Bupe: The Less Is More Myth Exposed

[Tchort]

After seeing way too many gross generalizations, half-truths and opinions flaunted as fact to people looking into Buprenorphine treatment or thinking of changing or leaving it, I did what I said I would do in one such thread and e-mailed two authorities on Buprenorphine maintenance treatment, the NAABT (National Alliance of Advocates for Buprenorphine Treatment) and Reckitt-Benckiser Pharmaceuticals, the company that manufactures most of the worlds Buprenorphine products (Suboxone, Subutex, Temgesic, Buprenex).

Here is my original e-mail sent to both groups:

Hello,

I am writing to you today to ask your opinion of some statements being made about Buprenorphine by members of a Harm Reduction/Drug Addiction Treatment oriented online community.

As a former Buprenorphine maintenance patient, I find the following remarks to be dead wrong, and those spreading them highly irresponsible, as the focus of the community is to help people looking for support and answers about addiction treatment. Please let me know if the following statements are, as I believe, incorrect:

"LESS IS MORE with buprenorphine. people post all the time about how they feel more and get more craving relief from smaller doses. doctors overprescribe bupe all the time. i'm prescribed 24mg/day but only take 2mg a day b/c i don't need that much, and i came off a half gram a day heroin habit, not a small habit by any chance.
what was your drug of choice and how much were you doing? cause unless you were doing massive amounts of something, there's no way you NEED that much bupe. i guarantee you will get the same relief, if not better relief from doing a little less. unless of course you psych yourself out by thinking its like most other drugs where you do more, you get more effects."

"If someone goes into buprenorphine maintenance thinking that more is ALWAYS better, then there is no chance that anything else will work.

While I do agree that 2mg is a little low for some people, 24mg is just outrageous. For the first month or so, I was on 16mg, and would have never imagined that just 8mg is just as good (or better), but that is the case.

Anything over 8mg is unnecessary. 2mg held me, but 4mg is where I feel comfortable.

People who can't manage with 8mg or less are still caught up in that drug-using/pill popping mentality where you are constantly looking for your next fix and always want more. They also were probably looking for effects like those of full-mu agonists, and find anything less to be unacceptable. "

"anything above 8mg a day is ludicrous. I came off just as big of a heroin habit as most people here (though I know others on this site were using more than me), and I never needed more than 6mg the first few days of coming down, and I never needed more than 4mg past that.

I'm now at 2mg a day."



This is a sample of the sentiment I am writing to you about. I would like to know NAABT's position on the subject of Buprenorphine doses for maintenance purposes in Heroin and other opioid addicted persons.

I used to be on 32mg/day, and it seems very clear to me that the generally accepted doses to prescribe are up to 32mg Buprenorphine a day, and that doses up to 32mg have been clinically proven to be effective for the purpose of Buprenorphine maintenance.

Thanks,

First, here is the response from the NAABT:

Hi,
Thanks for writing. Yes this is often misunderstood. Self contradictory statements like "less is more" don't help clear things up. What has been proven is different people will require different doses at different times. Two patients both taking the same amount of heroin for the same amount of time may require vastly different doses of buprenorphine to stop cravings and withdrawal. As time goes on and their brains adapt back closer to pre-addiction status the required dose will likely go down. This makes some patients think that they never required the higher dose in the first place, but the dose requirements have decreased as their brain healed.

For a given patient and time, at doses below that patient's ceiling dose, less buprenorphine produces less effect and more buprenorphine produces more effect, not the other way around. Most people's ceiling dose is thought to be around 12-16mgs, but with some it is much more (maybe even more than 32mgs) or much less in others.

The golden rule with buprenorphine dosing is "The correct dose is the lowest dose that effectively stops cravings and withdrawal and allows the patient to stop uncontrollable compulsive addictive behavior." It should be noted that this dose needs to be reevaluated periodically, as requirements change.

Since buprenorphine has a ceiling to its effects is relatively safe and few dose related side effects (with the exception of constipation) there is less consequence to dosing on the high side, especially when compared to the potential risk of fatal overdose from relapse when dosing too low. Doctors who favor dosing on the high side offer greater opioid blocking and greater craving suppression than those who limit dosing.

It is incorrect for anyone to make blanket statements like "24mgs is way too high for anyone" because it may be too low for some. There are some people who cannot reach a high enough dose of buprenorphine to suppress cravings and withdrawal, those folks have to go to methadone. Even 64mgs isn't enough for them. Also longer treatments have higher survival rates than do short detox treatments.

You may also be interested in this post on the AddictionSurvivors.org board: http://www.addictionsurvivors.org/vbulletin/showpost.php?p=231332&postcount=3

I hope this info was helpful,

NAABT

And here is the response from Reckitt-Benckiser:

Thanks for your enquiry.

The statements included in your email are in many ways typical. Let me try to clarify what is going on at different doses of buprenorphine.

As you may know, buprenorphine is classed a s a partial agonist. What this means is that there is effectively a limit to its effect compared to full agonists such as methadone, oxycodone or heroin. At lower doses (2-16 mg ) the effect of increasing the dose is to increase the effect of the drug. However, as the dose goes up and the effect of buprenorphine approaches, increasing the dose does not increase the effect by so much. In other words, whilst increasing a dose from 2 to 4 mg may double the effect, increasing the dose from 24 to 32mg dose not increase the effect by 33%. Rather it may increase it by 2-3% only. Therefore there may be little therapeutic benefit to increasing doses above about 16-24mg for the majority of patients. In fact most patients find that they can be maintained on a dost of 4-16 mg.

Whilst more is not always better, the converse is also true. The point of the stabilization phase of treatment is to find a minimum dose that is high enough to control withdrawal symptoms but not so high as to produce sedation or fogginess. When patients say they feel better when they reduce their dose, it may be that they are actually feeling more alert and clear headed whilst still being on a dose that is high enough to control withdrawal. The objective of controlling withdrawal is to allow the patient to focus on the other part of treatment which is some form of counseling or psychotherapy to help the patient deal with situations and triggers that might induce cravings. It is the combination of medication and psychotherapy or counseling that can produce the best results for patients.

Opioid dependence should be viewed as a chronic disease and whilst some patients find that they are able to gradually wean themselves off their medication completely, others find that they cannot stop medication all together, but are quite comfortable being maintained of a very low dose. In either case it is important to continue with counseling or psychotherapy.

So, in summary there is a degree of accuracy in some of the statements, but the science behind it is that there is little difference in effect between higher doses and most people are adequately controlled on lower doses. Some people do indeed feel better on lower doses, but the whole point of treatment is to dose to effect, meaning finding the correct dose for the individual patient and coupling that dose of medication with counseling.

I hope that this goes some way towards answering your concerns

Global Medical Director


Reckitt Benckiser Pharmaceuticals Inc, 10710 Midlothian Turnpike
Richmond, VA 23113, USA
www.reckittbenckiser.com

Everyone should freely post their opinions on a relevant topic. But there is a big difference from giving your opinion as your opinion, and giving your opinion and calling it fact or truth.

The 'less is more' theory of Buprenorphine maintenance is bunk, is not backed up by anything but the opinion of some BMT patients, and completely ignores the studies done by non-profits and pharmaceutial companies and experiences of BMT patients who required doses of 8-32mg/day.

 

[PillPoppingAnimal]

the R-B statement makes the most sense to me.

GREAT post.

 

[monstanoodle]

Good thread

It makes much more sense that being on a dose that's high enough to combat cravings and withdrawals, but low enough to maintain that clarity of mind and other such mental benefits, is where the "less is more" statement hails from.
Both Reckitt Benckiser and NAABT seem to agree in one way or another with this it appears.

 

[robatussin]

Rickett Bensckier is obviously not discounting the less is more theory, but the bottom line is they are a buisness. If they were to say 2mg is just as good as 8mg, they would lose tons of profit (they are the only company with the patent as of now). No company would intentionally put out information to reduce their sales unless they are forced to by the FDA or another government organization. I think their lawyers did a good job stating that while some people find relief even at a reduced dose, there is always the possibility that an addict will need more to avoid relapse. That is why doctors overperscribe it. Better safe than sorry right? Better profits make stockholders happy right? I am currently on BMT and despite being rxed 16mg a day, i find 2mg to be fine most days.

Does anybody know when this drug will be available in a generic form?

 

[PillPoppingAnimal]

Rickett Bensckier is obviously not discounting the less is more theory, but the bottom line is they are a buisness. If they were to say 2mg is just as good as 8mg, they would lose tons of profit (they are the only company with the patent as of now). No company would intentionally put out information to reduce their sales unless they are forced to by the FDA or another government organization. I think their lawyers did a good job stating that while some people find relief even at a reduced dose, there is always the possibility that an addict will need more to avoid relapse. That is why doctors overperscribe it. Better safe than sorry right? Better profits make stockholders happy right? I am currently on BMT and despite being rxed 16mg a day, i find 2mg to be fine most days.

Does anybody know when this drug will be available in a generic form?

i honestly dont think thats true that they would loose profit

i think that if anything, more suboxones would be on the streets...i know a bunch of my friends get scripted 16mgs a day but either dont take it or dont even need half, so they make money onthe streets

and, there a certain amount of time that the FDA needs for a company to make a generic form
-idk maybe like 1-2 years, u could look it up...

once a generic form comes out itll help basically ALL of us, cuz the price of subs is keeping me from getting clean, so i still get oxycodone frm my doc

 

[TheMatador]

Rickett Bensckier is obviously not discounting the less is more theory, but the bottom line is they are a business. If they were to say 2mg is just as good as 8mg, they would lose tons of profit (they are the only company with the patent as of now). No company would intentionally put out information to reduce their sales unless they are forced to by the FDA or another government organization. I think their lawyers did a good job stating that while some people find relief even at a reduced dose, there is always the possibility that an addict will need more to avoid relapse. That is why doctors over-prescribe it. Better safe than sorry right? Better profits make stockholders happy right?

I agree with you man, that's exactly what I was thinking when I was reading the OP's original post. The more pills they sell the more money they make, its simple, the bigger dose your on, the more money they make (in most cases).

i honestly don't think that's true that they would loose profit

i think that if anything, more Suboxone's would be on the streets...

How does that make any sense? Rickett Bensckier doesn't make money because more suboxone is on the streets, just the opposite, their making more money because just like you said, (for example) your friends are scripted twice as much as they need, paying for more meds than they need, and whether or not they sell them and make money from themselves, in the end Rickett Bensckier picks up the slack as a result of the scripts being more than the patient needs and therefore collects more profits

 

[Johnny blue]

I didn't necessarily view less is more as a fact from lecture. I viewed it as take the least amount possible, that still works. Don't asume you need x amount because of any reason and that the less you take the better in the long term.

I think less is more is a great statement to make to a bunch of addicts. The worst that could happen would be you need to take more. The effectiveness of dosage especially in higher levels has been covered here before.

I think you made a great thread and perhaps cleared up dosage issues for some. I also think you should realize that a lot of us get the drug illegally and as such need to conserve more. Personally I see nothing gained in taking more than you need and I don't think anyone ever said take less than you need. My own interpretation of "less is more" has always been take less and see how you feel, I see no harm in that at all as you can simply redose if need be.

 

[Tchort]

You guys are putting the cart before the horse with the Big Pharma conspiracy. I usually am a huge skeptic when it comes to pharmaceutical companies and their motives; however, in this case, the studies on Buprenorphine were done over the course of what, 10-15 years? Starting in the 80s Bupe was being prescribed off label for opioid dependance, then came the studies.

Suboxone and Subutex at 2mg and 8mg tablets were created due to the proper dosing regimine as directed by the studies done on the use of Bupe in opioid addiction maintenance.

They didn't just arbitrarily make 2mg and 8mg Bupe tablets.

If they wanted to make profit above using the medication correctly, they would not have made a new tablet size.

Temgesic sublingual Buprenorphine tablets have been around for over 20 years, at 0.2mg per tablet.

If the ideal dose for Buprenorphine were under 8mg a day, why would they have made a new pill at all? And if they did make a new pill, why make it at 8mg?

This line of thought makes no sense. In the grand scheme of things the highest accepted dose for Buprenorphine maintenance, 32mg, is very low considering that only takes 4 tablets of the most common size prescribed.

Both R-B and NAABT discount the idea that 2mg or 4mg a day is 'all it takes', that 8mg is 'the highest dose anyone should take', that 16mg or 24mg or 32mg are unneccessary for anyone, etc.

EDIT:

When I say 'less is more theory', I mean the specific philosophy that is spread like gospel by several members on BL, that basically believes the following:

-There is no added benefit to a dose over (either 4mg or 8mg depending on who you talk to)
-A low dose (ex, 2mg) will provide the same benefit as 8-32mg
-There is no need for anyone to use more than (4mg or 8mg) Buprenorphine
-Anyone who thinks they need more than (4mg or 8mg) is just acting on 'addict mentality' thinking more is better

Based on these core tenents, they give bad advice with opinion passed off as fact to people with questions about Buprenorphine in general, maintenance, taper, detox, etc, which is the wrong thing to do on a harm reduction board. This philosophy has been discounted by both the people who make Buprenorphine and the protocols for its use, and a non-profit organization that advocates for Buprenorphine maintenance and tries to spread true information about the subject.

 

[PillPoppingAnimal]

How does that make any sense? Rickett Bensckier doesn't make money because more suboxone is on the streets, just the opposite, their making more money because just like you said, (for example) your friends are scripted twice as much as they need, paying for more meds than they need, and whether or not they sell them and make money from themselves, in the end Rickett Bensckier picks up the slack as a result of the scripts being more than the patient needs and therefore collects more profits

idk if ur agreeing with me or not ha

but

im saying it wont make a difference, they will be making profit the same anyway.

im saying more would be on the streets cuz IF people needed less, than they woul d just be selling it... get IT?

 

[a100unitSHOT]

Rickett Bensckier is obviously not discounting the less is more theory, but the bottom line is they are a buisness. If they were to say 2mg is just as good as 8mg, they would lose tons of profit (they are the only company with the patent as of now). No company would intentionally put out information to reduce their sales unless they are forced to by the FDA or another government organization.

Agreed.

 

[SZodiac]

All I can tell you is from My experiance over 3-4 years on them. Initially I was on a higher dose 16 too 24mgs but over time I cut that back too 4mgs a day because there was absoutely no difference in a half an 8 a day versus doing 2 or 3 8's a day. That's just me though and no matter what amount I did, I still always craved H. That part never changes unfortunately.

 

[daddysgone]

To the OP

This is a great thread, and im glad you posted the replies from those 2 authorities. however, you end your post saying "the less is more theory is bunk".
Im not sure how you reached this conclusion based on the responses you received, especially the one from B-R. I dont think anyone takes (or should take) the "less is more" idea literally. obviously less is always less and more is always more. its a tautology. less can never LITERALLY be more. a more accurate mantra could be "less is better". and when it comes to bupe, less often is better, and even the makers of bupe seem to indicate that less bupe can often be better. bupe is rarely if ever underprescribed. ive NEVER heard of someone who says, "im trying to get off oxy but my bupe doc only gives me 4 mg a day and it wont hold me and he refuses to up the dose". however there are many many people who are scripted 32mg a day who quickly find that 6mg a day holds them perfectly well.
I know that i was scripted 24mg a day, and at this dose i felt very lethargic and foggy. after a week i tried taking 2 mg 2x a day and i had zero cravings also felt much more energetic and clearer headed. So for me, and many others, less is definitely BETTER when it comes to bupe.
So again to sum up- Less it not more..because less is always less-it has to be. but when it comes to bupe, less can be BETTER because docs very often prescribe a much higher dose then what is needed to hold ones cravings and WD at bay. These high doses often provide no added benefit, but carry with them, unneeded side effects

 

[phr]

I wasn't aware that there is a "less is more" issue, but then again I don't follow bupe threads. I was quite tired of them when I created the mega-thread.


Anyway, I think the confusion may partially be due to bupe being a partial agonist ,and having a "ceiling," and just by misinformation being spread.

The RB email does a nice job of explaining the ceiling, and both make a key points: people need different amounts, bupe tends to be stronger than expected, and the best dose is the least needed to maintain.

 

[PillPoppingAnimal]

Anyway, I think the confusion may partially be due to bupe being a partial agonist ,and having a "ceiling," and just by misinformation being spread.

i dont think im reading it right but just incase...

bupe isnt the only opiate with a "ceiling" dose.

codeine does also.

ok so i just wasnt sure if u were saying because it's partial, it has a ceiling or if u were just saying that it's a partial agonist AND/plus has a ceiling dose.

 

[smackem]

Tchort


Well, The idea with the less is more theory does not litterally mean less is more. It is the idea that the euphoria is more pronounced at around 2-4mg that 24mg. In other words, The opioid activation at 2-4mg is way different than the opioid activation going on at 24mg. And most prefer the 2-4mg route.


Here is my theory. bupe is a partial agnoist right? but norbupe or one of the other metabolites is a full agonist with less affinity to the mu receptor. And the bupe doesn't full block out the norbupe until around 8mg. or 4mg. So when you dose, after around 4mg there is different opiate acitivty going on, than when you dose 24mg. Because after 8mg bupe beats out the other metabolites and produces a different spectrum of effects on the opioid system.



The fact is tchort, whatever the mechanism, is whatever all of us, (about 60% of bupe users) are feeling cannot be discounted. I think the only thing we can agree is it is effecting the opioid system differently in low doses than in high doses.

 

[bow-viper1]

Well, The idea with the less is more theory does not litterally mean less is more. It is the idea that the euphoria is more pronounced at around 2-4mg that 24mg. In other words, The opioid activation at 2-4mg is way different than the opioid activation going on at 24mg. And most prefer the 2-4mg route.

Exactly. The only thing the OP exposed is that he didn't understand the statement.

Of course more of anything is always more. Buprenorphine has been used as an analgesic for quite some time now, and buprenorphine's analgesic properties have no ceiling.

In this case, the statement "less is more" was used around here about buprenorphine when it became apparent to everyone that the highest level of euphoria (and respiratory depression, coincidentally) was reached at a low dose, relative to what is being prescribed. There are a number of studies on just this at CoreText.

While I am sure there are a select few who need a higher dose than average, it doesn't change the fact that for most people, 8mg is plenty no matter what the tolerance. I have a friend with absolutely no tolerance to opioids who feels absolutely nothing from 20mg of oxycodone. And although people like him exist, I would never advise someone else with no tolerance that 20mg or more would be a good starting dose for a beginner - because I know that my friend is an exception to the rule. Just as I have found in my personal life and online that people who truly need 24mg per day to keep withdrawals at bay are exceptions.

I've also found that many people who claim to need such high doses of buprenorphine admit that they don't really understand the sublingual route of administration. That leads me to believe that although they may take 24mg, they aren't truly getting that much buprenorphine into their bodies, whether it is due to swallowing a lot of it, not keeping it under their tongue long enough, etc..

 

[chrisinabox]

I didn't necessarily view less is more as a fact from lecture. I viewed it as take the least amount possible, that still works. Don't asume you need x amount because of any reason and that the less you take the better in the long term.

I think less is more is a great statement to make to a bunch of addicts. The worst that could happen would be you need to take more. The effectiveness of dosage especially in higher levels has been covered here before.

I think you made a great thread and perhaps cleared up dosage issues for some. I also think you should realize that a lot of us get the drug illegally and as such need to conserve more. Personally I see nothing gained in taking more than you need and I don't think anyone ever said take less than you need. My own interpretation of "less is more" has always been take less and see how you feel, I see no harm in that at all as you can simply redose if need be.

agreed

To the OP

This is a great thread, and im glad you posted the replies from those 2 authorities. however, you end your post saying "the less is more theory is bunk".
Im not sure how you reached this conclusion based on the responses you received, especially the one from B-R. I dont think anyone takes (or should take) the "less is more" idea literally. obviously less is always less and more is always more. its a tautology. less can never LITERALLY be more. a more accurate mantra could be "less is better". and when it comes to bupe, less often is better, and even the makers of bupe seem to indicate that less bupe can often be better. bupe is rarely if ever underprescribed. ive NEVER heard of someone who says, "im trying to get off oxy but my bupe doc only gives me 4 mg a day and it wont hold me and he refuses to up the dose". however there are many many people who are scripted 32mg a day who quickly find that 6mg a day holds them perfectly well.
I know that i was scripted 24mg a day, and at this dose i felt very lethargic and foggy. after a week i tried taking 2 mg 2x a day and i had zero cravings also felt much more energetic and clearer headed. So for me, and many others, less is definitely BETTER when it comes to bupe.
So again to sum up- Less it not more..because less is always less-it has to be. but when it comes to bupe, less can be BETTER because docs very often prescribe a much higher dose then what is needed to hold ones cravings and WD at bay. These high doses often provide no added benefit, but carry with them, unneeded side effects

also completely agree.


tchort, when i say that I and many others seem to get better relief from lower amounts, i am not trying to spew this as a fact. you seem to misunderstand this. all i am saying is that from my experience and the experiences of ppl around me and on this board, they get better results from lower amounts usually, or at the very least get the same results from lower amounts. you keep saying how this is a harm reduction board and you act like we are endangering people's lives here by talking about this "less is more" theory. how is explaining to someone that i and many others get better results from smaller doses gonna harm anyone? if they try to take the lower amount and don't get the relief they want, they can just take more. nobody is trying to say this is fact, we are just expressing our opinions on this matter. i fail to see how mentioning to someone that alot of ppl get better results from lower amounts is going to hurt them in some way.

 

[phr]

i dont think im reading it right but just incase...

bupe isnt the only opiate with a "ceiling" dose.

codeine does also.

ok so i just wasnt sure if u were saying because it's partial, it has a ceiling or if u were just saying that it's a partial agonist AND/plus has a ceiling dose.

That first and shouldn't have been there.

 

[Captain.Heroin]

I don't think it's a "Myth" by your results.

If going from 8mg to 32mg doesn't produce that much of a significant difference, it's pointless to push your tolerance up that high just to get a few percentages of effect out of it.

If you had a big enough habit, maybe you need 16mg. The vast majority of buprenorphine patients don't though. If 16mg makes you feel better, I guess you are to be lucky that the little difference in taking twice as much actually makes a difference for you.

As the ceiling dose probably does vary for different people, my ceiling dose is probably around 8mg.

If I took anything more than 2mg at a time, I wouldn't get much out of it. If I took a whole 8mg at once, the effect would only be longer (if taken sublingually), not more intense.

If you're taking 16mg, or 32mg of buprenorphine, and it works for you, that's great. But the odds are you really don't need to be dosing that high. If you are someone who does need to be dosing that high, well...there you go. That's not the norm from what I've seen though.

If you're taking 32mg of buprenorphine a day, you're going to have a long way to taper down once you're feeling better from coming down. If you don't mind taking the longer scenic route, I guess, go for it.

However, I know it would bother me to hell to have to taper from 32mg of buprenorphine a day (which would theoretically be more equipotent than the heroin I was regularly doing), and I'm glad I'm only taking 2mg, maybe 3mg a day now. I've only had 1mg today, it's 6:25PM, and I'm feeling great. I'm going to go work out for at least an hour, then probably get a bite to eat afterward.

I guess it's not "ludicrous" to go above 8mg, it's just not desirable for most people, in my opinion. (Rare is probably a better word versus ludicrous).

"Less is more" with buprenorphine, because you get more of an agonist effect out of a lower dose, whereas you get more of an agitated, antagonist effect out of a higher dose. That's typical for most patients, but not for all.

 

[edarrin]

Rickett Bensckier is obviously not discounting the less is more theory, but the bottom line is they are a buisness. If they were to say 2mg is just as good as 8mg, they would lose tons of profit (

I think this is true to at least a certain degree. One can argue the merits of 'BigPharma' conspiracies but they do have a lucrative gig with the Bup in the U.S..

It could also be argued that for some people the dosage difference between not feeling w/d and not experiencing cravings could vary from patient to patient as well. A very subjective thing to measure in a study.

I find low doses are good to taper quickly and have minimal w/d in the classic sense, however the dreaded PAWS is omnipresent throughout the whole ordeal.