Methadone to Buprenorphine Transition?

[Drss888]

Hey I saw a few of your posts and you seem to know what your saying, I have tapered from 72mgs to 20mgs of methadone. My doc has prescribed me the 2/.5 mg suboxen. I took my last dose of methadone at 8am yesterday morning. I’ve been on a steady 20 for 3 weeks. How long in your opinion should I wait, my doc said 24 hours but I’m nervous...

 

[FLA]

Hey I saw a few of your posts and you seem to know what your saying, I have tapered from 72mgs to 20mgs of methadone. My doc has prescribed me the 2/.5 mg suboxen. I took my last dose of methadone at 8am yesterday morning. I’ve been on a steady 20 for 3 weeks. How long in your opinion should I wait, my doc said 24 hours but I’m nervous...

I would definitely hold off on the bupe until some of the more knowledgeable methadone metabolization members weigh in. I was on 120mg/day for a few years and landed in rehab. I had been off almost 5 days and still projectile vomited orange all over the place when they finally gave it to me. Don't recall it being like the one real time I went thru precipitated withdrawal though. I was about ready because what I kept down seemed to help though.

 

[Jabberwocky]

Welcome to BL!

Created your own thread for this OP.

Generally speaking you want to wait 3-5 days after your last dose of methadone to begin buprenorphine to avoid the buprenorphine precipitating withdrawal from the methadone already in your system.

Since you are switching from a lower dose of methadone, you should be fine waiting three days. Acute methadone withdrawal peaks around day five abstience, so on day three no methadone you'll only be getting a taste of it. But if it's too difficult for you not to use anything for those three to five days, you can use less potent short acting opioids like codeine or tramadol (or even kratom) to keep you well until you can safely start the buprenorphine.

If you use a short acting lower potency opioid like codeine or tramadol or keep you well during those three days before you start buprenorphine, give yourself 24hrs between the last dose of short acting opioid and initiating buprenorphine treatment.

So in others words...

Daily dose of 20mg methadone...
Wait 3-5 days before starting buprenorphine for the methadone to sufficiently clear your system...
You can use a short acting lower potency opioid during that 3-5 day period of stay well...
Give yourself 24hrs between any short acting opioid you've taken and beginning buprenorphine if you opt for that...

Transitioning from methadone to buprenorphine is a great way to get off methadone. And using a short acting opioid like codeine is a super easy and comfortable way to make the transition. It's a lot easier to transition when you've on a lower dose of methadone, so it's good you've tapered down to 20mg already.

Let us know how things turn out OP. Good luck!

 

[Beefy]

I've heard from a doctor to wait 48hrs+. So just to be safe, try to see how you feel 3 days after it. I think that's when you are in the clear. In the future I'll also make the switch and I've been told to wait 2-3 days. But the more days you wait, the lesser the chance of you getting violently sick with the combination.

 

[Jabberwocky]

Precisely. When someone isn't at a super high dose, 48-72 hours is ideal. So that would apply to their situation having stabilized at 20mg.

For someone at a higher dose, say 80mg or more, it's generally a good idea to wait four to five days before induction on buprenorphine.

I think the more people wait, the better the medication works. I totally agree with that. I also thing, to a point, it's healthy to know what withdrawal feels like. To a point...

 

[FLA]

Precisely. When someone isn't at a super high dose, 48-72 hours is ideal. So that would apply to their situation having stabilized at 20mg.

For someone at a higher dose, say 80mg or more, it's generally a good idea to wait four to five days before induction on buprenorphine.

I think the more people wait, the better the medication works. I totally agree with that. I also thing, to a point, it's healthy to know what withdrawal feels like. To a point...

I agree that it's a painful but valuable lesson to know what withdrawal feels like. I went to my primary doctor early in my bupe withdrawal that started Oct 1st. He wouldn't give me any meaningful comfort meds. He basically said you need to remember the consequences that comes with these meds. He said come back in 2 weeks if the situation is still really bad and told me to try and get some exercise no matter how terrible you feel. When I did contact him 2 weeks later he said you need to see a doctor that specializes in addiction. The result would have probably been maybe gabapentin and clonidine and marching orders to a 12 step program. I already did 3 years of AA so I wasn't interested in another doctor entanglement for some marginally helpful meds and having to listen to those depressing AA folks again. After I literally hadn't slept for about 3 weeks, I begged my wife to let me make a visit to the ER. She didn't want me to get forced into another semi corrupt rehab situation so I understood her reluctance to give me permission for an ER visit. But I was at my wits end. You know I'm not a young pup and my resiliency to withdrawal is not what it was.The ER doctor sympathized somewhat but would only give me a 2mg shot of ativan and 10 take home ambiens.

I do agree a lot of withdrawal is just dealing with it mentally. Looking back it's been a process. I switched from 6 years of the oxymorphones, exalgos, oxycontins etc. to methadone around 2010 to bupe in 2013. I know I got lazy and stayed on it too long, it helped somewhat with my bulging discs. So getting off the bupe now was just another step in that process. Stopping the minimal amounts of benzos and kratom I'm using to cope will be the next step when I'm ready but I'm not really that interested in being totally abstinence.

Hope your kratom weaning process is going well. You'll have to let us know, if you want, what dosages and length of time you were on it for our general edification. Hope you're enjoying your time off for the holidays.

 

[Erikmen]

Sorry to jump in like that. I have been on Methadone for ages and it took a while until I was capable to stop. A long time actually.

Why are you quitting methadone to switch to suboxen. What benefits of this transition are you looking after? if you don't mind me asking?

 

[Jabberwocky]

Buprenorphine is an ideal medication to treat the acute withdrawal involved in getting off methadone. So it helps someone deal when they jump off completely. So some longer term methadone patients an extended taper of six months of buprenorphine is actually recommended. In both cases buprenorphine is being used to get off the methadone, the reasons for wanting off are individual as we all know.

Is that what you were asking Erik, or something else?

FLA, it is uncanny how similar our experiences in recovery have been. I’ll say more when I create my journal documenting this. That will happen tomorrow after a *hopefully* good night sleep. So far the detox is going quite well.

 

[FLA]

Buprenorphine is an ideal medication to treat the acute withdrawal involved in getting off methadone. So it helps someone deal when they jump off completely. So some longer term methadone patients an extended taper of six months of buprenorphine is actually recommended. In both cases buprenorphine is being used to get off the methadone, the reasons for wanting off are individual as we all know.

Is that what you were asking Erik, or something else?

FLA, it is uncanny how similar our experiences in recovery have been. I’ll say more when I create my journal documenting this. That will happen tomorrow after a *hopefully* good night sleep. So far the detox is going quite well.

Looking forward to your journal! I've learned so much from you on how to deal with this, for lack of a better term, disease over this short time I've come to know you. I have no doubts that you have saved some people's lives along the way. So if that's not good karma, I don't know what is. DXM is one area where I can't quite get on board with you. To me that stuff feels toxic. Maybe it's just my body chemistry. Hope your kratom taper is going well. Enjoy your down time from your obligations.

 

[Jabberwocky]

Looking forward to your journal! I've learned so much from you on how to deal with this, for lack of a better term, disease over this short time I've come to know you. I have no doubts that you have saved some people's lives along the way. So if that's not good karma, I don't know what is. DXM is one area where I can't quite get on board with you. To me that stuff feels toxic. Maybe it's just my body chemistry. Hope your kratom taper is going well. Enjoy your down time from your obligations.

Yes, I actually have VERY mixed feelings about DXM. Short term, for withdrawal, as long as someone doesn't have serious health issues (so their liver, kidneys, etc work fine), DXM doesn't seem to be problematic at moderate doses. But long term, boy that is not fun. If used chronically at high doses it will eventually cause serious, life threatening harm. So it's not something I normally recommend, and not something I take lightly.

That said, I'd be disingenuous if I didn't mention it's potential benefit. When I discovered how it can be used to treat acute withdrawal, it was one of those life changing realization. It's what got me to fall in love with neuroscience and pharmacology. It's strong medicine, and use improperly can be very dangerous, but when used judiciously its use has the potential for great benefit. Costs and benefits, in other words.

And thank you for what you wrote, that really touched me. As one of my mindfulness friends has told me, I don't really have a choice in the work I do for BL - it's more like something I was meant for or something. I forget how he put it, but to me the work I do for this community is work I do for my own growth and development.

It's like how teachers learn more from their students than book learning. Thank you for being one of the healthier members of our community FLA - your growth is your own, but your mature and respectable character comes through loud and clear.

I'm thinking about going to bed. The first day of kratom detox was a breeze. Gabapentin and CBD for the win. I think some trazadone and melatonin will be enough tonight for sleep. Looking forward to tomorrow, as I haven't really unpacked or gotten settled in. After I do that I'm going to sit down and organize my notes from today's experience of detox and start my long awaited journal. I've never really had my own recovery journal despite my long term involvement in SL, so I'm excited for that.

 

[Erikmen]

Buprenorphine is an ideal medication to treat the acute withdrawal involved in getting off methadone. So it helps someone deal when they jump off completely. So some longer term methadone patients an extended taper of six months of buprenorphine is actually recommended. In both cases buprenorphine is being used to get off the methadone, the reasons for wanting off are individual as we all know.

Is that what you were asking Erik, or something else?

I get that but once you change to subs some people also keep on with those (buprenorphine) for a long time as well. We've seem this happening here. And it seems to be quite difficult to come off of that drug as well. Right?

They both work as replacement for opiates, so unless one's goal is to try to stop using and becoming sober - wouldn't the pattern be the same with Subs? Long term use, difficult to come off, etc.

 

[Jabberwocky]

I'm not entirely sure what you're asking? Are you asking: What it will be like using buprenorphine to get off methadone?

There is two uses of buprenorphine that are involved with getting off methadone: as part of the medication proved to ameliorates the symptoms of acute methadone withdrawal (this should be available to all methadone ORT patients), and to facilitate a six month extended detox period of use to treat the acute detoxification, the opioid use disorder more generally and any methadone specific "PAWS" that come up during the first six months off methadone (personally I don't love the concept of PAWS, but the idea works hrs; an extended detox should be available to patients who qualify for it according to their needs, condition and history).

So, buprenorphine, yes and no... It all depends on how it is approach and what the need is. Approach correctly and under the right circumstances, coming off buprenorphine is a little easier than coming off methadone. It's not so much just using buprenorphine for six months - it's all about how the buprenorphine is used.

I don't necessarily agree with prescribing an extended taper on buprenorphine as a matter of course with methadone detoxes, but this should absolutely be available as an option for those who would benefit. Any treatment that isn't tailored specifically to individual need isn't an effective process IMO, so I'm definitely not saying everyone should get on buprenorphine for a six month extended taper.

An extended taper is taking buprenorphine for six months, first stabilizing on it over the course of a couple weeks, and the remaining six month period to slowly and methodically taper to 0mg of buprenorphine. So it's essentially just tapering off over the remainder of a six month period. It happens to be a well recognized, highly effect use of both buprenorphine and methadone, the idea of an extended taper I mean, and given the correct set of individual circumstances it's should definitely be available.

If the goal is to get off opioids, sometimes there feels like there is is a certain irony here. For many people, it takes learning how to take opioids properly to maximize one's chances of success in transition out of the habit of their use. That often means securing the support of a doctor or clinic's program, with the various checks and balances it employs to help orient the patient in healthy directions (control would be another word, in extreme cases), and hopefully auxiliary treatment. Just musing on how sometimes it ends up taking opioids properly according to the the goal of getting off them that is necessary to get off them, in the end.

 

[Erikmen]

Yes, nicely put. I wish I knew more when I came off of my extended methadone use. I can clearly see now that there were more options I could have followed if I had known other paths. That would have saved a lot of pain during the process and things would have been much easier, more reasonable.