Bupe Is this how bupe is supposed to work?

[Lindhorst]

So I'm heavily considering going back to bupe from heroin/fent but every single time I've gone through monstrous precip WDs. Well, except for the last time and that's what my question is about.

Maybe eighteen or so months ago, I decided to switch to bupe for the fourth, or fifth, or fiftieth time. This time, however, I was gonna wait until I was so sick I wanted to bash my head in before taking anything at all.

So I did. I waited close to 72 hours from the last bit of h and I was sweating, shaking uncontrollably, nearly shit my pants twice, had RLS so bad I spent half the time standing until I collapsed from weakness, and so on.

I took 1mg to start slow like I had read and this time, it seemed to really work! Within 10 minutes, my entire body relaxed and I felt a warm, peaceful sensation. So much so that I fell right asleep.

Two hours later I wake up and the WD symptoms are coming back fast. I told myself, okay, you just probably didn't take enough. So I took another 0.5mg, but this time no noticeable change at all. In fact, it got worse. I was completely confused, annoyed, and angry as hell.

It didn't make sense at the time. Anyways, I end up taking more 0.5mg pieces over the next 36 or so hours and finally the worst was gone (except for the ever present burning sensation in the back of my neck). I wrote it off as another reason I despise bupe and went on with my life.

Four or five months later, however, I ran across an old box of subs that still had all the directions in them. I had never actually read what the drugmaker said because what do they know right? They just synthesize the thing, spend many millions on trials, and stake their reputation on it. Well, according to them, I had been doing it wrong. I had taken the advice of some people on a bupe forum who said to only go up by tiny increments. What the drugmaker said was, and I'm paraphrasing, "Take 2mg. If withdrawal symptoms return within a few hours, take another 2mg or as much more is as needed until you no longer are experiencing any withdrawal symptoms."

All of a sudden, the feeling I got from that first 1mg made sense, and just like the instructions said, my symptoms did return after a few hours. What I DID NOT do was take another 1mg or 2mg. I took 0.25 or 0.5mg doses. It became apparent that what went wrong was that I hadn't taken enough, and therefore suffered for a day and a half until enough microdoses built up on my bloodstream to have an effect.

I had read on forums that taking too much would surely make everything ten times worse. Well, I was an idiot and if I had taken 2mg when I woke back up, Im pretty sure I would've saved myself a great deal of hassle.

So, does this experience ring any bells with anyone else or am I just completely crazy? In retrospect, the symptoms we're getting worse after the microdose because I was in the midst of actual withdrawal and was not taking enough bupe to control it.

I repeat this story because once again, not by choice, I will be making the move back to bupe once again. I now know about the Bernese method and that sounds promising, but Im also not going to keep microdosing like I did the last time.

Thoughts? Criticisms? Open mockery? Just anyone who can corroborate what I went through will do me a world of good. Thank you.

 

[MadGnome]

Personally, I go through nasty precipitated withdrawal every single time I swap from Fentadope/Heroin to Suboxone/Subutex. Even 72 hours from my last dose and I'll be starting to feel better ill take a sub and boom I'm back in full-blown precipitated withdrawal.

I've read in a couple of places before that Fentanyl analogs tend to be more fat-soluble than most other opiates so they stay in your system much longer and because of that, you're at risk of PWD for much longer than say, oxycodone.

I've also read that there is a method to onboard yourself. It's called the Bernese Method. Essentially you use the bupe, enter into PWD, then use Fentadope to take the pain away while you swap over. Over time you use less Fentadope and more Bupe. You can find the dosages and regiment needed in a Medical paper online. I don't know if I'm allowed to link to it so just google it. It's what I'm gonna do the next time I try to switch to Suboxone.

 

[JamesB1985]

Once you had taken that first 1mg and it soothed your withdrawal symptoms an you went to sleep you were good to dose basically as much as you want but building up slowly with buprenorphine is always the best bet.
Once you take that first test dose when your withdrawaling and wait 30-45 minutes and it doesnt make you feel WORSE...you are good to go with more buprenorphine. But like I said always start small..0.5mg or 1mg like you did and wait to see how you feel.

 

[JamesB1985]

Personally, I go through nasty precipitated withdrawal every single time I swap from Fentadope/Heroin to Suboxone/Subutex. Even 72 hours from my last dose and I'll be starting to feel better ill take a sub and boom I'm back in full-blown precipitated withdrawal.

I've read in a couple of places before that Fentanyl analogs tend to be more fat-soluble than most other opiates so they stay in your system much longer and because of that, you're at risk of PWD for much longer than say, oxycodone.

I've also read that there is a method to onboard yourself. Essentially you use the bupe, enter into PWD, then use Fentadope to take the pain away while you swap over. Over time you use less Fentadope and more Bupe. You can find the dosages and regiment needed in a Medical paper online. I don't know if I'm allowed to link to it so just google it. It's what I'm gonna do the next time I try to switch to Suboxone.

Exactly. Fentanyl is highly lipid soluble and stays in the fat...because fentanyl has a short half life you wouldn't think you would have to wait long before taking Suboxone but thats the reason so many people experience PWD after fentanyl use..and the fact that we weren't exactly using pharmaceutical grade fentanyl off the streets..

 

[Lindhorst]

I think you're referring to the Bernese method, which has seen considerable discussion here and seems to be a good way to induct while staving off the worst of precip. WD's.

 

[MadGnome]

I think you're referring to the Bernese method, which has seen considerable discussion here and seems to be a good way to induct while staving off the worst of precip. WD's.

Yes, it's the Bernese Method. I didn't realize I didn't include the name of it in my original reply haha. I edited the original reply with the name.

 

[rave23]

I was on fentanyl for only 2 months or so, and when I wanted off the ride I decided to switch to suboxone. I only waited 12 or so hours, and was thrown into the worst withdrawals I've ever experienced. It lasted for 72 hours or so, and I kept taking more and more suboxone up to 16mg a day over the course of those 72 hours, thinking it would stop it. Well, it sucked big time.

Switching from fent to suboxone is tricky buisness. You'd think that as soon as you enter withdrawals you'd be good to go, and whatever else accumulated in your body won't do anything, because it's not keeping you out of withdrawals. Maybe it's because of fentanyls ridiculous potency that withdrawal comes on strong as soon as *some* fent leaves the receptor. And then when you take the suboxone it displaces the rest. It's nuts.

Anyone have some details on this Bernese method?

 

[Deru]

Thoughts? Criticisms? Open mockery? Just anyone who can corroborate what I went through will do me a world of good. Thank you.

I can think of many issues with what the instructions said, especially because it goes against best practice in the medical community currently. Those recommendations to start low don't just come from some forum, they have basis in peer-reviewed articles and research. So, in other words, the world changes and so do best practices.

Beyond all that: fentanyl. Fentanyl has a short half-life right, so why does it cause precipitated withdrawals days after last use? That's because when you do a drug, there is something called volume of distribution. The drug circulates through not only your cardiovascular system, but organs and your tissues as well. The greater a drug's volume of distribution, the more it is able to distruste into your tissues as well instead of just your cardiovascular system and organs. For fentanyl, with continued use, it takes an incredibly long time for it to leave the tissues, so there are amounts that make it into your bloodstream and can make it to your opioid receptors for days. That is why the micro dose induction method is imperative if the drugs you're using contain fentanyl.

 

[Deru]

Use the COWS test to limit precipitated withdrawals risks.

This is a horrible system for a person to use to self-assess, especially with fentanyl and fentadope. I have no idea why aemetha over there started suggesting this. Reason #93393939 that place is going to hell.

I wouldn’t fuck with the Bernese method until you switch to a lower affinity opioid than buprenorphine, otherwise you have a very uncomfortable time inducing suboxone or similar drugs.

This method is designed for fentanyl, specifically. This all grew out of research done in Canada where they are experiencing a huge fentanyl pandemic. It's not possible nor realistic for a lot of people to have the choice or power to switch to a different opioid due to the economics of the market.

 

[Deru]

Are you a physician, doctor? If not, this is about harm reduction and I do not know this patient.

PS; I am no longer ‘legally’ allowed to give out medical advice. (curious... are you Deru?)

Just curious,

—Wizard

It doesn't work because of the issue with fentanyl and it's issues leaving the tissues. If you use the COWS system, its a guaranteed precipitated withdrawals and would be the opposite of harm reduction. There is a ton of peer-reviewed articles and research I could link if you're interested, @The Wizard of the Creek. We actually had a ton of discussion about it over there, too. All my posts on the topics are sourced to peer-reviewed sources over there, probably be easier for you to find them that way. I can't access my account to search quick.

I'm also somewhat confused, I'm not offering medical advice. I'm discussing the topics themselves, and disputing and clarifying the [medical] advice you offered to the OP, no?

 

[dopamimetic]

The Bernese method sounds pretty good to me, but what I don't understand yet is how fentanyl can interfer with it - having a higher affinity than bupe should rather mean that there is no or much less precipitated withdrawal because bupe can't displace the fent.. as the half life of fent passes and it becomes metabolized out, the bupe will take over - this will create kind of a crash but it should be less than either regular precipitated wd (because metabolism is a slow, steady process vs. the almost instant 0 to 100 onset of a new substance after it reaches the receptors) or skipping a dose of fent (because you'll only go gradually down to the partial agonism of bupe instead to zero).

But read before that with some of these fents it is horribly difficult to switch to bupe and I'm glad that I threw my sample of butyr-fent away.. Still wondering if this is the whole thing or whether we have novel derivates with kappa agonism involved which the buprenorphine blocks and thus would out kappa agonists on a sudden turkey. Or these other, lesser known receptors like nociceptin (admittedly, I know less about it yet.)

Some brave individual should try memantine, or other nmda antagonists to help with the transition to bupe. For the usual opiates like morphine they can take much up to almost all symptoms besides diarrhea, for which we have loperamide. If these fents should be too strong for the nmdaa's to work, they might still give you more time to let the body removing these fents and then just titrate the bupe up and when you feel fine again, taper down both. You could use the nmda antag just for the transition or keep it for longer to help with the withdrawal and PAWS like symptoms (anhedonia, fatigue etc).

As bupe is administered subligually, a solution for volumetric dosing would make sense. Maybe go even ower than 0.125mg - if we think of naltrexone, which is used as ultra-low at doses 50 times less the usual starting dose. So maybe even as little as 0.04mg (4mg pill dissolved in 20ml, and use 200ul - just an example, don't have any syringe handy or dropper right now to check the usual amounts of doses), administer sublingually or with a nasal spray (benefit of faster absorption, with the goal to find a dose which is below threshold this doesn't hurt but avoids you quite a bit of waiting time in between the doses). Wait 15min or so, next one. Until you feel some discomfort but still in the range you can live with. Then wait.. after some hours, repeat.

Don't know, how long does usual precipitated withdrawal last? Is this a thing of some hours or even days? Depending on the half life of the previously taken opioid or less/not (so that e.g. fent would be very intense but short lasted, and methadone less extreme but lasting for more than a day).

But as always, not intended to diagnose treat cure or prevent any disease - it's plain theory at the moment.
Good luck anyways

 

[Deru]

I'm just about to go to bed, but I'll grab the sources for the fentanyl issues making it's half-life not the whole picture and the problem with leaving the tissues, and the resultant research that led to discovering the mirco dose induction method when I wake up, I promise

 

[JamesB1985]

I can think of many issues with what the instructions said, especially because it goes against best practice in the medical community currently. Those recommendations to start low don't just come from some forum, they have basis in peer-reviewed articles and research. So, in other words, the world changes and so do best practices.

Beyond all that: fentanyl. Fentanyl has a short half-life right, so why does it cause precipitated withdrawals days after last use? That's because when you do a drug, there is something called volume of distribution. The drug circulates through not only your cardiovascular system, but organs and your tissues as well. The greater a drug's volume of distribution, the more it is able to distruste into your tissues as well instead of just your cardiovascular system and organs. For fentanyl, with continued use, it takes an incredibly long time for it to leave the tissues, so there are amounts that make it into your bloodstream and can make it to your opioid receptors for days. That is why the micro dose induction method is imperative if the drugs you're using contain fentanyl.

Ahh...I see. So fentanyl has a high volume of distribution meaning much of it goes into the tissue and organs compared to how much stays in the blood/plasma?? Do I have that right? I know a lot of it goes into fat but I didnt know about this.. I'd also like to see some articles/sources for this.

 

[Deru]

"Although fentanyl has a rapid onset and short duration of action, it is lipophilic, resulting in distribution to the peripheral tissues in a manner that is not dose dependent.2,3 Consequently, continuous and prolonged use of fentanyl can result in increased volume of distribution systemically with slow dissipation overall.2 Accordingly, the pharmacokinetics of fentanyl combined with its high prevalence in the illicit drug market appear (at least anecdotally) to be increasing the incidence of precipitated withdrawal during the induction process of buprenorphine–naloxone. This occurs despite patients objectively being in moderate to severe opioid withdrawal before starting the medication."

Buprenorphine–naloxone “microdosing”: an alternative induction approach for the treatment of opioid use disorder in the wake of North America’s increasingly potent illicit drug market

www.ncbi.nlm.nih.gov

Other sources for various reading:

A Review of the Use of Fentanyl Analgesia in the Management of Acute Pain in Adults

(Peng) Staff Anaesthetist, Department of Anaesthesia, The Toronto Hospital and Mount Sinai Hospital; Assistant Professor, University of Toronto.(Sandler) Anaesthetist-in-Chief, The Toronto Hospital and Mount Sinai Hospital; Professor, University of Toronto.FENTANYL was one of a series of opioids...

anesthesiology.pubs.asahq.org

Case report: Successful induction of buprenorphine/naloxone using a microdosing schedule and assertive outreach - Addiction Science & Clinical Practice

Background The requirement for moderate withdrawal prior to initiation can be a barrier to buprenorphine/naloxone induction. Case presentation We aimed to use a microdosing regimen to initiate regular dosing of buprenorphine/naloxone in a high-risk patient with a history of failed initiations...

ascpjournal.biomedcentral.com

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onlinelibrary.wiley.com

I can't find the specific one that is part of Canada's Health recommendations for it, I'll keep looking for that one specifically as it's the best and explains the actual mechanism very well. As you can see from a lot of these articles, it's only been studied very recently, with one article fully dedicated to figuring out why people on fentanyl go through very bad precipitated withdrawals long after they theoretically should. With all this said, this is why using the COWS system is impossible to avoid precipitated withdrawals - it's going to hurt if you do and why the microdosing induction method has been adopted (I was wrong about where the actual Bernase method was originally made, it was in Switzerland but adopted and modified recently for fentanyl, specifically, although sometimes the words are used interchangeably)

 

[Deru]

This article, after quoting in it specifically what I quoted in my earlier post from the Bruneau et al article, continues:

"To address this, some prescribers in British Columbia (and likely beyond) are adopting a ‘micro-dosing’ approach for BUP/NX inductions. Officially recognized as the Bernese method,(4) ‘micro-dosing’ involves the prescribing of BUP/NX in a very small initial dose (e.g., 0.5/0.125 milligrams [mg]) with incremental increases to both dose and frequency over time (Table 1). Coinciding with this, patients can continue to use other opioids (either prescribed or illicit), until a therapeutic dose of BUP/NX has been achieved (e.g., usually >8 mg daily), at which point full opioid agonists are generally discontinued.(4) The entire induction process takes place over a 7 to 10 day period and has been associated with significant success. Individuals consistently report the induction process to be well-tolerated with a reduction or elimination of cravings and avoidance of precipitated withdrawal."

Buprenorphine/naloxone ‘micro-dosing’: an alternate induction approach for the treatment of opioid use disorder in the wake of North America’s increasingly potent illicit drug market

www.cmaj.ca

 

[Deru]

I'd like to add, the buprenorphine doctors from the leading substance abuse and behavioral health facilities in my state (I'm in the US) have all recently adopted this method within the last year or so. It becomes increasingly difficult because the drug screening using immunoassay (urine drug tests) don't test for fentanyl, so the majority of users can pass their drug tests while continuing to use the whole time since most of the market here is only fentanyl now - there is no heroin in it anymore, so most people don't have the luxury to choose. And that was my initial point earlier, the world changes and with it so do best practices. We need to be flexible to adapt to these changes to find the best treatment for current conditions.

 

[rave23]

If fentanyl sticks around for so long (it does in my personal, lived experience), how come I go into withdrawals a few hours after my last dosage? That's what I don't understand.

 

[Deru]

If fentanyl sticks around for so long (it does in my personal, lived experience), how come I go into withdrawals a few hours after my last dosage? That's what I don't understand.

It's two different components. It does have a short half-life and needs more frequent dosing to achieve what would be considered clinical efficacy, or being able to get desired effects. The component that contributes to precipitated withdrawals, is imagine having a slow drip of fentanyl from tissues back into your bloodstream, long after the effects wear off. The amounts are too tiny to aid in withdrawals, but enough to bind to receptors and cause precipitated withdrawals. This only becomes noticeable with continued and prolonged use, so if you use it here and there, you may not notice the issue with precipitated withdrawals as mentioned here. And since the "drip" is so slow, it can create agonizing precipitated withdrawals for long periods of time.

 

[Deru]

This should hopefully help explain my answer better, with appropriate sources:

"Fentanyl concentrations fell rapidly and 98.6% of the dose was eliminated from plasma in 60 min but the terminal elimination phase of fentanyl from the body was slow (t1/2 beta = 219 min) due to the slow return of the unchanged drug from a peripheral compartment to the central compartment where elimination occurred primarily by biotransformation"

Intravenous fentanyl kinetics - PubMed

Fentanyl is considered to be a short-acting narcotic analgesic but prolonged and recurrent ventilatory depression has been reported. We examined fentanyl kinetics and excretion in 7 healthy male subjects who were given a 3.2- or 6.4-micrograms/kg dose of 3H-fentanyl intravenously. Arterial blood...

pubmed.ncbi.nlm.nih.gov

You're looking at the half-life almost quadruple when it comes to that portion left in the tissues. Too small to be of any benefit, just enough to cause some severe complications with buprenorphine induction.

 

[rave23]

I did test positive for fentanyl for 21 days after my last dosage, so it worked its way out of my body for a long ass time. The way I just took subs after what I felt like was long enough it's really no shock that I experienced PWDs. What was shocking was pissing hot for almost a month.