suboxone info for the noob

[simco]

I know there are a lot of threads going on about suboxone right now, but I'll risk starting one more. The reason is that even though I've now been on subs for a month, I still don't feel like I really know how they are most effective, and specifically, whether what I'm doing is similar to what's most effective. I've read a lot (on BL and elsewhere). My doc is a good guy, but extremely busy, so not keen to chat. But somehow I always feel like I don't know what the fuck is going on with suboxone therapy.

Any thoughts from the SL community? Here are a couple concrete things I've been wondering. But other info is appreciated, too.

1. What is it "supposed" to be like when you're doing suboxone therapy? The first week or so on it, it was a miracle: all of my cravings for dope vanished. But they've been creeping back and now they're not almost as bad as before I started. Other folks at my clinic claim they have zero cravings now that they're on subs. The times I *have* mentioned that I'm still shaky, the doc just increases my dose. Is the aim in suboxone treatment to medicate cravings *away*? As much as I'd like that, it seems unrealistic. Which brings me to question two.

2. Am I on an insanely high dose? I know this is a medical question that can't really be answered outside of a dr/patient setting. But until yesterday my guy had me on 16mg a day (8 in the morning and 8 at night). At my appt yesterday he raised me to 24mg. I don't know which points are relevant, so I'll list a few things that might bear on this.

• I am a very slim guy (120 lbs).
• My heroin habit was small by the standards of people I know. I was doing about a point or two of #4 IV per day.
• I have very bad mental health issues (major depressive disorder). But aside from that I'm healthy.

I'm also interested in viable strategies for managing the duration of suboxone therapy. I'd like to make mine fairly brief. But given how badly I'm craving dope, I'm hesitant to quit subs any time soon. I started them b/c using had just become impossible to accommodate in my life; dope was going to kill me. I really, really don't want to pick up again, even if it means staying on subs. I'm kinda keen to start a taper with the idea of weaning myself, but I don't even know enough about the goals of the therapy to weigh my options.

Thanks in advance folks!

 

[Cherrysoduh]

Following this thread.

I plan on going this route for the first time on Monday. Like you I have read a lot both on here, other places on internet, and even on the suboxone manufacturer website. I still have many questions. Not going to hijack your thread with my questions but I am going to follow along.

 

[Jabberwocky]

Yes, 18-24mg is a high dose (like very high, 24mg is pretty much the limit, so insanely might be just the adjective).

Suboxone (buprenorphine/naloxone) is "meant" to do any of three (but really four) things:

1. preventing withdrawal,
2. stabilize patient, and
3. prevent cravings
   (*although I've never heard a prescriber tell me or anyone this - which is funny, because no prescriber has ever explained any of this to me LOL - buprenorphine is also very effective as a partial agonist/antagonist at minimizing your "normal," e.g. not super duper intentionally premeditated, relapse - rather, buprenorphine is very good even at low doses at helping patients get over and bounce back, even entirely avoid in some cases, what I will call lapses, or slips, as opposed to the full blow super I-want-to-get-fuck-up-use-as-much-dope-as-necessary relapse)

Depending on how it is used by the practitioner.

Most rehabs that do use it only use it to prevent (or rather address, because they don't even use it this way properly) withdrawal.

Most psychiatrists or out patient prescribers use it to stabilize the patient and attempt to prevent cravings.

It is a very, very effective medication at preventing withdrawal. It is fairly efficacious at stabilization, especially within the first 24-6 months.

It is very useful at addressing cravings for some populations (such as people who recreationally used hydrocodone or other mild-moderate full agonists primarily orally), which less efficacious at addressing cravings for other populations (such as people who used IV/IM heroin for decades).

Likewise it isn't as efficacious at stabilizing, or in some likewise extreme cases preventing withdrawal, for people who have used heroin or other potent full agonist for long periods of time, especially when compared to something like methadone (there are huge benefits of taking buprenorphine to methadone in some areas of the world like the US however, but this has nothing to do with treatment efficacy).

Now, buprenorphine (whether in the form of Suboxone, Subutex, whatever), is pretty useful at treating people who has been using potent full agonists for moderate to long periods of time (say, 6 months -15 years pretty much non stop), but it needs to be used properly.

I'll post about how to do this shortly if you're interested. Now I need to take a poop!

EDIT:

A note on mental illness:

And before I go into any more detail, from rereading your first post OP, now hear this: It is highly unlikely you will truly overcome the challenges posed by addiction until you address both those and those cause by your mental illness - e.g. until you address your co-occurring disorder(s). Until I began to really address my mental illness, I was an utter failure regarding my recovery re: addiction. Once I started really, effectively treating my mental illness, my recovery re: addiction really, really took off in ways I couldn't have ever imagined.

When I first sought help with my experience of addiction, I was literally denied mental health treatment, told "We don't do that here," but still told I had to do what they did there anyways. I honestly feel that now, if I had encountered actual professionals and had my mental illness treated, even if my addiction wasn't as much the focus, early on (given my particular history of self medication however), I would have been so, so much better off today. Oh well, live and learn!

*I'm talking about how if you try to use while taking even just 0.2mg of buprenorphine (regardless if it has naloxone with it, like Suboxone or not, like Subutex) you won't be able to get high. I mean, if you use enough dope and with a potent enough method (e.g. IV/IM) you will be able to feel your full agonist even after just taking buprenorphine, but you have to use a shit load of it and it is very, very dangerous because of the higher dose of full agonist required to overcome the partial antagonist effects of the buprenorphine.

In regards to moderate to high doses of methadone (80mg+), buprenorphine has a blockade effect that can really help prevent a lapse from spiraling out of control or turning into a full blown relapse. That said, I believe buprenorphine is much more efficacious at this "blockade effect" thing than methadone, as pretty much any dose of buprenorphine will achieve this, 0.1mg-24mg, although higher doses of buprenoprhine will make it hard and hard to get high from a full agonist.

With a full agonist like methadone, that doesn't have any antagonist properties, you can easily get high on low-moderate doses (1mg-80mg), and of course like buprenorphine you can get high off any potent full agonist regardless of your methadone dose, just that unlike buprenorphine it is even MORE dangerous to try and get high while on a "blockade dose" of methadone due to extremely high risk of OD.

 

[simco]

Thanks @Toothpastedog! These are exactly the kinds of things I need to hear. And you brought up one point that in your edit that I want to suss out a bit.

I'm currently in long-term, intensive psychotherapy with a psychiatrist whom I like quite well. It was him who suggested that I try suboxone. The thinking was/is: if I can get some relief from the very specific cravings for heroin, then we might have more stability and better odds of dealing with the *real* shit-show that's causing my war against myself.

To me, that's a compelling argument. I have no doubt that my using stems mostly from depressive artifacts. And it's definitely true: as long as I was caught up in the cycle of using/quitting/lapsing, it was hard to make much psychiatric progress.

Maybe a worthwhile mental exercise for me is to think about what kind of relationship with subs would make that kind of progress most likely. Of course I'd *like* to take my meds as directed. But I am also willing to take less than the doctor prescribes. Maybe I can find a dose that isn't going to deliver me to a giant suboxone habit, but that will give me enough stability to resist the cravings, without necessarily avoiding feeling them.

I guess the thing that weirded me out was how everyone at the clinic had an attitude like "why suffer from cravings when you can take more suboxone?" I didn't have a ready answer for this, but it seemed creepy.

On a lighter note, @Toothpaste dog, I want to extent a special thanks for doing me a solid, going above the call of duty, even while you had to poo. But that would be juvenile of me .

Last, other readers... feel free to jump in. I certainly won't accuse anyone of hijacking the thread!

 

[Jabberwocky]

Sadly, higher doses of buprenorphine only help with cravings up to a point, both in the amount/dose of buprenorphine taken and how long you use it (after about a 6-12 months my cravings got worse and worse on Suboxone).

You have an astonishingly positive and constructive attitude simco! You are so right on the money about exploring what kind of relationship you want to have with buprenorphine.

I'd really suggest experimenting with lower doses (2-0.5mg, one to four times a day, although two times a day is better than three or four) of your Suboxone.

Lower doses seem to help with cravings more, and result in a more pronounced agonist effect of buprenorphine than antagonist. Higher doses are really only truly across the board useful when it comes to preventing relapse and causing that blockage effect I added on to my earlier post about.

You have a pretty darn good psychiatrist, or so it would seem, because you are so right. It's really hard if not impossible to make progress dealing with symptoms of mental illness if not address your symptoms of addiction. Likewise, it's really hard on making progress dealing with symptoms of addiction if not addressing your symptoms of mental illness.

Experiment with what works for you. I know it isn't part of our junkie logic, but as other will attest lower doses of buprenorphine (2mg or less) tend to work really really well. Only concern there is if you feel like you're literally about to go out and use, but if your true intent is to work on your recovery (from both addiction and mental illness), then I'd highly suggest trying a lower dose for a few weeks.

Don't just start taking a low dose, like ween yourself down from where you are to like 2mg twice a day (I'd suggest jumping down to 8mg twice a day, to 6-4mg twice a day, to 4-2mg twice a day, to 2-1mg twice a day).

If you feel like it isn't helping or you feel at increased risk of lapse/relapse due to insane cravings, try combining your buprenorphine with Tagamet/cimetidine. This isn't going to solve your moderate to long term problems, but it will increase the subjective and agonist effects of the buprenorphine, thus decreasing risk of lapse/relapse by satisfying your urge.

There are some serious side effects to using cimetidine at the moderate to high doses required to potentiate buprenorphine, especially if you are male, so it is only truly useful in the short term (if it seems like cimetidine will be required long term, you best try methadone rather than buprenorphine or buprenorphine+cimetidine).

The dose of cimetidine you would need to potentiate your buprenorphine is about 400-600mg of cimetidine FYI, more is generally useless if not harmful due to moderate-long term side effects. Side effects of moderate to long term use of moderate to high daily doses of cimetidine include serious complications with certain other meds, such as how it can potentate alprolazam, and, IMHO more importantly, galactorrhea/gynecomastia.

 

[simco]

Thanks, @Toothpastedog. I had been leaning towards this as a possibility and I think I'll try your suggestion of reducing my dosage. I never actually took the 24mg/day my doc prescribed, so I'm at 16/day right now. I think I'll do a week a 8mg/day, with the aim of reducing down to a significantly lower dose gradually but steadily. Again, intuition had me thinking around 1-2mg/day...maybe even 0.5 if you think that would have an actual effect.

Ultimately, my goal here is to keep myself steady enough that I can stay off dope. But I *really* want my physical dependence on bupe to stay as small as possible...ideally negligible.

It's just astonishing to me how hard it is to get good information about this stuff. I've always researched my psych meds and had great luck finding enough info to convince myself that I knew what was going on. With suboxone, not so much. So I really do appreciate the advice. It's serious business...I can't believe how casual the doctors are about it.

 

[Jabberwocky]

Well, even with psychiatric medication it's hard to get really good info. The Icarus Project is something I always liked that can help with that. But I do agree with you, it's hard enough to get a good education about psych meds, it's damn nearly impossible to make any sense let alone get educated about MAT stuff. Things are getting better, but it is so so so sad. So much entirely unnecessary suffering and waste of both good lives, time and resources. Thank you for your thank you BTW, I'm glad you can appreciate how much I enjoyed responding to your initial post considering I wouldn't go poo until I had finished my response

 

[simco]

That's saying something... as an opiate addict, any chance I get to shit, I jump on IMMEDIATELY!!

 

[Cherrysoduh]

I plan on taking this route tomorrow if I can make it to the place on time. The place I plan on going to tomorrow is a privately ran done/sub clinic. That's all that they do. I have been told by someone who goes there that I would go everyday for a week and then I would be given a script for a week or two then I would have to go back to check in for another script. I'm okay with this.

There is the option to go to a private doc, but they charge a $350+ first time office fee, and then give you a script to fill the sub. Depending on what the doc says you either go back in a week, or 2 weeks for a f/u and another $125 office visit fee.

I know the sub isn't a magic script and that I have to have the willpower on my own as well. I wish there was a magic script as I know other wish the same. Haha

Is it best to do a short taper of sub? If you had to do it all over what schedule/dosing would you suggest? Does sub truly have an addictive component to it? I've read stories saying yes and no. I did just watch a documentary on dateline on h addiction 2 weeks or so ago. The chick had been on sub for like a year and they showed her scrapping together literally pennies, and dimes to go get her dose for the day. Or she would be in wd. This seems just as scary as a full on habit. Although cheaper in the long run to be addicted to sub than pills and h.

Also, the clinic said I needed to be 24+ hours clean to start the sub. Friday I dosed 40mg OP in the AM, 20mg OP in the PM, 2 lines of h snorted about .25mg. Saturday I only dosed about 30 mg of done at 10pm. Nothing today and don't plan on taking anything today. Do you think if I go tomorrow morning that I will be okay to start the sub. I'm sure the clinic will tell me yes. I sometimes wonder about the clinics though.....money machines. Even when I called to get pricing it seemed like they were trying to steer my towards the done. I imagine the done is there eggs and bacon not the subs.

Thanks in advance for any and all help

 

[simco]

I'll let people more knowledgeable than me talk about strategies and prospects long-term. But as a suboxone newbie, I will saw a couple things. First, I was amazed: it really was like magic at first: the cravings vanished. Mine are seeping back now, but it was heavenly for a while.

Second, people understandably assume the worst about these clinics' motives. Money. Keeping you strung out, etc. I'm sure some of that goes on. But the couple places I've talked to seemed totally on the up and up. And really, in my town, they were fighting mainstream opinion by even operating...people were always trying to shut them down. So I tend to give them the benefit of the doubt. But of course, your mileage may vary.

Good luck. Let us know how it goes.

 

[Jabberwocky]

I'll stand by simco's post. If money is a huge issue a short taper is a good idea. But if addiction has caused you lots of problems, or if you have both addiction and some other mental illness as many (if not most) of us do, longer term Suboxone use is advised.

The caveat is that you shouldn't really be using any more than 2mg (at most twice a day, but even 1mg or 0.5mg twice a day would be better) if you go long term. Maybe 4mg, but anything above that is only really advisable if you need to prevent yourself from getting high from using other opioids, which kinda makes me think buprenorphine maintenance isn't as productive an option as a more controlled longer term environment might be for you.

Now, about controlled long term environments, I wouldn't recommend that route either. I'm sure there is something out there that works well, but I sure as fuck have never heard of it, and there is really no way for you to know until you try it. Given the personal nature of addiction treatment and the long term commitment required, I'm not comfortable recommending something like that to anyone really.

Good luck my friend! All my love to you

 

[Cherrysoduh]

Thank you for the replies. I'll go in the morning and see what the clinic doc says. The only reason I was thinking of going to a private subscribing doc is it is closer to me and it sounds like less visits which equals more money upfront out of pocket but less chance of being late to work and a ton less travel time daily. I can't say money isn't an issue because I am not rich by any means but the sub route w even long term doc visits and private pay of scripts will be less than what I dish out every month for opiates.

I agree that most clinics probably operate with the best interest of the patients in mind. Although, some are questionable as with most things in life.

I find it interesting how there are so many varying experiences with sub. I tend to believe I'm more in a situational depression stage than long term depression but who knows how that will turn out once I'm all done and completely clean.

Thank you for the support. Best of luck to each of you. As long as I make it down there tomorrow I will let everyone know how it goes.