Bupe New on Bupe after heavy Oxy - Need Advice ASAP

[VisceralChems]

Hello All,

I have been reading so much lately my eyes feel like they are going to fall out. I imagine there is information available, but I just can't find something that specifically answers the exact question, and feel in critical time period of bupe use, so please feel free to point to other thread if already answered! A brief background about my friend:

He is typically sensitive to chemicals, and has historically been able to experience strong effects (both positive and negative) at very low doses. He fell in love with oxy, and after a good run at keeping a very low dose, it exponentially shot up and stuck around the 350 - 450 mg of crushed OP 80s. He can't financially support that habit for a any longer, nor should he, and he tried CT detox. Thinking this was a 3 day experience, at day 5 gave in and decided to taper better. This did not work as planned, and six days ago started on suboxone. He waited 24 hours to dose, although honestly not at COWS 26, based on Dr orders, and thinks he went into PW. In other words, symptoms went from mild to moderate, to very severe (bed ridden hot/cold flashes, fatigue, etc) after taking 2mg sub-lingual suboxone. Took 2mg every two hours up to 8mg. Day 2, take two 4mg doses, still have moderate withdrawal symptoms. Day 3, 8mg, still mild withdrawal symptoms. Dr says not taking enough to rid WD thus increased to 12-14mg on day 4, then dropped to 10mg day 5, and so far 5mg day 6. The sudden drop to 6mg didn't bother him much, and actually felt slightly better than prior day, but still have sweaty hands/feet, no appetite, mild sleep issues, and lack of energy appitite (but very manageable relative to the CT oxy WD)!

Main question: If wanting to avoid WD symptoms from the suboxone, yet fully take care of physical oxy WD symptoms, is it best to do a fast taper now and jump off before the Suboxone fully takes hold? Or, should he stabilize doses, then do a longer taper, yet risk using the suboxone for 3-4 weeks instead of 2 weeks. I have seen on this forum where very short term sub uses have been very successful, but in these cases the starting dose was usually much smaller (~2mg), thus easier to taper faster, or they felt better instantly after taking it and didn't get PW, or did not have near as much oxy habit to start.

Opinions / experience very much appreciated as I feel he is in a critical time window to make this decision. Thank you in advance fellow BL members!

 

[VisceralChems]

P.S. Many of the posts I read talk about getting down to .125 of bupe before jumping off...however, this seems crazy small dose to get to using 8mg sub-lingual films. When people are talking about doses in the .1 - .5 range, are they talking about IV'ed bupe, or does this hold true for the sub lingual films? In other words, since I have heard that .3 IV bupe is equal to around 2mg of sublingual, would I only need to get down to 1mg of sublingual bupe before jumping off?

Thanks!

 

[BlueHues]

^We don't use nonsense like "My pet snail" and "SWIM" here on Bluelight, for starters...

You likely took the initial dose of suboxone too early and went into precipitated withdrawals....You're doctor(for whatever reason)instead told you your discomfort was due to not taking enough suboxone, and then you stabilized after a few days of taking increased doses of suboxone...probably much higher doses than you would have ever needed in the first place were you to wait long enough to take the initial induction dose...

Now, you want to get off the suboxone as quickly and painlessly as possible?

I think you should continue cutting your doses in half daily until you reach 2.5 mgs...I'd jump to 1 mg from there, and then take that dose for 2 days...Then 2 days at .5, a few more days at .25, and then off....

Of course, you might be better off just halving it, switching to 1 mg for a few days and then jumping...Either way, I wouldn't stay on the suboxone longer that 5-7 more days maximum...

 

[VisceralChems]

^We don't use nonsense like "My pet snail" and "SWIM" here on Bluelight, for starters...

Sorry, I'll edit and change. Some forums I have seen strongly encourage that.


Also, yes, the goal is to get off the suboxone as quickly and painlessly as possible. I think you are probably spot-on in regards to what happened with regards to the Dr and PW, so I will definitely take your taper advice!

Between your two options, your first option would mean 7 more days, vs only 4 more days for the second option. So I think the second option may be more ideal assuming the drops are handled well. In your opinion, would suboxone withdrawal be able to be avoided completely tapering as such? Or should some prolonged withdrawal from the bupe be expected regardless given the high induction amount (as well as high prior habit)?

Thanks again, very helpful!

 

[Larc]

There are two options in any withdrawal regardless of substance. You can do it quick and painfully or slowly with less severe side affects that are prolonged.

Bluehues has laid out 2 perfectly acceptable detox plans. Whichever you choose I dont think will really matter. Get off it as soon as possible if the best advice.

Expect mild yet prolonged withdrawal symtoms. The devil must be paid.

 

[Lorne???]

What is wrong with you people? You CANNOT AVOID BUPRENORPHINE WITHDRAWAL. Why? Because they're really is no such thing as buprenorphine withdrawal, or oxy withdrawal, etc. Ok, so we all know different opioids have they're own distinct detox. But ultimately, opioid detox is opioid detox.

Buprenorphine has not cured your physical dependence, it is only masking it. You are still addicted to opioids. You cannot "avoid" buprenorphine withdrawal.

If you want to taper down, quickly, good for you, but don't rush it, because you somehow think you will become "addicted" to bupe, because it's too late. Especially since you we're coming off of OP's. You can't snort OP, so it was really like an oral dose.

The reason why people attempt to taper with buprenorphine, is because SUBLINGUAL buprenorphine(not other MOA's) has a very long half-life. And it is extremely potent. Yes, you can get down to less than 1ng sublingual bupe.

In fact, when administered via liquid solution, sublingual buprenorphine is active at 200-300mcg. Personally, I'd suggest dissolving in liquid to maximize the dose(note that liquid buprenorphine is 1.5-2x as potent as tablets, and more potent than strips as well.) and then rapidly get down to just 2mg, which should be enough to hold you even now(4mg at most, if dissolved in water).

Then go down to 1.5, then, to 1.25, then 1mg. Get yourself adjusted to 1mg, then down to around 750mcg. Then 500mcg. Stay on that until your ready to drop to 0.25mcg. At that dose. Withdrawals shouldn't be much of a problem, though getting that low certainly can be...

 

[VisceralChems]

Yeah, in retrospect, if it were known it was going to cause PW, and that there wouldn't be much relief, probably would have handled things quite a bit differently.

So much for the wishful thinking that six days would be short enough to avoid paying for bupe experience , some people seem to have gotten away with it, but this scenario understandably is a bit different, so thankful for the good advice! I just can't get over how misinformed Sub doctors can be!

 

[Lorne???]

To clarify, you definantly need to taper down to LESS THAN 1mg before jumping off. I would suggest jumping at 200-400mcg, but definantely no more than 0.5mg when you jump. 2mg buprenorphine is actually a lot more than people think, it is 5-10x the starting dose for analgesia.

And I do not suggest dissolving in water just to make it stronger, but because it will give you more control over your dose. And it will be easier to administer, especially at low doses, I mean 0.5mg is 1/16th of a strip, good luck administering that sublingually.

The method is simple, take the desired dose, place it in spoon/measuring cup or something similar, add around 0.5-0.75ml of water, let sit for a few minutes, shake it up, and once dissolved, place directly under the tongue. As I said, it is 1.5-2x stronger than tablets, and it absorbs much faster.

Good luck!

 

[Lorne???]

Yeah, sub doctors are idiots. I'm sorry, but it's true. They shouldn't be prescribing a drug they don't understand.

But if you taper properly, you really can avoid severe DT symptoms. Whether you do it quick or fast is up to you, but I strongly suggest making sure you are stable first, then dropping. But I wouldn't take more than 4mg per day, or maybe 6 if you are not going to dissolve the doses in water. Bupe is much more potent that people think. At this point your best bet is probably to go like 36-48h without dosing to drop tolerance, and then starting over at 4mg. But make sure whatever you do, you at least feel normal before taking this on.

But if your at 5, I would try to drop to 2-4mg, and then, decide what your going to do, after you are stabilized.

 

[VisceralChems]

Okay, that's a good point, I was wondering how I was going to get down to .5mg and below with a 8mg strip. I'll have to go buy some non-needled syringe or something.

I have read several times that sublingual strips are much less potent than IV due to absorption of only 40-50% of the bupe by that method...so wouldn't taking 1mg sublingual really only be equal to .5mg? Am I thinking about this wrong? Or does the recommended jump off point already factor that in, and so the intended jump off is really 40-50% of .125?

 

[VisceralChems]

Yeah, sub doctors are idiots. I'm sorry, but it's true. They shouldn't be prescribing a drug they don't understand.

But if you taper properly, you really can avoid severe DT symptoms. Whether you do it quick or fast is up to you, but I strongly suggest making sure you are stable first, then dropping. But I wouldn't take more than 4mg per day, or maybe 6 if you are not going to dissolve the doses in water. Bupe is much more potent that people think. At this point your best bet is probably to go like 36-48h without dosing to drop tolerance, and then starting over at 4mg. But make sure whatever you do, you at least feel normal before taking this on.

But if your at 5, I would try to drop to 2-4mg, and then, decide what your going to do, after you are stabilized.

Note sure the difference between "quick and fast," but I agree with previous posts in that I should get off as soon as possible. However, I am concerned with the "stabilized" part. How exactly do I know? Since I started this with PW, I never really felt normal, and although I feel the best I have since, I am still not 100% normal. I still have mild typical WD symptoms like sweaty palms, feet, enhanced smell (like I usually couldn't smell anything and now I can smell an ant fart from across the room), and mild leg discomfort, and mild insomnia, but to be honest it is very manageable...so is that stable? Or do I need to feel completely normal with zero signs of WD first?

 

[jeng1128]

I just went thru this with my friend. My actual friend. She got kicked off methadone, tapered 5mgs/3days got to 32mgs(started doing dope around 60mgs if I remember, but once she got to 32 she stopped going, did dope for a week and tried to go to her idiotic sub Dr, only 12hours after her heroin, she thought she was sick enough but really wasn't & that was the problem. I asked my methadone counselor & she told me to switch from Meth to. Subs she should've done no opiates for 72 hours. Since the subs weren't working her idiotic sub Dr kept putting her up to like 45mgs/day. After a month she says their working & it's so much better than methadone, but she actually thinks that she can jump off them in another month wo any wd symptoms.
I then asked her if she was smoking crack because of course she's gonna have wds.
I am currently tapering off methadone & it sucks. But subs are no easier. I live w someone who's been on subs for a while & has gotten down to 8mgs. He says he wakes up every morning(he does I see him since I'm not getting much sleep these days) @ 330-4am & takes a half a sub. He went on them when it was still the "suboxone is a miracle drug, w no wds. " he went to the rx to get his 1st script(I'm not sure when but years ago) and this girl saw him at the rx & she said "you're going on suboxone, " which he replied yes. She then told him that if he thinks theirs no wds, he would be in for a rude awakening. " he brushed it off,but remembers everyday how he had no idea. I mean u can't jump @ a 4mg sub dose. I mean you can but it's not going to be very fun. When people say get down to .025mgs there saying it because it's true.

 

[VisceralChems]

I definitely believe it, no question there. I know sub is no light weight free lunch, and it was not an easy decision. I was just ignorant of the all the relevant factors, and wish I would have been more informed.

It has been an educational process - although not much help from the doctor. My first follow-up visit, he asked what my primary concern was, and I told him that I wanted to taper off really quick because I was worried about becoming dependent, and didn't want these week / month long withdrawals I have been reading about. He stated that if that is my concern, that it is an indication that I am focusing on the wrong part of treatment, and not to worry about that....

He wants me on them longer so I don't get off and relapse...ok fine, I get that...but to purposely withhold information about specific questions asked and concerns addressed? Not cool. Let it at least be an informed decision / experience. Furthermore, the whole induction process was explained very haphazard, and in my state at the time, I wasnt in a great place to ask the questions I should have. Although he probably doesn't have the same perspective given his subjective education from the manufacturer, but still...he has to have patients who have told him of all the issues...right? Unless they either stay on forever, or jump practices, or lie?

The only reason I even posed the possibility of a jump from 4mg is due to the fact that I have only been using it for 6 days. Lorne??? brought up the issue that it is not withdrawal but detox, which I view as somewhat semantics, but the fact is that it has a different detox profile than other short term opiates, and based on my experiences with my various other chemical experiences, 6 days is very rapid to fall into a state of needed detox of that degree from something. However, I openly admit that this is more my lack of understanding likely, and that it probably has everything to due with my prior sister opiate dependence as well.

In retrospect, would I have still used subs? Probably....as the fact that I couldn't run out and score and make it all stop was a huge factor...but I would have gone about the sub induction WAY differently. The problem is there are so many different accounts of how it works, and people either usually don't provide necessary data to help compare to my situation, or are just in an entirely different situation. Regardless, I know everyone acts different too, so I chalk it up as a learning experience and don't get too upset with it. After all, I am closer to my goal than I was...

 

[Lorne???]

Note sure the difference between "quick and fast," but I agree with previous posts in that I should get off as soon as possible. However, I am concerned with the "stabilized" part. How exactly do I know? Since I started this with PW, I never really felt normal, and although I feel the best I have since, I am still not 100% normal. I still have mild typical WD symptoms like sweaty palms, feet, enhanced smell (like I usually couldn't smell anything and now I can smell an ant fart from across the room), and mild leg discomfort, and mild insomnia, but to be honest it is very manageable...so is that stable? Or do I need to feel completely normal with zero signs of WD first?

Haha, yeah, I meant "fast or slow".

But the thing about comparing IV and sublingual buprenorphine, is that their is no comparison. First off, the 40-50% refers only to liquid buprenorphine. I know it sounds silly, but a liquid solution placed under the tongue really is 1.5-2x as strong as simply tablets. So a rough description of the sublingual BA is:

Tablet form: 13-35%, mean roughly 25%
Oral solution: 27-65%, mean ~47%.

But, IV bupe is not 2-3x as string as sublingual, as you might think. It is several times stronger.

The problem in comparing them is the half-life. It is so dramatically extended with sublingual administration that it changes the potency exponentionally. It is kind of like taking a super ER tablet, that would release a drug over 36h...

You see, the half-life of sublingual buprenorphine is highly variable, but invariably long, ranging anywhere from 12-40 hours, with a mean of around 24 hours.

However, the half life of IV buprenorphine is much, MUCH shorter, ranging from 1.5-7h, with a mean of 3-4h.

So clarify, IV buprenorphine averages 3.5, with a range of 1.5-7h(though it is usually on the lower end of that scale)
Sublingual buprenorphine averages 24-30, with a range of 12-40.

Because of this ridiculous difference in half-life, IV buprenorphine ends up being exponentially stronger than sublingual.

Think about it this way: 1mg IV buprenorphine lasts 3-4h. Now, you take 2mg sublingual buprenorphine, dissolved in water like a smart addict , and you end up absorbing 50% of the drug. So technically you end up absorbing 1mg of bupe.
Here's the problem: That 1mg of buprenorphine ends up being slowly absorbed eliminated over 24h. At first this sounds great(and indeed it can be), however, the drug does not magically lost longer. The drug, in this case, has such a long half life, because it is released VERY SLOWLY, over the course of 16-24h. The trade-off, is that just like with an ER pill, the plasma levels are much lower than they would be with IV.

Specifically, with sublingual administration, it typically takes 2-3h to reach peak plasma(tmax). And once you do, the peak plasma(cmax) is exponentially lower than with IV.

The result is that peak plasma levels(cmax) after IV use, are, on average 15x higher than sublingual. Note that it varies among people, with IV cmax ranging from 10-20 times higher than sublingual cmax, and averaging 15.

So as you can see, they're is simply no meaningful comparison between IV and sublingual, the absorption elimination profiles are vast different. Now to be fair, cmax can be somewhat deceptive, as I wouldn't say IV is literally 15 times stronger than sublingual,(ESP. With a liquid solution) but it is undoubtedly several times stronger, I'd say the peak effect is 5-8x.

PS: the above figures ate based upon dosing via liquid buprenorphine, so think about that...)
But yeah, 0.5mg sublingual bupe with be like 50-100mcg IV, but with a MUCH longer duration.

 

[jeng1128]

Oh Yah 6 days you'll be fine. I used it to detox back in 2005(when it first came out.) My insurance wouldn't pay for a "methadone " detox(private insurance, weird) but they actually sent me to a Florida rehab/detox where they used I'm pretty sure it was subutex, and they gave it to me for like a week, then I went into rehab & was fine. Couldn't believe it. The problems came of course from relapsing & relapsing, which I got to the point where I needed a maintenance drug. It sucks to come off, but it really helped my life immensely. But that's where the honesty comes in, do you really want to quit? It's kind of hard to answer, because (in my experience )I wanted to quit wholeheartedly @ the time, but I stayed in Florida and ended up relapsing in 3 months.

It just got to the point where I knew I needed a,maintenance drug. Sub Dr's seem to be very uneducated, not all, my pcp is one & has been one for years. He knows his shit. But I think it comes from his experience.

 

[VisceralChems]

But yeah, 0.5mg sublingual bupe with be like 50-100mcg IV, but with a MUCH longer duration.

Well, I know enough to know enough that I don't know enough to know how exactly this will help me in my detox :D, but it is interesting to learn and DEFINITELY clears up my initial question that stemmed from a lot of people talking about ideal dosages and not explaining which rout of administration was being discussed. However, I have gotten so much good information in this thread, I have what I need to make an informed decision about a good taper schedule using what I have (sublingual - which I will now be dissolving in water )

I still would appreciate clarification regarding what is meant by "stable" as this one suboxone experience is the only one I have, and thus nothing to compare in terms of what is expected. I think it is critical I get a better understanding of this as it seems to be the last piece of the pie before having all the information I need to select the perfect taper for my situation.

Also, if you don't mind me asking, you have provided so much good information, I am curious where you learned it (scholastic, forums, experiences, books, etc), so that I may become better informed going forward myself.

 

[VisceralChems]

Oh Yah 6 days you'll be fine. I used it to detox back in 2005(when it first came out.)

Can I ask what dose they started you at and tapered you to? Also, what kind of tolerance to oxy were you treated for?

I think these are pretty relevant for comparison. Also, I am currently on day 6, but I will be on day 11 by the time I finish the recommended taper.

 

[Lorne???]

Yeah, I know the information may not seem relevant to your situation, however you specifically asked about comparing the MOA's, so I was explaining how they are a world apart

What I mean by stable, though, is that you feel completely normal on whatever dose you are on. I guess with an ultra-rapid taper, you will never feel completely normal, but in my experience, if you do not get regulated first, you are setting yourself up for failure.

In your case, I really think you stares the sub to early. I would suggest going over 30 hours without taking anything; once you feel truly shitty then take 4mg(dissolved in water lol) and you feel pretty fucking regulated. Buprenorphine is a partial agonist, so it is much, much, MUCH more effective at a low(ER) tolerance. I have been in a similar position, and starting it to early(especially off a very large dose like 300-400mg oxy) and you'll never feel normal, without high doses. But if you let yourself get back into full withdrawals, and then take a good dose, you can start fresh, with a lower tolerance(remember that opioid tolerance drops ridiculously fast during abstinence.

I know this may seems counter-intuitive, but I think it is important to find a stable dose before you taper. Another thing about reaching a stable dose, is that sublingual bupe takes a few days to reach full effect, because of the long half-life. Thus, 4mg chronic buprenorphine= 6-8mg acute. But since your tapering, don't worry to much about that.

 

[Lorne???]

So, my "official" recommendation is as follows:

First, go 36h without anything, let yourself get really sick. Next, take 4mg(dissolved in liquid ). Now you have to wait 2-3h, as it takes a while for sublingual bupe to reach full effect. If you do not feel straight 2-3h later, take 2 more mg. If 6mg doesn't hold you, I'd be shocked, but whatever you do, don't exceed 7-8mg, or your going backwards. The next day, take the same dose, or a maximum of 6mg.
Now, drop a mg a day until you hit 4, unless you we're already at 4. Once you hit 4, get stabilized, and drop to 3. Then 2.5, then 2, then 1.5, then 1.25, then 1, then 0.75, then 0.5,,, You get the idea? But in order to formulate a plan, you have to find the dose that makes you comfortable, otherwise you'll likely end up too miserable to go through with it. Just keep us posted, as you said, you have plenty of info to make an informed decision, but all the planning in the world may not prepare you for your body's unique response.

Good luck, of course, and keep us updated.

 

[VisceralChems]

Thank you again. Your posts have been very helpful. I will keep you posted. Right now I am leaning towards your suggestion of going 36 hours without and then taper, since I already don't feel great at high doses, and as you stated I think tapering will be a lot more hellish than it needs to be if I would have started this process without PW. But its really late right now, and I am sleep deprived, and I want to think on this some more tomorrow and reread posts before I decide to get really sick again.