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24mg of subs (6, 4mg strips) IS IT ENOUGH????

Regarding the cimetidine, 2-3 pills (400-600mg; all OTC cimetidine I've seen in the form of brand or generic Tagamet has been 200mg/pill) is a good does to potentiate buprenorphine - no more than 3 pills should be necessary. You can take it with or a few minutes before taking the buprenorphine. The whole process seems to work by inhibiting certain liver enzyme(s), slowing down the metabolism of bupe. The subjective effects of this at 24hrs post cessation of something as short acting as hydromorphone may very well be a bit of a buzz. That really depends upon his metabolism and liver and all that though. He may feel a bit of the bupe, he may not (but it's much more likely he will with the cimetidine).

I say don't take the cimetidine for more than 1-2 weeks simply because of the potential for some serious side effects taking it long terms daily. But one to two weeks shouldn't be a problem in that regard. You should look into these for yourself. The cimetidine may potentiate other side effects of bupe, such as constipation, etc. Generally speaking, taking cimetidine with buprenorphine is something like putting the focus on bupe's agonist properties.

Given how many of our bodies goes through something like hydromorphine, your friend may not even need to wait 24 hrs. I generally didn't have to wait more than 6hrs, although I don't recommend that at all. 12hrs in he should be good and able to avoid precipitated withdrawal, but you're absolutely right. The longer he can put off taking bupe, the better the bupe will work for him and the more relief he will get from it - that's also a bottom line.

In my case, it is amazing how much a difference cimetidine makes when I take it with bupe. It almost turns the bupe into something like methadone, actually preferable to methadone as it isn't as sedating and I'm much more functional given how good I feel. Only draw back is, unlike methadone, taking high doses of cimetidine every day for significant periods of time can have some embarrassing effects.

I don't think one can really say X amount of bupe + 600mg of cimetidine = Y amount of bupe (without cimetidine). It isn't a linear relationship at all. In my case it turns bupe into a superior drug in terms of subjective effects, the trade off long term again are side effects. He'll probably function better on cimetidine and bupe than just bupe alone short term.

I'd say getting more bupe should be the priority over just relying on cimetidine however, and I think you already had this in mind.
 
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i agree with toothpastedog...def get some more bupe. Is there no doctor he can wiggle in an appointment and see? They usually induce you the first day and you walk out with some.
 
Not sure if it works that way up here....I understand it's like that in FL though. How does this look....he got this schedule from a friend of his who used subs before.

Day 1:

1. Take 2.0mg
2. 120 min later take .5mg
3. 90 -120 min later take .25mg
4. 90 -120 min later take .25mg
5 90 -120 min later take .25mg
6. 90 -120 min later take .25mg
7. 90 -120 min later take .25mg
8. 90 -120 min later take .25mg
TOTAL 4MG


Day 2:

1. 8am take 2mg
2. 8pm take 2mg
TOTAL 4MG


Day 3:

1. 8am take 2mg
2. 8pm take 2mg
TOTAL 4MG


Day 4:

1. 8am take 1.5mg
2. 8pm take 1.5mg
TOTAL 3MG


Day 5:

1. 8am take 1.5mg
2. 8pm take 1.5mg
TOTAL 3MG


Day 6:

1. 8am take 1mg
2. 8pm take 1mg
TOTAL 2MG


Day 7:

1. 8am take 1mg
2. 8pm take 1mg
TOTAL 2MG


Day 8:

1. 8am take .75mg
2. 8pm take .75mg
TOTAL 1.5MG


Day 9:

1. 8am take .25mg
2. 8pm take .25mg
TOTAL 0.5MG


GRAND TOTAL SUB USE 24MG


I think he wanted to have a longer taper, rather than just several mid-high doses for 4-5 days. But again...you guys know best. He told my bro that he should get more subs and induce at a higher dose than 4mg.....should be closer to 6mg.
 
Yea, ideally he'd have more bupe to work with. The first thing that came to mind after looking at that schedule is that, well, it seems unnecessarily complicated. Especially the first day. I really don't see how all the tiny doses would be preferable to a few less slightly larger ones. Working with the strips can also be a pain, because you have to measure and cut them (razor blade) just so. I mean, it's not hard, but with that many little bits that your taper suggests, it seems like it would be a headache.

I can't help but think that keeping the dose a bit higher for the first 4-5 days (phase one; 4mg 2x/day or 2mg 2x/day) and then dropping down to a lower dose once the worst of the acute withdrawal has passed (phase two; 1mg 2x/day or 0.5mg 2x/day) for another four or five days would work at least as well.

I'm interested to hear how this all works out. The one big thing he has going for him is that hydromorphone and heroin have relatively very short half lives, and, while the withdrawal will be intense, it will be relatively short lived. That bupe's half life is nice and looong will be a big advantage here. By day seven he should be pretty much out of the woods, if not earlier.
 
While he is on the bupe, I would help him find a support network in order to help him stay clean. Getting clean seems insurmountable but it is totally easy once you get through the first few days. Staying clean is the hard part. This requires rigorous self honesty, and a high level of self discipline. Having a support network will make it so much easier. Try some NA. There are meetings everywhere! Go to them, if just to have an hour to meditate.
 
Thanks for the feedback people. I know and read how important it is to support groups or NA or something of that sort....but the honest truth is, he will be working so much and traveling, not only will he not have access to those opiates, he will be so occupied with work....and I see that as a good thing. He knows he has to come clean, and he knows I'm there as well as a few others to support him in any way. But again, when he is traveling and going to meeting and having his plate full with other things....I hope that will be enough of a distraction. Again, I'll be there to help him should he need it. I just feel horrible I came up short on the subs.

As for the first day you guys asked about, I got that information here:

http://www.drugs.com/forum/featured-drugs/suboxone-subutex-therapy-50887.html

"We suggest using an initial 1mg - 2mg dose for those with long term >>>>>> addictions and long term methadone addictions .(Using 1mg or 2mg is determined by the patient’s using history.) For those with a history of using RX pain medications be it in pill form, fentanyl patches, etc I suggest starting the induction with a dose of .5mg and wait for two hours. This allows the patient enough time to ensure they are receiving maximum benefit from the medication prior to taking each additional increment while stabilizing. After the first two hour period we can add another .5mg if needed but we often find that adding .25mg doses every additional 90 minutes or so will allow the patient to stabilize at doses less than 3mg. This has become the average with most everyone we induct using this protocol."

I don't know how much truth there is to all this during induction, but many swear by it. Please let me know what your opinions are on this. Yes, 4mg 2X a day or 2mg 2X a day sounds MUCH easier....but the protocol above suggests feeding him small doses because it allows the patient enough time to ensure they are receiving the maximum benefit from the medication prior to taking each additional increment while stabilizing. I honestly don't know what is a better way to approach this. I have been told of so many ways to induce him. Some have said just give him one 8mg dose on day one.

How will I know if I should give him 4mg or 8mg the first few days?? Damn it I wish I had more subs....
 
Lol, yea it is very limiting. The above induction method certainly wouldn't hurt. Frankly, it's never seemed to make any difference with me or others I know. As long as you take bupe is what is important, that and the overall dose.

Ideally you'd want to give him enough bupe for him to feel more or less normal. That doesn't sound very practical in his case. Since you have to work with a limited supply, it's just going to be something of a gamble, a bit of challenge, and he likely won't feel quite normal.

If the priority is making the bupe supply last (good idea) while giving him as much as possible to keep him feeling as best he can (good idea), it'll be a balancing act. You really can't go wrong with giving him 4 or 8mg the first day.

Since you have a limited supply perhaps it is best to give him small amounts, checking back in every 90 minutes until he feels "okay." First day or four, that will probably 2-4mg a go, as it will be when the withdrawal is most intense. And more for the first seven or eight days, as that is when the acute withdrawal will really happen, than after that period.

Other than that, I'm not sure what else there is to offer.
 
I'm really at a loss as to how to start him off...I don't want to give him more than he needs the first day or two, than run short later on. When will he feel the worst?
 
Given his habit he'll almost certainly want 4-8mg the first few days. Actually he'll probably want that for the first week, if not more. What he wants and needs to stay out of the worst of acute withdrawal aren't necessarily the same thing unless he is really committed and determined, as well as very aware of the position he's in. An understanding of the withdrawal process and what to expect will really help him and push him to challenge himself with what he believe he needs. Even just 2mg of bupe make a huge difference during acute withdrawal, even though I think he should take a bit more to stay more functional.

Day three or four will be when the acute withdrawal likely peaks, probably more like day four. The first day will, suck, but it won't be as bad as three/four. W/d generally increases for opioids like heroin/hydromorphone for the first four days, peaking then, then starts dropping off day five to day seven. He'll probably feel pretty nasty for a few more days, up until day ten, at which point he should be, physically at least, back to "normal." I mean out of acute withdrawal. He'll continuing to feel better in a remarkable way after the first ten days.
 
WOW....10 days huh? I was really hoping he would be out of the woods by no more than 7. Christ....part of this is all my fault, but I just couldn't bare to see my best friend sit in a dark room shaking with pain. Now he will be back in that room, sitting there....waiting for this mess to pass. I really wish there was more I could do. I feel as if I failed him not coming up with a few more subs.Ugh....this sucks.
 
That's at the longest, and all the significant symptoms will have basically cleared us around day seven.

It really is wonderful that your friend's got someone as supportive as you. Watching someone go through the agony of w/d sucks, being in w/d sucks, but I think it will be worth it.

Has he gone through this process of kicking a lot (recently or not)?
 
Couldn't get more subs...today is his day 1. He held out for 18 hours, than began....now he feels a bit better, but knows there is more to come. I wish I could do more to help....
 
My friend just did a short taper after about the same amount of usage except oxys and h. He used a similar schedule to the one you posted with the lower doses through the week equaling 24mg. Same situation, it's all we could find him. He just finished 7 days ago. It helped but still some withdrawls. Cold symptoms and tummy issues but it was way better than cold turkey. You have such an arsenal after the subs are over look up the Thomas Recipe and use that. It will help with the discomfort a ton and you basically have all the stuff. I am on day 28 c/t using it and I feel really good.
 
Keep encouraging him to hold off on each dose of bupe for as long as absolutely possible. I know it's hard watching someone struggle so, especially when you can so easily remedy the problem in a second with a little bupe, but it'll do him a lot of good.

Good luck! Keep you head up!
 
I'm trying, he keeps wanting more and more, but I only gave him 4mg in small doses. Tomorrow, I will give him 2mg in the morning....and another 2mg at night. I have him on a dozen other supps. I hope so...
 
He will be okay. Part of getting clean and staying sober is understanding that quite a bit of the time life is uncomfortable. He is going to need to develop other coping strategies for discomfort (because the one that most addicts have, using, just isn't working anymore). I would highly suggest learning to meditate, or use positive self talk.

As toothpastedog stated...he is going to need to challenge himself if he wants to get sober (not just abstinent). Sobriety is a state of mind that is achieved through honestly and wholeheartedly working on the problems that caused the addiction in the beginning. If you have an hour here and there I would hit a meeting with him. It will do a world of good in early recovery.
 
What you are doing for him is helping him. My fiance was so supportive when I came clean and through the whole process of withdrawal and continuing with staying clean. The more support the better you feel. Having someone to talk me down and listen to me cry and celebrate the little wins was key to me quitting this. You both are amazing and I have faith you'll get through this ?
 
Hi guys...today is day 3. I think I managed to get him stable. The first 18hrs for him to reach 28 on the COWS sheet was a nightmare for him....and for me watching him. I felt so damn bad. Poor guy tried to work but was shaking and couldn't stay still....even when he felt the worst in his life, the man still wanted to continue to work. I told him not to and he just kept going back and forth to the bathroom not able to keep still.

I think the worst part of it is past...day 1, he took 4mg of sub. Day 2 he took 3.5mg of sub. Today is day 3, he woke up feeling a lot better. He even said he was hungry. I kept waking him to drink something because of all the imodium I fed him. Wanted to be sure he was hydrated. He kept wanting more sub....but I told him to hold off, and he managed to do so. When he woke up this morning, he asked me not how much he should take....but IF he should take. So I took that as a very good sign....he didn't call me to ask me how much because he was hurting, he wanted to know if he should take any at all.

So IMHO...from what I have read here and there, I should now tell him to take half the dose...or close to half of what he took on day one and two. I'm thinking I should tell him to only take .5mg and another .5mg in the PM. Or maybe 1mg when he starts to feel that he needs it? I'm trying to make him go as long as he can now without taking more sub because he is stable....AND because he only has a limited amount.

I think I made a mistake telling him to start up again on his seroquel. I know I read in many places that it helps with WD. BUT...he said he is feeling crappy, like when he first took seroquel many years ago. He had double vision and everything was fuzzy and shaky. He described what he was feeling as the same as when he first started taking seroquel. So I am going to cut that back a little, and bring his xanax dose back up a bit to where he is used to. I cut his xanax dose a bit as I read it can blunt the effects of the subs. True? I don't know...but we discussed it and he said he can cut it back a bit.

Well....this is where we are. The start of day 3. Like I said, I told him to hold off taking the next dose for as long as he can...than take .5mg. If he still doesn't feel well, to take another .5mg 120 mins later. Christ....I hope I am giving him sound advice and this all works. He found something in his office....something he didn't know he still had, and he was sooooo tempted to use it. I explained to him if he used it, he will get sick and it won't have any effect on him. I told him to flush it down the toilette. He just kept it in his desk. I'm very happy he didn't end up using it and he had the will power not to take it. I kinda scared him and told him that it would be VERY risky for him to take it....and he didn't.

Thank you all for your help...I will keep you guys posted on his progress. He is miserable right now....but I keep telling him the light is at the end of the tunnel and he is just half way out. He is a body builder like myself, and he can't even train...I didn't expect him to. He spends most of his time right now reading and watching movies...trying to keep his mind occupied.
 
For myself and many others, Seroquel, and any atypical antipsychotic meds, actually makes the withdrawal worse. It can really exacerbate RLS. It's a very potent medication, with a LOT of side effects, and can cause a lot of problems. Just make sure it's absolutely necessary for him to take this if he does, whether now or once he's done kicking. Be very careful in weighing the costs and benefits.

It's pretty rare that it really worth taking, especially without a specific kind of condition it's indicated for. Insomnia, anxiety, these are not very good reasons to take it. There are a lot other much safer medications that work better with fewer side effects than any atypical antipsychotic like Seroquel, Risperdal or Zyprexa.

The Alprazolam/Xanax will not blunt the buprenorphine. Definitely increase that and significantly decrease if not discontinue the Seroquel. Alprazolam will not cause him any problems during acute withdrawal, and if anything it will make it a lot easier on him. It would be better to use clonazepam/Klonopin or daizepam/Valium or even temazepam/Restoril, but work with what you have.

Normally day three to four is the worse, but because he's been taking buprenorphine it shouldn't be so bad since it is in his system now. Even though you don't have much to work with, and this is regardless of how you dose it (whether in a couple bigger doses or many smaller doses I mean), just make sure he continues taking enough buprenorphine to be comfortable. I would think this will be about 4mg per day at the least for now.

If he still has the runs really bad, increase his dose of loperamide/Immodium. There is no downside to that medication right now.

As you should know, he should really really get rid of whatever he found. It will do him no good. If he uses it now, he won't get sick. Just as long as it isn't a huge dose, it won't even affect him much because the buprenorphine won't allow it to properly bind to his opioid receptors. At best it might help with some of the physical or GI side effects of withdrawal. What I'd worry about is if he doesn't take it now, saves it until he stops taking buprenorphine, and once the bupe's out of his system and no longer blocking his opioid receptors he takes whatever he found and gets fucked up. I mean, it wouldn't be the end of the world, but it also is a very bad idea.

One of the hardest things for me to do in acute withdrawal is to get outside and get even a little exercise. Encourage him to go on a walk in the morning and evening, and go out with him if you can because it will make it easier for him. It's amazing how supportive you are. If only I had someone like you in my life last time I kicked!
 
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