Tchort
Bluelight Crew
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- Mar 25, 2008
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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:
First, here is the response from the NAABT:
And here is the response from Reckitt-Benckiser:
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.
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.