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Opioids 80mg/day methadone to suboxone

123beepbeep

Greenlighter
Joined
Dec 24, 2015
Messages
2
I've been on methadone maintenance since June 2014, and managed to stay clean from other opioids until roughly 6 months ago, when I started smoking heroin and fentanyl again in addition to my daily methadone dose. My ECG shows a prolonged QTI, and due to this as well as my inability to stop using, my doctor is switching me to Suboxone. I've done some research and it seems like the standard protocol is to taper down to 30mg of methadone, stop for 72 hours then work up to a max of 16mg of Suboxone from there... However, my doc simply had me stop my methadone at the usual 80mg (Sunday was my last dose), and is planning on giving me 16mg of Suboxone on Thursday to start, expecting to quickly move me up to roughly 32mg total. Although he didn't exactly condone it, he did say that if I used short-acting opioids on Monday and Tuesday, it wouldn't be a problem as long as I didn't do any in the 24 hours before my Thursday appointment.


It's currently Tuesday evening, and I've spent the last two days on a steady diet of Morphine pills and heroin/fentanyl powder. I've had to do a hell of a lot of both to avoid getting sick, which hasn't been an option given I've had to work. But as long as I stop everything by tomorrow morning (24 hours before first Suboxone dose) I should be ok and not experience any precipitated withdrawals, correct
 
32mg of bupe is way way too much, that'd be equivalent to around a gram of morphine.
Imo 6-10mg should be enough for you
 
so basically you've been using methadone, fentynal, and heroin for the last 6 months except for the last 3 days you've been without methadone but are still ingesting morphine, fentynal, and heroin daily. you'll stop using everything exactly 24 hours prior to being inducted onto suboxone. Does that sum it up?

if I were you I would ask the doctor why he is suggesting to jump from 80 mg of methadone straight to suboxone vs tapering down to 30mg first. even if it's was a really fast taper down to 30mg first would be optimal. i don't think they came up with the suggestion of first getting to 30mg of methadone cause they felt like it but because of equivalency ratios between the two. ones a full agonist and the other is only a partial agonist. Is it being advised by him due to your prolonged QTI?

there's really no guarantee that won't experience PWD just because you wait 24 hours because everyones body is different. some people say they got PWD after waiting 48 hours and some say they didn't get any PWD after inducing suboxone after only waiting 12 hours.

i myself have never had PWD when inducing sub's but i believe that's because i've always started out very low, example is that I wait until my withdrawals are medium to bad. hot/cold chills, diarreha, aches and pains, runny nose, cough, and extreme anxiety then I will start with only like 2mg of sub. i'll wait at least a couple hours and if i don't feel any relief i'll take another 1 or 2 mg and repeat this process until I am well.

it sounds like your doctor is just going to through 16mg of subs into you immediately (post 24 hours from last full agonist opiate) which will undoubtedly throw off all the opiates from your receptors but i would suggest you speak with your doctor about this plan and see if he'd allow you to start small and titrate upwards as I described above. and I agree with kleinerkiffer and to stay low. anywhere from 8 to 12mg IMO. just take enough to rid yourself of the withdrawals as it's futile trying to get any sort of euphoria from subs since you're not opiate nieve.

either way, let us know how it goes. best of luck
 
^yup, you understand perfectly.

I will definitely see if I can start a lot lower than 16. My appointment is at 8:45am and my doctor works all day, so maybe they'll let me try 2-4mg to start and move up from there every few hours. Thank you both for the advice. I'm also going to finish off my stash now (7 hours earlier than I initially planned to, and 31 hours before the appointment).
 
I agree with Mazda that your doctors planned protocol sounds a bit off. As you rightly say it's usual to taper down to around 30-40mg methadone and then have around 3 days off it before introducing the buprenorphine. The reason being that you need to be in moderate withdrawl first before commencing the subs to avoid precipitated withdrawl. With your dose being 80mg the risk is that 3 days won't be enough time for the methadone to have cleared your system making

]p PWDs a distinct possibility. Alsovas has been said above, 16mg is a very high dose for induction. Usually they give you 2-4 mg and see how you are for a few hours before adding a little but more if no PWDs are present. The shorter acting opiates should be clear of your system if you discontinue them 24 hours before starting the subs but the real risk is your plasma methadone levels still being too high after discontinuing 80mg only 72 hours before.

You could do the maths and calculate how much methadone would be left in your system at the 3 day point by using methadone's half life to calculate this but the half life of methadone can vary hugely from person to person depending on how fast you personally metabolize the drug. I dont have the figures to hand but if you look up methadone on wkipedia you can see how greatly the quoted half life figures can vary.

In summary what your doctor is planning for you might be fine but if it were me I'd be pretty worried that he is going against the established protocol that you rightly describe in your post in the fact that your stopping methadone dose is very high as is your induction buprenorphine dose....

Sounds like a very high chance of experiencing precipitated withdrawl to me and PWDs are very, very unpleasant.

Good luck mate and let us know how it works out.
 
Methadone to suboxone is always a tricky one, and that's where most people run into pwd. I would say take the shorter acting opiates up to 24 hrs before induction, but be off the methadone for 5 days just to be safe, 'cause pwd suck! Good luck


- Hopeless
 
Your doctor is an idiot. Ok maybe that's harsh--lets just say he's not very educated about methadone, suboxone, and transition between the two.

As someone stated above, the 30 mg isn't some random number. It's the equivalency to a ceiling dose of buprenorphine. In other words, if your tolerance is above 30 mg methadone, bupe is not going to hold you. So...that means that until your tolerance drops, you're still going to be sick on the bupe. And in a worse place than on methadone, because doing all those other opioids on top isn't going to help much as the bupe will have your receptors saturated.

Methadone takes *at least* 5 days of being off to prevent precipitated wd during transition. You stopped Sunday, you're supposed to start bupe Thursday, that's only 4 days. That's not so good.

And even if you get lucky and avoid the precipitated wd, as I said above you're still going to be in withdrawal due to the inability of bupe to hold you at an 80 mg equivalent. (Yes I know you've been doing short acting agonists but if you have done enough to not be sick you're still at or close to the 80 mg equivalent).

What would have made sense was to slowly bring down your dose to 30 mg then switch. But then again maybe with you doing all the extra stuff you would've done more of that to make up for it....still, it would be a much better scenario than the one you're in now.
Have you asked why he is going against standard procedure for switching? Id be very hesitant to switch, knowing it'll be a few shitty days at least until your tolerance falls enough for bupe to hold you. Hopefully it goes quickly for you, keep us posted

And sorry, but 32 mg of bupe is completely unnecessary and pointless.

On second thought, I think I may reinstate my opening sentence....
 
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As someone stated above, the 30 mg isn't some random number. It's the equivalency to a ceiling dose of buprenorphine. In other words, if your tolerance is above 30 mg methadone, bupe is not going to hold you. So...that means that until your tolerance drops, you're still going to be sick on the bupe. And in a worse place than on methadone, because doing all those other opioids on top isn't going to help much as the bupe will have your receptors saturated.

You're underestimating buprenorphine's potency here quite a bit. 30mg of methadone is a low dose, certainly not a equivalent dose for buprenorphine's ceiling dose, the recommended dose of methadone before switching to buprenorphine is 30mg, but it's not because higher doses have no equivalent doses in buprenorphine, the ceiling dose of buprenorphine is more or less equivalent to about 80mg of methadone. Mainly it's because a patient to receive buprenorphine who is at a higher dose of methadone will start experiencing withdrawal much earlier than it's safe to give him buprenorphine without causing precipitated withdrawal (and much earlier than it's possible to stabilize on buprenorphine which does take a few days too), the goal is to diminish withdrawal symptoms during the transfer to a minimum. The first dose of buprenorphine shouldn't be 16mg right away at once either,.
 
^^^Adder said everything I came here to say and more. (What else is new, right? :p )

I would just like to add one thing, buprenorphine's EFFICACY at the mu receptor is variable, based on concentration (of course it's affinity is maintained)

It seems as if doses under ~4mg sub lingually have more pronounced agonistic effects than higher doses. This does not mean that lower doses will necessarily decrease risk of PWDs, but in regards to simply being in a state of "semi withdrawal" once stabilized on a partial agonist, coming off of a full (or nearly full) agonist: A lower dose may (counter intuitively) feel more "opioid - like" than a higher dose, especially in the beginning of therapy.

I have a suspicion that one of the reasons doctors frequently prescribe border-line irresponsibly high doses of buprenorphine, especially initially, is because it is actually less euphoric in that way, combined with the fact that there does seem to be some evidence that very low doses of suboxone don't always prevent other opioid from binding. Strange drug, really.
 
I tapered down to 30 mg of methadone and then waited 72 hours before switching to Suboxone. I still experienced a small amount of PWD from the process. Within 5 minutes of taking the first 2 mg I was sneezing, yawning and shaking. The doctor suggested waiting another 24 hours before taking another 2 mg. That is just what I did and I am glad that I waited before ramping my dose up otherwise I believe the PWD would have been much worse. It took about 7 days for the cross over withdrawals to subside after switching. So don''t be caught off guard if you feel slightly sick for the first 10 days. Now I only take 0.5 mg after taking 16 mg for 4 years and I hope to be totally off in the next month. I can easily say 16 mg for 4 years was way to high of a dose. I would have been much better off on just 8 mg. Before the sub I took 150 mg of methadone for a number of years and tapered down to about 30 over a few weeks. I am really thankful I looked up the protocol before making the switch or else my doc would have had me transitioning from 80 mg meth to 8 mg sub. I showed him the standard protocol and he was more then happy to follow some basic guidelines.
 
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While I would work my way up with the dosage, starting with maybe 2-4mg, I wouldn't be surprised if you did need a much higher dosage at first. The thing is that like methadone it takes a few days for the buprenorphine to build up in your system. Someone taking 16mg/day for a month is much different then someone who takes 16mg one day, because the person who's taking that dose daily has at least another 8mg built up on top of that dosage. When switching from methadone to suboxone, especially in a situation like this, I would think more would be more because you want to make sure you're getting all those receptors covered.

Also, while I agree that most of buprenorphines 'agonist activity' pretty much peaks somewhere between 4 and 8mg, I do believe that exceeding that dosage will result in more 'receptor activity' (or whatever you would call it) it's just that after say 6mg, an increased dosage does not produce the same increased effect that say going from 1-4mg would produce if you follow me.

But like I said before, work your way up until you feel comfortable. It would suck to just take 16mg and be stuck in a hellish precipitated withdrawal and have your receptors blocked by the subs.
 
The main reason for doctors starting people at 16mg suboxone or more is because after a few days at that dose it does a very good job with the cravings. It's not very helpful if you just take 1mg and feel fine but keep relapsing.

I always thought high doses were stupid and I am on 8mg now and could get by lower but I know going down from here might give me cravings and I can't afford a relapse now. I will gladly face 3-6 weeks of withdrawal as a price for getting my life back, paying off my debts and working full time, being able to get in shape physically before getting off maintenance makes it a bit easier on you
 
If being on a higher dosage reduces your cravings then I'm all for it. Unfortunately I never found that to be the case, on higher dosages I just felt over medicated and craved like a motherfucker. At lower dosages I was happier because the Buprenorphine acted like a more conventional full agonist, but different strokes for different folks.
 
Well I am a doctor (not actually) but I am just going on what I see from friends who can't stay on sub because they take a low dose and keep relapsing. I'm sure it's different for everyone but there's not much other reason to justify high doses because 8mg or less could hold probably 90% of opiate habits but they still give out a crap ton of it to everyone.

I also believe higher doses should not be given to anyone who isn't a serious opiate addict (.5 IV heroin + or 300mg oxy + etc) and for things like a low dose oxy or hydrocodone habit (50-100mg) maintenance shouldn't be necessary
 
yeah I totally agree with you there. I mean there is the argument to be maid that suboxone is a more 'sustainable addiction' maybe, for someone who is buying hydrocodone or some other weak opioid but in the end subs are a much worse kick.
 
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