Bupe Told My Bupe Doc That the Bupe Dosages Commonly Scripted are Unnecessarily High

[daddysgone]

I am of the school of thought that in nearly all cases, bupe doctors prescribe absurdly and unnecessarily high doses of bupe for their bupe maintenance patients.

For instance, when I first went to my bupe doc, he started me at 16mg per day (and this is a lower dose then what many patients are prescribed).
For the first 2 weeks, I took the 16mg per day, and while I felt completely "held", I also noticed that I experienced quite a bit of drowsiness and dizziness at this dosage.

After about 2 weeks at this dosage, I decided to see what would happen if I took 4mg per day (2 doses of 2mg per day). On that day, I noticed that I felt 100% as "held", noticed NO feelings of even minor withdrawal, and also noticed that my drowsiness and dizziness almost completely disappeared.

After a few days at this dose, I cut my dose again to 2mg per day (1mg taken twice a day). Again, I felt just as comfortable, and all drowsiness/dizziness were gone. So essentially, I had cut my original dose down to 1/8th of what I was prescribed, and the result was that I felt just as "held" and comfortable, and any side-effects I had experienced at the higher doses, completely disappeared.

Now, if this was just my experience, I would not draw any grand conclusions since one person's experience is meaningless. However, again and again, I read reports which mirror mine exactly. Even for people who had very high opiate tolerances, nearly all seem to cut their doses to 2-4mg per day MAX, and suffer no decrease in effectiveness, and actually find that the lower doses are more comfortable and effective.

So at my bupe appointment today I decided to tell my doc that I have been taking only 2mg of bupe per day (he still scripts me for 16mg per day). Now his first concern was what was I doing with all the excess bupe (I imagine he was concerned I was selling them). After I explained that I have just been saving them and would never consider selling them, he seem satisfied and then wanted to have a discussion about dosages and hear my side of the story regarding why I felt that such a smaller dose is almost always sufficient, and in fact, often more effective. He also wanted to hear my thoughts regarding why the literature indicates that such high doses should be used, if its the case that so many patients feel thatmuch smaller doses seem to be just as, if not more effective.

I gave him my point of view/theory regarding why the manufacturers advocate such high doses of bupe when it seems that these high doses are counter-productive.

My first response was based on simple economics. Clearly the manufacturers of bupe stand to earn higher profits if they convince bupe doctors to prescribe high doses of an expensive drug. I also provided a less sinister reason based on the idea that at high doses, it becomes very hard for addicts to abuse other opiates since bupe effectively blocks other opioids at high doses, whereas addicts can fairly easy take full agonists on top of their bupe if they are on small doses of bupe. With that in mind, it does seem a legitimate reason to prescribe higher doses of bupe in order to prevent the abuse of other opioids while on bupe.

Lastly, I suggested that because bupe is a partial agonist, and is fairly unique in that unlike most other opioids, high doses of bupe really dont cause higher levels of euphoria or levels of abuse then they do at small doses. This, coupled with the fact that unlike full agonists, high doses of bupe are very unlikely to cause a dangerous overdose. So with these facts in mind, there really are no downsides (from the manufacturers perspective) of prescribing high doses of bupe, while they to stand to benefit (profit) from convincing docs to prescribe high doses of this expensive drug.

So....first Id like to know if people generally agree with all I have said on the matter. I truly feel that for those that find success with bupe (note that there do seem to be some people who cannot be "held" from bupe regardless of dose), but for those who find success with it, I am convinced that 4 or perhaps 6mg MAX per day, is a completely sufficient maintenance dose. I find it hard to believe stories of people who suffer pain and withdrawal from a 4-6mg dose, but then find a 20mg dose per day, to be effective.

The other question I want to ask is if anyone thinks it was a bad idea, for any reason, that I had this conversation with my bupe doc. I didn't want to insult him by implying that I am more knowledgeable on this subject which he is alleged to be an expert, but the truth is, I think most of us on bupe maintenance are indeed more knowledgeable about this subject, simply because of the practical experience we have with it.

I really just wanted to share my views with him because I am angered by what I view as deliberate deceit on the part of the makers of bupe. I genuinely believe they purposefully have spread false info regarding their product in order to increase their profits. I therefore felt compelled to give him an opposing view from an educated patient so that he is now exposed to both sides of this issue, and is now no longer only aware of the BS that the manufacturers of bupe have convinced him of.

So...did I overstep my bounds? Should I have kept my opinions to myself? Thanks-DG

 

[monstanoodle]

No, you're quite right. A lot of people on this board also think that a lot of people are given much higher doses than are necessary.
4-8mg will usually hold most people (habit taken into account).

 

[charmcity.exile]

The pharmaceutical business is just like any other racket to a great degree. Not only in the field of addiction medicine, but especially with regard to depression medication and preventitive medicine.
Their basic attitude is best summed up by a quote somebody in the industry once told me: "There's no money in cures." Treatment is where its at.
If you ask me, methadone programs are the most notorious for overprescribing. I've seen people in parts of the country get on MMT for little Percocet habits, then end up having a dose of 100mg+/-. Thats ridiculous.

 

[Captain.Heroin]

I think some doctors are 100% well aware of what they're doing, they just give out extra Suboxone because they know people are likely to need it later down the line and they know how expensive it is. If you're someone who has insurance they tend to give you a lot since you're paying a fair bit of money for it anyways. For people without insurance or with shitty insurance they'll just load you up with the generic Subutex.

Then there are probably other doctors who are 100% unaware that 16-32mg/day is absurdly high for 90% of the population of opiate users (10% of opiate users may actually need more than 8mg day, but I am not going to argue this one way or another, I'm just saying there are some people who do need more than others).

I wouldn't say you should have kept your opinions to yourself, but either they would have heard your point and took it to heart, or they'll ignore it and pretend they know better than you because they're a doctor (like that mandates they're knowledgeable or something).

 

[BIGsherm7272]

why bother? Having extra bupe can never hurt

 

[StaffWriter]

Daddysgone- I agree with you on all points. I've gone from the obligatory 16mg dose down to 4mg daily and I am "held" just as well as I was on 16mg. However, I have noticed that I'm having cravings I didn't have before and have taken advantage of the fact that you can indeed breakthrough a dose as low as 2-4 mg. To be honest, I wish I had the money (my ins. does not cover bupe) to stay on a higher dose so I won't be tempted to cheat and those cravings could be kept at bay. Other than that, you're spot on.

BTW: Been on bupe for 18 months now.

 

[morphonorconic]

I agree as well. Even when my habit was huge, and I was doing dope, Oxy, and Morphine everyday, I found that 1mg of Bupe was plenty to hold me over. Even 0.5mg made me fairly comfortable in the absence of the aforementioned agonists.

 

[WSB15]

Couldn't agree more. Although I bet part of the reason they think such high doses are necessary is b/c some addicts say they need that much in an attempt to either catch a buzz off it or save up a bunch to either sell or save. I tried to explain how potent Suboxone was to my first doctor, but she just ended up thinking I was just an anomaly rather than the norm.

A more problematic aspect of docs underestimating Suboxone's potency is that a lot of them think you can get off it at 1 or even 2 mg with barely any withdrawal. Ask your doctor if they follow up with patients at any point after stopping Suboxone, none of them do. They seem to think that because its a partial agonist its a miracle drug devoid of withdrawal, unlike methadone. Personally I don't see any reason not to taper to 0.5 or 0.25...Why jump off methadone at 20 mg when you could go down to 5 mg?

 

[Cornishman]

American doctors over-prescribing drugs?
Whatever next.

 

[thelung]

When i took it, 2mg was fine for the pretty regular opiate user that i was @ the time. I read about people being on 32mg/day and i think "whoa there!"

 

[bagochina]

I do agree that bupe is given in to high of doses but hey I am still alive! I always think it is better to have to much than to little. I was on 32mgs for a couple years.

Clearly the manufacturers of bupe stand to earn higher profits if they convince bupe doctors to prescribe high doses of an expensive drug.

When bupe was first scripted it definitely seemed like high dose bupe was the norm and as experience set in the dose curve started to lessen. The manufacturers dont have to do anything to make $ they know they are going to make money by just putting the product out there. Although if they wanted to save opiate addicts money they would have just put out a 24mg pill instead of lower dose tablets. Perhaps that is why they only released a 2mg and 8mg tablet because they know eventually the dosing would correct themselves and those were the both ideal/effective for making money and correctly dosing patients.

Peace,
Seedless

 

[Pegasus]

I'm curious what your doctor said after you told him all this?

Hopefully he respects what you said and can use the knowledge to better treat others... I guess if he keeps treating you the same in the future as he did in the past, there is a good chance that he did respect what you said. I think the crucial thing here is that you pretty much exhibited the opposite of drug-seeking behavior (you were saying that you needed LESS drugs!)... hopefully he sees that!

 

[sixpartseven]

Good for you, DG. I've always thought Bupe doctors prescribed ridiculously high doses. It breeds this feeling that high doses are required. People taking 16 or 24mg of Bupe think they absolutely need it when really, they could get by on so much less. At the same time, these high doses are increasing the patients tolerance and leading to addiction to Bupe, which is completely counter-productive to what the drug is intended to be used for.

Unfortunately, telling one doctor that the doses they are giving are too high isn't going to help, but I commend you for doing something about it. If only all Bupe patients were willing to accept the fact that they do NOT need these super-high doses they are being prescribed and would tell their doctors the same, then change would be more likely, but I have a feeling most patients being handed high doses either A) think they really need it, or B) know they don't need it but won't say anything because they are essentially being given surplus drugs that they can do whatever they want with.

I was lucky and both Bupe doctors I've had asked me what dose I wanted to start out with and maintain on. I chose as small of a dose as possible and they were perfectly OK with it. More doctors need to do this, but at the same time, patients with doctors like this need to not abuse it and ask for stupidly high doses.

It irks me like nothing else that this is happening. It's increasing the number of people addicted to pharmaceutical opiates and working against the effectiveness of Buprenorphine as a maintenance drug.

 

[dankstersauce]

why bother? Having extra bupe can never hurt

I agree. It just makes sense. Like I've been scripted 32mgs a day and would take 8mgs max at first. Now I'm down to 2-4mgs and still using a script from 2-3 months ago when I was getting 24mgs a day. I love it. You really get you're moneys worth because a script can last 4-6 months or longer. I agree they over prescribe but it's fucking expensive and if you can get by fine on less great. Especially when I was getting 32mgs a day, it cost a $50 co-pay whether I got 30 pills a month or 120. So obviously I asked for more since it's the same cost either way.

 

[sixpartseven]

If R&B would stop fucking around and allow a generic version to come out, cost wouldn't be an issue. I would vote for better prescribing practices and cheaper prices before I'd vote for having a larger supply. The current prescribing practices are getting a lot of people deeper into addiction than they are helping people out of addiction, which is completely backwards.

 

[daddysgone]

If R&B would stop fucking around and allow a generic version to come out, cost wouldn't be an issue. I would vote for better prescribing practices and cheaper prices before I'd vote for having a larger supply. The current prescribing practices are getting a lot of people deeper into addiction than they are helping people out of addiction, which is completely backwards.

Are you referring to R&B coming out with a generic suboxone? I was certain that R&B are the makers of suboxone. If Im right about this, why would you expect them to make a generic of their own drug?

In any case, apparently manufacturers are running into difficulty with making an effective formulation of the bupe plus naloxone. I cant fathom why this would pose any sort of difficulty (especially considering that the fact that suboxone already exists is evidence that such a formulation can be manufactured). However, the fact remains that I have read several times, that the reason subutex has gone generic and not suboxone is that manufacturers are having difficulty (for God knows what reason) in making an effective formulation of bupe plus naloxone.

Its possible I totally misunderstood your post sixparts. Did I interpret you correctly?-DG

 

[morphonorconic]

I'm not sure if that's what sixseven meant, though it is quite common for manufacturer's of brand name drugs to also offer a generic version of the same drug. For example, Watson makes brand name 'Norco 539,' but they also make generic for Norco 10/325, with imprint 'Watson 853.' Exact same drug, same pill, same everything except for the pill imprint.

 

[sixpartseven]

Are you referring to R&B coming out with a generic suboxone? I was certain that R&B are the makers of suboxone. If Im right about this, why would you expect them to make a generic of their own drug?

What I meant was that R&B is reluctant to relinquish the patent. I might have been mistaken and it could be other companies that are having trouble developing a generic (sounds like a BS excuse, more in next paragraph) which is what you referred to, but regardless, a generic NEEDS to come out so this drug doesn't have to be so expensive. I am certain that R&B is saying something about not being able to create a stable version of the generic. It can be found somewhere here in OD (again I am unable to find it, probably got pruned last spring). My point in my previous post still stands, just swap "R&B" out and put in "drug companies" and it's still a valid point.

"Unable to develop a stable product," is such a lame excuse for not being able to make a generic. If they were able to make a stable brand name form, why can't they make it generic? It's ridiculous, and that's why I am sure R&B is behind it because it sounds like an excuse to keep only brand name Suboxone on the market at expensive prices.

And it is not unheard of for companies to make a generic of their own drug. Take Purdue Oxycontin, for example. They released the ABG generic when generics became available so they had a product to compete with the other generics, and it was practically identical to the brand name OC. R&B will probably do the same when other companies start releasing generics of Suboxone.

 

[daddysgone]

I see. Well if it really is R&B stating that they are having difficulty in formulating an effective bupe + naloxone tablet, then that might be the most hilarious statement I've ever heard a drug company make. They would essentially be saying that they are unable to effectively formulate a tablet which they have already produced successfully for years. What, did they forget how to do it?? Or is it that the formulation only works if there is an 8 dollar price tag attached to each pill. Absolutely laughable. In fact, its such an absurd statement to make, that I have to believe that it is other manufacturers who are claiming that they are having difficulty in making this formulation. I mean honestly...while I don;t put much past a pharma company, I can't believe that even they would have the gall to try to convince the public that they can't seem to make an effective formulation of a pill which they have already manufactured successfully.

Moving on. To be honest, I actually don't see the point in creating a generic suboxone. The reason I say this is due to the fact that I don't see the point of suboxone in general- considering the fact that subutex, and now brand name subutex are available.

I think we have reached the point where we can agree that the inclusion of naloxone in the suboxone formulation is pointless from a pharmacological standpoint, and the decision to include it in the suboxone formulation was nothing more then a brilliant marketing ploy on the part of the manufacturers. When naloxone is co-administered with bupe (as in the case of suboxone), the naloxone is an inactive ingredient for all intents and purposes. All the initial claims and hype made by the manufacturers who convinced the medical community that the inclusion of naloxone results in a less abusable medication, is patently false, and flies in direct opposition to our knowledge regarding these particular opioids and their binding affinities. Simply put, the naloxone in suboxone exerts no real effect on the action of suboxone, regardless of what route of admin. is used.

So with this fact in mind, what need is there for suboxone, whether it be brand name or generic? I see absolutely no need for any pill, generic or otherwise, that is simply subutex with an added pharmaceutical which offers no benefit, and exerts no action, aside from the occasional headache.

I suppose if we were living in a perfect world where doctors were fully educated on these matters, then suboxone would be viewed as pointless, and would likely leave the market. However, the sad truth is that many docs have been duped by the manufacturers of suboxone and truly believe that suboxone is far less abusable, and therefore opt to treat their patients with suboxone instead of subutex. If you are one of the unfortunate patients who have such a doctor, then I suppose there is a legitimate need for a generic suboxone since the release of a generic would at least lead to a scenario where these patients whose doctors will only script for suboxone, are no longer forced to pay outlandish prices for this pointless formulation.

Man...Ive been ranting alot on the subject of bupe lately. -DG

 

[lozgod]

I've always thought this. I have a 600mg+ tolerance for oxy but 2mg of suboxone can bring me out of sickness and can keep me good at that dose easily. If I could break the pill further I bet 1 or even .5mg could do it.