pain pills and if you think sub is then think again..One last thing, try and ****** suboxone withdrawls and guess what youll find??? first 50 sites pop up are paid for by the drug maker of sub and you have to dig to find real facts from patients with experience.. Drug maker pays big bucks to keep all the info ” positive” on subs… They are no dam different then the crooks on wal-street !

My Response:

Before my answer, a quick comment–  I do like the ‘crooks on wal-street’ remark;  I haven’t seen that ‘play on trademark words’ before.  I am assuming that he was making a joke–  he had to be, right?

OK, here is my response.  As usual it is a bit ‘snotty’– but you have to remember that I get this garbage all the time, and it gets old:

I am sorry to be the one to break this to you, but you are an opiate addict. Moreover, you will always be an opiate addict; hopefully you will be an addict ‘in remission’. The brain pathways that make up ‘addiction’ are laid down in a manner that involves memory processes; becoming a ‘non-addict’ would be like forgetting how to ride a bike. It cannot happen. Again, you can be in remission, but with opiates, that is very difficult– and unfortunately very uncommon.

Many people write about how they used will power or vitamins or some other silly technique to quit opiates– once they have gone over 5 or 10 years, I am interested in listening to them. It is easy to quit using for a year– it is another thing entirely to quit using for 10 years. I got clean in 1993 and felt pretty proud of myself… I quit through AA and NA, not Suboxone. I worked with opiates the whole time, giving patients IV fentanyl, morphine, demerol, etc in the operating room… but in 2000, thanks to a little market in the Bahamas that sold codeine over the counter, I relapsed. I ended up losing almost everything, including my career, all my money, a vacation cottage, my medical license… ****** ‘mens health’ and ‘the junkie in the OR’ and you will read my story.

There is no ‘fraud’, no ‘slick doctors’. There are doctors trying to help, and some work harder than others to keep people on track. We now know that Suboxone is best thought of as a long-term treatment, just like most other illnesses; we treat diabetes, hypertension, asthma, etc with long-term agents; if you stop your blood pressure meds abruptly you will have ‘rebound hypertension’ that can be very dangerous… Suboxone is similar to any other treatment. The thing is, pharmacy companies never used to care about addiction; the money is in treating other illnesses– just watch the commercials on TV! The money has been in viagra-type drugs! Suboxone is the first generation of opiate-dependence medications; the next wave will have fewer side effects, and so on. That is what happens with every disease. I am glad addiction finally has the attention of pharmaceutical companies. As for ‘slick docs’, there are many easier ways to make a buck in medicine! I am at the ‘cap’ of patients; the money I make treating patients with Suboxone is a tiny fraction of what I made as an anesthesiologist; I could drop the Suboxone practice tomorrow and take one of the 30 jobs in my area frantically looking for psychiatrists and make as much or more money. Yes, there probably are some ‘bad docs’ out there– there are ‘bad everythings’. But a bad doc will make a lot more money treating ‘pain’ using oxycodone than treating addiction with Suboxone! For one thing, there is no cap on pain patients! And when a doc wants to prescribe Suboxone, he/she can have only 30– THIRTY– patients for the first year. Hard to get rich on 30 patients!

Suboxone has the opiate activity of about 30 mg of methadone. When tapering off Suboxone, the vast majority of withdrawal symptoms occurs during the final parts of the taper– the last 2 mg. That is because of the ‘ceiling effect’. But you are not just tapering off Suboxone…

Do you remember when you started Suboxone, how lousy you felt, and how Suboxone eliminated the withdrawal? YOU NEVER FINISHED GETTING OFF THE STUFF YOU WERE ADDICTED TO. There is no ‘free lunch’; Suboxone allowed you to avoid all that withdrawal; if you stop Suboxone, you have to finish the work you never finished before– going through the withdrawal that you ‘postponed’ with Suboxone! Welcome to the real world– you likely abused those pills for years, and if you don’t want treatment with Suboxone, you had better start a recovery program, or you will be right back to using again.

Human nature can be a disappointment at times… When I ‘got clean’ after my relapse 8 years ago, I was just grateful to be ‘free’– even for just a few days of freedom! To get to freedom, I was in a locked ward for a week, no shoelaces (so I wouldn’t hang myself!), surrounded by people who were either withdrawing or being held to keep them from self-harm (it was a psych ward/detox ward combined). After that, I was in treatment for over three months– away from my family all that time, and I couldn’t leave the grounds without an ‘escort’ (no, not that kind of ‘escort’!). Treatment started at 6:30 AM and ended at 10 PM. The rare ‘spare time’ was used to do assignments. After those three months I was in group treatment for 6 years, and also AA and NA meetings several times per week. I still practice and active program 8 years later– I know what happens to people who stop: they eventually relapse, and some of them die. I AM NOT EXAGGERATING ‘FOR EFFECT’ HERE.

I had better stop or I will spend all of 2009 with this post… My final comment: Most of what you are feeling is not ‘Suboxone withdrawal’. I have watched many people stop Suboxone; some have bad withdrawal, some have NONE. When you talk about ‘anxiety’ or other problems facing life on life’s terms, you are experiencing life as an untreated addict. ADDICTS WHO SIMPLY STOP TAKING THEIR DRUG OF CHOICE FEEL MISERABLE!!! That is not withdrawal, and it doesn’t go away! Suboxone held things ‘in remission’ and allowed you to pretend you were not an addict; it is NOT a cure. So now, off Suboxone, you will see what it is like to live life as an opiate addict without treatment– and if you don’t get treatment, you will likely relapse. You will relapse because untreated addicts find life intolerable.

My human nature comment– everyone wants good things, but nobody wants to do the work to get them… (I’m in a bit of a mood today I guess– sorry). Recovery from opiates has always taken work– very hard work. And even then, success was rare– most people had to go back to treatment over and over and over before finally getting it. If people stopped working, as I stopped working in 1997, they eventually got sick again. Enter Suboxone: now you can have instant remission from active addiction! So are people grateful for that fact? That now, instead of years and years of struggle, they can take one pill each morning and hold their addiction in check? NO. Now they complain that ‘I don’t feel good when I stop Suboxone!’. Sorry, but a part of me says ‘poor baby’. You have a fatal illness, and you think you are done with it… you will find going forward that you will either use, or you will take buprenorphine or a new medication along the same line, or you will be attending meetings for life. Those are your three choices– pick one.

If you find a 4th choice, tell me about it in 5 years. I would like to hear how you did it, and yes, I hope you do find it (rather than die using). But I looked for that other path myself for years and never found it, and so did millions of other addicts.

OK… on with life…

Suboxone: a Drug for a Drug?

A common refrain of the anti-Suboxone crowd is that ‘Suboxone is just replacing one drug for another.’  I have one question for the people who write those angry messages:  why do you care so much about people using Suboxone?
Here is my next youtube submission:

Help– I Can't Stop Suboxone!

I am still experimenting a bit with youtube.  They tell me that video is the future of the internet, and who am I to argue?  Tonight’s ten minute video deals with a common video title at youtube, and the title of this post.
So… why is it hard to stop Suboxone?  I resisted the urge to put a ‘duh’ here…  in case you are missing the answer…  one reason is because Suboxone has opiate properties, and stopping it causes withdrawal.  Pretty much anyone who is taking it has demonstrated an inability to stop any other opiates– probably over and over again.  So why would such a person be able to stop Suboxone?
Actually, most opiate addicts that I have gotten to know over the years, myself included, have trouble stopping just about anything– opiates, sleeping pills, antidepressants, ice cream, Cap’n Crunch…   if ‘the addict’ in me likes something, he doesn’t want to give it up!!  I don’t know why, but he is stubborn like that!
I realize that there is physical withdrawal to buprenorphine and not to ice cream… so I would expect Suboxone to be a bit more difficult to stop.  But I have a bit of information to add to our database of information here…  although I realize that some people will not believe what I am about to say.  But I really have no reason to lie;  I’m sure the conspiracy theorists think I am up to something– I got a comment today that said that I ‘push Suboxone to rake in more money than I ever dreamed of’.  One thing I can guarantee, just in case the writer is reading this–  I can dream of a lot more than that!  Darn– where was I?  Oh yes…  a patient of mine who takes Suboxone– he is about 45 or so and used opiates for many years for chronic back pain, and has been on Suboxone for only about a year… he is having a great deal of tooth problems related to trauma years and years ago, and will have the remaining teeth pulled in a few days.  To prepare, he took himself off Suboxone a couple weeks ago by tapering down to 4 mg and then stopping.  I saw him today and he insists he had NO withdrawal at all– ZERO.


This guy has been using opiates for decades and has had withdrawal many, many times, so I would have expected him to suffer a bit going off Suboxone.  On the other hand, he is a tough guy– and I don’t mean that any way but literally.  He could probably have his fingernails pulled off one by one without flinching, and he is not prone to ‘working himself into a frenzy’ over fear of something.  But I was still surprised at his claim– I believe it entirely, but I am surprised.
I did have one young woman as a patient who stopped Suboxone after taking it for several months without telling me ahead of time– she also claimed to have no withdrawal, although in retrospect she said she did feel ‘a little tired’ for a few days.  I have had a number of patients taper off Suboxone and have never had one claim that the experience was worse than oxycodone, vicodin, or methadone– not one.  I read the posts on the internet– ‘the hardest thing to quit EVER!’  I don’t know what to make of them.
OK, enough horsing around.  There is no longer any reason for you to watch the video, unless you want to look deep into my eyes to determine if I am telling the truth.  But here it is anyway– my description of the reason for the phenomenon, ‘I can’t stop Suboxone!’

Precipitated Withdrawal– Now What?

I saw this question on another board– I didn’t want to add my reply to the other five answers already listed, so I’ll put it here for hopefully the next unfortunate person in ‘precipitated withdrawal’ to find.
For those who don’t know, precipitated withdrawal occurs when a person’s level of opiate stimulation is suddenly reduced by another medication blocking the receptor site.  This occurs when an overdose patient is given an opiate antagonist such as IV naloxone.  As soon as the naloxone hits the receptors in the brain, the oxycodone, methadone, heroin, or other agonist is ‘displaced’ and the receptor is ‘blocked’ by the naloxone.  I actually did this to myself on several occasions back in my using days; once by out of desperation and stupidity using an unmarked syringe that contained naloxone, and two other times by ingesting naltrexone, an orally-active opiate blocker, in attempts to make myself ‘get clean’.  Those experiences lead to my first comment about precipitated withdrawal:  you won’t die… but you will wish that you did!
The active ingredient in Suboxone, buprenorphine, will cause withdrawal if a couple things are present: first if the person has taken an opiate agonist recently enough so that there is still agonist drug bound to the receptors, and second if the person’s tolerance is greater than that associated with about 30 mg of methadone– equal to the opiate-stimulating activity of Suboxone. If a person just took his first 20 mg of oxycodone, I wouldn’t expect the buprenorphine in Suboxone to induce withdrawal because at his tolerance level, his receptors will see buprenorphine only as an agonist– not as an antagonist. The rules are not ‘hard and fast’, but depend in a complex manner on the interaction between recent use, half-life of the recently-used drugs, and the person’s tolerance. For example, if a person is used to 600 mg of oxycodone per day, but hasn’t used for 24 hours—long enough to get most of the oxycodone out of the system—I would still expect the person to have precipitated withdrawal– because even after 24 hours without using, the person’s tolerance level will still be quite a bit higher than the ’30 mg of methadone’ level of stimulation caused by buprenorphine. There is a bit of an art to avoiding the withdrawal, but sometimes it can’t be avoided. For example, in the 600 mg oxycodone case, I could tell the patient to go without using for three days;  that would be enough time for their tolerance level to drop closer to the ’30 mg methadone’ mark… but the person will feel utterly horrible during that time, and sometimes it is obvious that there is NO chance the patient will stay clean that long. So there are two choices; schedule an induction in three days and then cancel when the person breaks down and uses something the night before the induction, or shoot for 24 hours of clean time and let the patient know that he/she is going to be a bit sick at the induction.
I should mention that the ‘proper way’ to manage the patient taking 600 mg of oxy per day is to taper the person down to the equivalent of 30 of methadone per day.  This never works;  first of all, it is illegal for any doc to taper opiates for the purpose of treating opiate addiction, unless the doc is part of a registered methadone center– and methadone centers, in my experience, are not interested in doing the work of tapering people off opiates.  They tend to do what they want, and that is to increase the dose of methadone– not decrease it.  But even if the patient found a doc willing to break the law and schedule a taper, the tapering schedule cannot be followed by the addict.  I suddenly think of the old joke…’if I could walk THAT way, I wouldn’t need the talcum powder!’…  as I think in a similar vein, ‘if I could do a taper, I wouldn’t need an addictionologist!!’

The good news is that precipitated withdrawal is much shorter than real withdrawal.IF you have precipitated withdrawal, all is not lost—providing you do the right things.First, understand that you are going to be sick for about 24-48 hours no matter what you do.Your choice, at this point, is: after you get better, will you be on Suboxone, or will you be using?

If you have PW (I’m sick of writing out Precipitated Withdrawal), the most important thing is to FINISH THE INDUCTION! Complete the dosing of Suboxone, as quickly as possible—take the full 8 or 16 mg. If you stop the induction early, after only 4 mg, you will likely end up using later in the day to try to overcome the block.  That gets real dangerous, and only prolongs the misery– and in a few days when you finally have the Suboxone out of your body you will still be using. On the other hand, if you complete the dosing of Suboxone– take the full induction dose of 8 to 16 mg– you will be at a place where no amount of using will overcome the block (so don’t even try!).  Try to deal with the withdrawal in the usual manner (clonidine, immodium, warm bath) and the next morning take another 16 mg dose of Suboxone. Keep dosing each morning—DON’T mess with multiple daily doses as they won’t help and they can potentially make it worse (if you take very large doses of Suboxone it becomes a pure antagonist). If you just keep dosing 16 mg per day each morning, by day two you will be much better, by day three you will be 90% better, and by day 4 you will be out of withdrawal. It’s fast—unless you play with it.

By day 4, you’re done with the misery and on Suboxone. Your addiction will be in remission, provided you do the other things required to get better—things which are usually fairly easy to accomplish if you have some level of desire for the sober life. And it is wonderful to have the chains removed! Once you are at this point, KEEP TAKING THE SUBOXONE! I read the comments at some sites about ‘coming off sub’—it is important that you understand that virtually ALL of those people—the ones who go on Suboxone, get their lives back, but then believe some idiot ranting that ‘they aren’t really sober’ and go off Suboxone— will only be using again, probably in a matter of weeks. It is so unfortunate… people go to these message boards and read ‘support’ and ‘encouragement’ to ‘get off Suboxone’, usually doing the taper wrong, suffering through unnecessary withdrawal, and blaming their misery on the Suboxone…  Then they write with excitement how they are now ‘really clean’… But in a week they are gone from the message board, too busy to write, scrounging up money to buy dope—or more likely, selling their computer for the money for dope. It doesn’t work, people.

Is it ever possible to get off Suboxone?  Yes– if you are willing to treat your addiction with something else, usually twelve-step-oriented recovery.  Suboxone alone is not a cure– it is a means to induce remission of opiate addiction.  For someone who got clean ‘the old fashioned way’, the glass is half full!

Too Many 'Suboxone Experts'

Every day I receive several comments from self-identified ‘Suboxone experts’ who repeat the same comments over and over again. I am tempted to post a few here, and then pick them apart piece-by-piece, but I am afraid that somebody will pop in, read them out of context, and think that I am agreeing with something that I actually take issue with. The comments are generally something like this: You are wrong. You are replacing one drug for another. Suboxone is the same as methadone. Suboxone is the worst thing in the world to get off of. You should check your facts. Trust me doc—you don’t know what you are talking about.’ Then they often add something like ‘have a nice recovery’, or ‘may you rot in hell’, or ‘if you get defensive that only proves that you are wrong’ (my personal favorite).

Other times I will get comments from amateur pharmacologists, using long chemical terminology (note to writers: if you want to impress someone by using the big words, at least look them up to get the spelling correct!). Tonight I read comments where a person had taken the potency-comparison chart for buprenorphine—the one that says that 1 mg of bupe is as potent as 15 mg of methadone—and projected it out to predict that a certain dose of bupe would be appropriate for a higher dose of methadone. In other words, if 1 mg of bupe is as potent as 15 mg of methadone, ‘that means that 10 mg of bupe is needed for 150 mg of methadone’. This is just plain incorrect; bupe has a ‘ceiling effect’ that is responsible for its usefulness for addiction, and the writer was assuming ‘linear kinetics’. In reality, 1 mg of bupe equals 15 mg of methadone; 2 mg of bupe equals 30 mg of methadone, and 4 mg, or 8 mg, or 16 mg of bupe also equal… you guessed it… 30 mg of methadone!

I want to tell people that there is a huge body of literature out there about addiction, about buprenorphine, about Suboxone… Understand that addiction is a world-wide problem that kills millions of people each year! Millions, if not billions of dollars have been poured into addiction research over the past 20 years. There are many peer-reviewed journals that deal only with addiction. There are hundreds of academic centers that do research into addiction. There are dozens of meetings each year, where scientists with MDs, PhDs, and other degrees discuss the current research findings. For Suboxone to be approved, the pros and cons of the drug had to be studied over and over in research costing millions of dollars. DATA 2000 had to get approved by Congress for Pete’s sake!

The world’s best minds have already thought all of this through. But more than that, studies have been done, looking at what happens in the various treatment scenarios. The ideas about the use of Suboxone have been knocked back and forth for years—over ten years. As for my own comments, I feel a bit obnoxious explaining my credentials over and over, but I do it to try to explain that I’m not just coming up with things off the top of my head because they ‘seem right’… I’m reporting on what we KNOW. We know the ideal dose of various antidepressants because of studies looking at the effects of different dosages. And we know that the withdrawal syndrome after stopping Suboxone are less severe, in humans and in animals, than the withdrawal from methadone or oxycodone—from studies investigating the withdrawal symptoms from various opiates. We also have clinical impression—the accumulated experiences from doctors treating addicts. Today I wrote back to a particularly annoying ‘expert’, ‘do you really believe that Hazelden and all the other treatment centers that use Suboxone as a tapering agent, because it is easier to come off of, are wrong—and YOU are RIGHT?!’

Yes, I realize I am getting a bit ‘pissy’ over this. But people die from opiate addiction! Young people, old people, men, women… they die in part because they don’t get expert help. Instead they try to fix it themselves, or listen to the comments on the internet that they happen to come across. I remember a guy in med school who always thought he was right, even when he was completely wrong. I remember thinking, ‘that is a dangerous way for a doctor to think’. As I have said before, a good man knows his limitations. And when dealing with something that is life-threatening, the stakes of ignorance are very high.

For people looking for information or advice, please try to check the credentials of any person making claims about Suboxone. Some people are so smug about their own ‘sober recovery’ that they take pleasure in cutting down others who found help a different way. Some people mean well, but they can’t help making up the science ‘as it should be’ rather than as it really is—an example would be me writing that ‘the different colors of a rainbow are from each raindrop shining a different colored light from the sky’—sounds almost logical, but it isn’t anything like what really happens (light waves refracted from different relative viewing angles, specifically). A general tip—when someone starts talking about dopamine levels and endorphins being depleted, they are almost always making it up as they go along. Do levels of endorphins go up or down during chronic opiate dependence? I don’t know!! I would have to check the literature. I could make up a neat story about why they go up or down… but it wouldn’t be accurate or true. It is always more complicated than a ‘story’ would suggest!

I need to get to bed at a reasonable time for a change. Keep it real!!

SD