Tapering Off Buprenorphine or Suboxone pt. 1

Many patients taking buprenorphine live in fear of a dark world around the corner where they will have to taper off the medication.  They see horror stories on YouTube posted by people who, for some reason, abruptly stopped the medication and kept a video log of their experiences.   My own patients sometimes ask, nervously, if I plan to retire some day.  Some have asked what they should do if I ever, say, drop dead.

It needn’t be all that bad.  Yes, sudden discontinuation of a typical dose of buprenorphine will result in withdrawal symptoms.  But if you taper correctly, your body will slowly reset your tolerance without putting you through the wringer.   In this post I’ll describe my typical approach to helping a person through that process.  But first we should correct some of the misconceptions about buprenorphine and opioid dependence.

It does NOT get harder and harder to stop buprenorphine the longer you take the medication.  I have heard that idea over and over in one form or another, and I presume it comes from the experience people have with active addiction where use tends to grow with time, and other facets of life gradually fade away.   But the opposite occurs in patients treated with maintenance agents like buprenorphine or methadone, where use of the medication does not trigger a reward or relieve the ‘punishment’ of withdrawal.   The conditioning that occurred during active addiction is slowly extinguished, and most people gradually lose the desire to use opioids.   I’ve witnessed this process literally hundreds of times over the past 12 years in patients on buprenorphine or methadone. Patients of successful treatment also develop interests and accomplishments that help them avoid returning to opioids.  And after a few years away from ‘using friends’, people no longer see themselves as part of the using scene.  Patients get to a point where they have too much to lose to get close to that world again.

Opioid withdrawal has physical and psychological dimensions.  During short-term detoxes, minor physical symptoms trigger fears that magnify the perception of those symptoms.  A bead of sweat on the neck signals that hot flashes, diarrhea, and depression are on the way.  Patients who have been away from the cycle of using and withdrawal don’t seem to have as many emotions about their physical symptoms.  I see the change very clearly in methadone-assisted treatment, where the minor withdrawal at the end of the day is a big deal to people starting treatment, but a minor inconvenience in patients tapering off methadone after several years of treatment.

Does buprenorphine ‘get in your bones’?  YES, of course!  Bones are living tissue, so anything in the bloodstream gets in the bones.  Glucose gets in your bones.  Aspirin gets in your bones.  But so what? When you taper off buprenorphine, the buprenorphine in your body will be metabolized and removed.  It does not accumulate or stay in bones or other tissues beyond what occurs with other fat-soluble molecules.

Is buprenorphine or Suboxone ‘the hardest opioid to stop’?  No.  The brain keeps no record of the molecules that pushed opioid tolerance higher.   The challenge during a taper is that opioid receptors have become down-regulated by opioid stimulation, resulting in reduced endorphin tone as the opioid is removed.   Opioids that leave the body quickly tend to have more-intense discontinuation effects than those that leave more slowly because the latter mimics a taper, where opioid activity decreases over time.  The longer half-life of buprenorphine also slightly extends the total period of withdrawal by a few days.

I’ve heard people claim that ‘heroin was much easier to stop’, and rather than tell people what they should think I’ll let them have their opinions on the issue.  But that opinion is not supported by studies comparing withdrawal from different opioids.  Usually the claim is followed by the comment that ‘with heroin I was fine after 4 days’ or something along that line.  But it takes longer for tolerance to reset, after ANY opioid.  I suspect that perception comes from the severity of early heroin withdrawal, making subsequent weeks easier by comparison.  Again, the brain doesn’t care which opioid you used to take;  it only cares that the opioid stimulation that was there is now gone.

In a few days I’ll share the approach I recommend to patients tapering off buprenorphine.

Opioid Withdrawal Treatments

A post on the Forum asked about the best remedies for opioid withdrawal.   I will review the medications and other treatments for opioid withdrawal that I have heard discussed by physicians or by people on the internet.  Hopefully readers will leave comments about medications or approaches that they have found useful.  Likewise, if you are a physician, please weigh in with the approaches that you have found to be useful.
For readers, it is very important to understand a couple things about this post.  First, the medications listed here are not FDA approved for treating opioid withdrawal.  They have not been systematically tested for that purpose. Most of the medications that I will list are available only by prescription— and must be taken ONLY by prescription.  They all have interactions with other medications, and they all have toxicity in certain doses, and in people with certain conditions.  Do NOT take them other than through guidance by your doctor.  This post is intended to spark discussion with your doctor— and to help doctors learn about approaches that they have not heard about elsewhere.
I will encourage doctors or other contributors to this post to avoid discussion specific dosages.  These medications must be prescribed by physicians who understand them, or who know how to become knowledgeable about them.
One problem for doctors is that CME meetings generally discuss treatments that are FDA indicated.  I do not know of any medications that have been approved or marketed specifically for opioid withdrawal, and I do not have the sense that the field of medicine views opioid withdrawal as a pressing issue.  But I am aware that for buprenorphine patients, the treatment of withdrawal symptoms has the highest priority of any medical concern.
With those caveats, here are the medications that I have heard the most about, roughly in the order of what consider their usefulness:
– Clonidine:  Available by tablet or by patch.  The medication reduces CNS excitability, and relieves all opioid WD symptoms to some extent.  Side effects include sedation (which may be useful), dry mouth, and hypotension.
– Gabapentin:  An anticonvulsant that some people find relieves anxiety and perhaps the sweating during withdrawal.
– Benzodiazepines: A controversial topic.  They are potent sedatives, but they are also potent respiratory depressants when combined with opioids.  Most overdose victims have these drugs on board.  They relieve anxiety, insomnia, and muscle tension, and cause fatigue.  Should NEVER be combined with opioids unless under very careful supervision (i.e. ‘self treatment’ = NO treatment).
– Phenobarbital: A Forum participant wrote that his/her doc prescribed phenobarbital for opioid withdrawal with great success.  All barbiturates act similarly to benzodiazepines, and have potent respiratory depression, especially with opioids.  Again, must NOT be used except under close supervision.  Have effects similar to benzodiazepines.  Dangerous if combined with alcohol.
– Quetiapine: AKA Seroquel.  A potent sedative, used to treat psychosis, bipolar mania, depression… and off label, insomnia.  Side effects include dry mouth and sleepiness.
– Natural ‘remedies’: A variety of withdrawal remedies are advertised on opioid-related web sites.  I’ve had patients who tried most of them, and I’ve never heard anyone say they were useful. Some come in ‘daytime formula’ and ‘nighttime formula’.  Always read the ingredients– and if you see a long list of herbs and roots, realize that there is NO oversight of the claims that are made.  You could put bundles of dandelions into empty capsules and sell them over the internet, making the same claims.  How hard do you think it would be to find a people to write ‘testimonials’ for twenty bucks? Or you could just write them yourself! Buyer beware.
– Amino acids:  Again, advertised on the internet, and offered at steep cost by ‘select’ doctors.  One of the ‘pioneers’ of amino acid treatments for withdrawal was convicted of fraudulent practice in Texas, and now offers the same as he did in Texas, but safely across the border, in Mexico.  He has clinics in the US, run by other doctors, who boast of using his methods.  The appeal of buying into a treatment that was proven fraudulent in court escapes me.  But the treatment of opioid dependence is strongly influenced by perception, and so is strongly subject to placebo effects.  The appeal of snake-oil remedies has created a living for many, many charlatans over the years, and a sucker is born (at least) every minute.
– General sedatives:  Insomnia is such a big problem that anything that helps with sleep will help during opioid withdrawal.  Meds include diphenhydramine and hydroxyzine (antihistamines), zolpidem and zopiclone (short-term sleep meds), and trazodone and mirtazapine (sedating antidepressants).   Cyproheptadine is a sedating antihistamine that reduces nightmares, and stimulates the appetite.
– Stimulants:  I’ve read of people using them to fight the depression and fatigue during withdrawal.  That use of a schedule II medication may be illegal in some states, and is probably frowned-upon by agencies that regulate medical practice.  The energy and mood effects from stimulants are temporary, and must be ‘paid back’ with fatigue and depression when the stimulants are discontinued.
– Naltrexone: An opioid antagonist that has been used to speed the reduction of opioid tolerance.  Naloxone and naltrexone are used during rapid detox, under strong sedation or anesthesia, but I believe that some have used naltrexone in very low doses in awake patients.  If you are a doc who knows about this approach, I’m all ears…
– Antidepressants:  Depression is one of the worst aspects of opioid withdrawal.  Antidepressants would seem appropriate… but I know of no antidepressant medications that have a chance against the severe depression caused by opioid withdrawal.  I’ve used them for patients after the withdrawal ends, when depression lingers… but I see little use for them during acute withdrawal.
Gosh, I thought my list would be longer.  Given how many people suffer through discontinuation of opioids, our approach to easing misery is pretty limited.   I will remind readers–  most of the medications listed above will cause serious harm, if taken without doctor supervision.
If you are a doctor who has found success with other medications, or if you are a patient of such a doctor, leave a comment to help spread the knowledge.  If you are not comfortable with leaving a post, send me an email, or a message through LinkedIN.
 

A New Way to Stop Suboxone?

Originally Posted 10/27/2013
I usually have my wife/business partner review my posts and provide her opinion whether my arguments are sound.  For the record, she tells me that this post is technical and boring.  I disagree, but we aren’t planning to separate over the issue.  A valid criticism, I think, is that I’m doing a lot of guessing and wondering in this post.  This post is an example of the things I waste time wondering about.   I try to avoid writing things that are somewhat speculative, but I wanted to give it a shot for two reasons.  First, because there may actually be something to the idea I am about to describe.  But more important, I wish to point out some of the many ideas in the addiction world worth exploring…. And I hope that pharma continues to search for answers (i.e. spend money) in this area of medicine.
So I’ve been thinking more about ALKS 5461, the Alkermes pipeline medication that is a combination of buprenorphine and ALKS 33, which is a mu opioid antagonist also called Samidorphan with the structure shown at the left. ALKS 5461 is being developed by Alkermes for the treatment of major depression.  I don’t know much about the clinical actions of ALKS 33, (a proprietary molecule), except that it comes from a family of drugs that bind with high affinity and specificity to mu or other opioid receptors.  Samidorphan, a mu receptor antagonist, allows investigation of buprenorphine’s potential therapeutic effects at kappa and delta opioid receptors by blocking effects at the mu receptor.  Drugs with actions at other opioid receptors have be developed, and in some case patented.Until recently, theories about depression revolved around abnormalities in brain monoamine pathways or deficiencies of monoamine neurotransmitters.  Monoamines include serotonin, melatonin, and the catecholamines (noradrenaline, dopamine, and adrenaline). Most modern antidepressants act at serotonin or catecholamine receptors or reuptake sites. The new Alkermes medication ALKS 5461 is the first serious effort that I am aware of to treat depression from the opioid perspective.
Our brains contain natural opioids called endorphins and enkephalins.  Endorphins and enkephalins are neurotransmitters in pathways with a wide range of actions, including blocking pain and raising mood during injury or sexual activity. Pain pills such as oxycodone displace endorphins and hijack the natural endorphin pathways, providing euphoria without the trouble of buying flowers.  Of course, a relationship with self-administered opioids always becomes more destructive than even the most codependent partnership!
As an aside, when I presented for addiction treatment 13 years ago I told the addictionologist about my background in neurochemistry, and went on to explain that I was fairly certain that I suffered from a deficiency of natural opioids.  That doctor got a kick out of my story, and I would enjoy a sense of justification if my hypothesis someday proved to be correct.
When one considers using treating depression with buprenorphine, the obvious deal-breaker is the same issue that has prevented every other serious consideration of treating depression with opioids, namely the development of tolerance at the mu opioid receptor.  Because of tolerance, anyone who finds relief from depression with buprenorphine would be cursed by the need for eventual withdrawal, as well as other consequences of opioid dependence. I assume that Samidorphan is added to ALKS 5461 to prevent mu activation and tolerance.  Beyond partial agonist effects at the mu receptor, buprenorphine antagonizes (blocks) delta and kappa opioid receptors.  These blocking actions are not subject to tolerance, and may provide avenues for treating pain and/or depression.
Depression causes significant morbidity throughout the world, so there are huge profit incentives for new antidepressant medications. Addiction creates a large market as well, but companies rarely go as far out on a limb for addiction products as they do for other diseases. The need for new antidepressants is acute, but in an alternate universe where pain and addiction treatment take priority, Samidorphan and related opioid molecules might have a number of benefits. I’ve posted, for example, about my experience treating severe chronic pain by combining buprenorphine with an opioid agonist.  I expect the combination to be exploited eventually given the need for effective pain treatments, perhaps using an analog of Samidorphan.
Doctors use buprenorphine to treat opioid dependence.  The goal of buprenorphine treatment is to block the cycle of use and reward for some period of time, and to allow patients to create support systems, establish self-sufficiency, regain self-esteem, and practice living ‘life on life’s terms.’  The amount of time that it takes to accomplish these goals likely varies depending on the individual’s premorbid function, life experiences, insight, genetics, and other factors, but studies suggest that a year is not long enough to make meaningful headway.   It is possible that for some people, opioid dependence is a relatively permanent condition that is best controlled with life-long maintenance treatment.   But for those who would like to try to maintain sobriety off buprenorphine, the tapering process reignites the circuits that were set up by the initial addiction, causing cravings, withdrawal, and the constant obsession to delay the taper and resume the prior day’s dose of opioid.
If ALKS 33 has a long half-life and blocks buprenorphine in a dose-dependent manner, I could picture an alternate strategy for stopping buprenorphine where the antagonist (ALKS 33) is introduced to buprenorphine patients at a gradually-increasing dose.  The goal would be to eventually have the person on a daily dose of Samidorphan sufficient to block all of buprenorphine’s effects at the mu receptor, at which point the person could discontinue buprenorphine without withdrawal.  I suspect that the patient would experience withdrawal in response to each increase in dose of Samidorphan, although withdrawal would be reduced by introducing the drug at a measured pace.
What is the value in tapering in such a ‘reversed’ way?  Why would adding an antagonist be preferable to the current process, i.e. simply reducing the dose of buprenorphine over time?  The answer comes from an understanding of the nature of addiction.  A person stopping buprenorphine by gradually adding Samidorphan would face the decision once per day, whether to take the next dose of Samidorphan.  Compare that once-per-day decision to the current method of tapering buprenorphine, where the person must decide, thousands of times per day, to NOT take more buprenorphine.  I would expect that deciding to take an antagonist once per day would be more likely to succeed then CONSTANTLY deciding NOT to take buprenorphine all day long, throughout all of life’s ups and downs—times when the patient was conditioned to take opioids.
We will learn more about Alkermes new medication in coming months. I hope that someone in a power position will consider some of the other diseases that might respond to these interesting chemicals, including opioid dependence.

Withdrawal Work-Up II

First posted 11/11/2012
In my last post, I wrote about the work-up of a patient who experiences symptoms similar to opioid withdrawal that start about an hour after each dose of Suboxone.  We decided that the symptoms were signs of withdrawal—i.e. reduced activity of mu-opioid pathways—and that the symptoms were triggered by taking a daily dose of Suboxone (buprenorphine/naloxone).
Note that I wrote that the symptoms seemed to be caused by reduced mu activity, i.e. not necessarily by reduced mu-receptor binding. Endogenous opioid pathways are very complex.  Decreased activity in opioid pathways may arise from decreased binding of agonist at the receptor, or from changes in a number of other chemical or neuronal pathways.
This diagram shows the processes that are triggered by mu-receptor binding in humans before and after opioid tolerance.  The diagram only shows the complexity of processes within one type of neuron with opioid receptors; realize that each neuron 1. Has receptors for many other neurotransmitters as well, and 2. Receives input from thousands of other neurons.  As we sort through possible causes of our patient’s symptoms, keep in mind the complexity of neural pathways.
While we are on the subject of complexity, the web site linked above is an incredible resource for those interested in biochemistry.  The site includes diagrams of a number of metabolic pathways that describe how different molecules, including neurotransmitters, are manufactured by the human body.  I encourage people to browse the site.  You will gain insight into why the actions of substances are difficult to fully predict.
The withdrawal symptoms experienced by our patient might arise from dysfunction in any one of the many chemical pathways that affect opioid tone. But since a dose of Suboxone contains naloxone, a mu-receptor inverse agonist, it is possible, maybe even likely, that the naloxone is related to symptoms.
Naloxone is less lipid-soluble than buprenorphine and so only a small portion—about 3%– of a dose is absorbed through mucous membranes.  The rest of the naloxone is swallowed, consciously or inadvertently, and eventually absorbed from the small intestine, to pass to the liver via the portal vein.  The entire dose is usually metabolized by the liver before gaining access to the general circulation, a process called ‘first pass metabolism.’  If our patient’s withdrawal symptoms are caused by naloxone, we have to find a way for the naloxone to enter the general circulation, so that it can displace buprenorphine from mu receptors in the brain.
Absorption through oral mucosa is unlikely to vary from one person to the next.  Some molecules become more lipid-soluble in acidic or basic pH environments, but not naloxone.  I suppose that absorption might be increased by removing layers of the oral mucosa by vigorous brushing, but I doubt we could get a significant increase in absorption without considerable painful damage to the oral mucosa.
Likewise, there is little difference in the absorption of molecules by the small intestine in the absence of significant disease processes affecting the GI tract.  Absorption and liver metabolism of some drugs may be changed by surgeries, such as gastric bypass.  But our patient has neither gastro-intestinal disease nor history of surgery to his GI tract.
Naloxone is metabolized by a liver enzyme called UDP-glucuronyl transferase.  The enzyme attaches a molecule called glucuronic acid to naloxone, creating a larger molecule that is easily excreted by the kidneys.  I have been reading up on glucuronidation, suspecting that something may be interfering with that process in our patient to cause an increased blood level of naloxone.  Biochemists are invited to correct me if I am wrong, but from my reading, the glucuronidation process is not limited to specific cytochromes.  Whereas buprenorphine is metabolized by CYP3A4 and CYP2C8, two groups of enzymes that are inhibited by certain medications, the glucuronidation of naloxone is not blocked by other medications.
In layperson’s terms, I suspected that the patient was taking a medication that blocked the breakdown of naloxone at the liver, causing an increased blood level of naloxone that then interfered with buprenorphine activity.  There are a number of medications that block the breakdown of buprenorphine, but none that I could find that block the breakdown of naloxone.  Dead end.
The patient was taking an antihistamine, cetirizine, which is excreted mostly unchanged at the kidneys, but I have not found any evidence that the excretion of cetirizine interferes with the metabolism or excretion of naloxone. Likewise for the Lexapro he was also taking.  Dead end again.
It would have been cool had I discovered a precise explanation for the patient’s symptoms.  Had I found a logical explanation for his symptoms, I would have suggested changes in his medications and submitted the drug interaction to a peer-reviewed journal as a case report.  The patient would feel better, and fame and fortune would be one step closer…
But the true outcome is more instructive, as it is more consistent with what usually happens.  I will explain to the patient that I do not have a good explanation for his symptoms, and whatever we do going forward will be ‘educated guesswork.’    But I hope that after reading this, people will understand that even when we can’t find the answers, it isn’t from lack of trying.  And like other doctors I will continue to read the literature, as our knowledge of med/med interactions, while complex, still has a long way to go.

Withdrawal Symptoms on Suboxone

Originally posted 11/7/2012
I struggle with the length of my posts.   I shoot for 1000 words—an amount of reading that most people can knock off in a typical trip to the bathroom— but I find it difficult to limit posts to that size.  So as I have done in the past, I will break this post into a couple of sections.  In the first, I’ll lay the groundwork for investigating symptoms of withdrawal in a patient taking buprenorphine.   The second post will go into greater detail.
A patient recently contacted me to complain that he was experiencing withdrawal symptoms for several hours after each dose of Suboxone.  I will describe my thought process, in case the description helps someone else experiencing similar symptoms.
My first decision point is whether or not the person is truly experiencing symptoms of withdrawal.  Some people will misinterpret symptoms from excess opioid stimulation as withdrawal symptoms, for example.  Nausea is a not-uncommon complaint among people taking buprenorphine, and patients often assume that nausea is the result of insufficient opioid activity, and so take higher doses of buprenorphine.  But nausea is actually more common in opioid overdose than during opioid withdrawal, along with constipation, whereas withdrawal primarily causes diarrhea.
Pupil diameter is a good indicator of withdrawal vs. overdose; small or ‘pinpoint’ pupils suggest an excess of opioid activity, whereas withdrawal is associated with very large pupil diameter.
Other symptoms are also misinterpreted as withdrawal.  Many opioid addicts develop a strong fear of withdrawal over years of using, and so ‘withdrawal’ is often the first thing to come to mind, during unpleasant symptoms.  I also believe that the experience of withdrawal becomes learned in a way that allows the symptoms to re-occur after certain triggers.  I remember an experience years ago, when I awoke from a dream experiencing significant withdrawal symptoms, even though I had not taken an opioid agent for years.  I feel back asleep, and was grateful to find that the symptoms were gone, when I woke the second time.
People are angered by the notion that their symptoms have ‘psychological’ origins. But as a psychiatrist, I have seen people blinded or paralyzed by conversion disorder.  If the mind can cause paralysis (and it can), I have little doubt that the mind can cause other physical symptoms.
If, after these considerations, the symptoms seem consistent with symptoms of opioid withdrawal, the next step is to compare the timing of the symptoms with what would be expected from various causes.  For example, withdrawal symptoms occurring shortly before the next dose of buprenorphine (or Suboxone) suggest that the dose is not quite high enough.  Buprenorphine eliminates cravings if kept at a blood level above that necessary to maximally occupy mu opioid receptors, because then fluctuations in blood level have no effect on opioid activity.  But if the blood level of buprenorphine decreases below that threshold, cravings and/or withdrawal symptoms will occur.
If the symptoms occur shortly before dosing, the solution would be to increase the daily dosage of buprenorphine, decrease the dosing interval, or increase the efficiency of dosing.  I have discussed ways to increase dosing efficiency here.
This particular patient describes symptoms of withdrawal beginning about an hour after taking Suboxone.  Absorption of buprenorphine takes 1-2 hours, and so the timing could suggest that the dose needs to be increased.  But if dosage is truly the problem, we would expect even worse symptoms if he delays his daily dose by several hours—as that would allow the blood level of buprenorphine to fall even further.  But in this person’s case, delaying the dose of Suboxone delays the withdrawal symptoms.  The symptoms continue to occur about an hour after taking the medication, suggesting that the dosing itself is causing the symptoms.
I cannot imagine a scenario where a sublingual dose of buprenorphine would cause true symptoms of withdrawal, an hour after the dose.  At this point we need to look at the naloxone component of the medication, and determine whether the naloxone is causing unpleasant symptoms— and if so, why.
To be continued…

Withdrawal from Suboxone or Buprenorphine

I received a question from a reader about withdrawal symptoms from stopping buprenorphine. My answer has relevance to opioid withdrawal in general, and to a common misconception about the duration of withdrawal symptoms.
The message:
Basically I quit Suboxone about 18 days ago. When I decided to quit I was taking about 8 to 12mgs per day. I got into taking Suboxone from trying to quit a Percocet habit that developed after a car wreck. I was stuck on Suboxone for near 3 years before I finally realized the person I thought I was really wasn’t the person I expected myself to become. So I decided I had enough and quitting Suboxone should be easier than quitting Percocet. I still laugh over that because I should have educated myself better before I landed myself where I am now. I am starting to feel marginally better but I have zero energy and my depression is off the charts. . . My question is because Suboxone has such a strong half-life being a partial instead of full agonist, how many more days weeks months do I have to suffer through before I can expect to return to normal? I am terrified of relapsing and have set a zero tolerance for myself. Hopefully I am strong enough and smart enough to stay away but is there anything extra I can do to help ease anxiety and the depression? Honestly I feel like I live in a personal hell no one gets or understands. I was just hoping u could give me some advice. Thanks for reading my message.
My answer:
There are many misconceptions about withdrawal and buprenorphine. Many people make the mistake of thinking that the long half-life of Suboxone lengthens withdrawal. The long half-life of buprenorphine reduces the intensity of withdrawal, but has a very minor effect on the duration of withdrawal symptoms.
Before going there, though, I’ll comment about where you are, and where you came from. I admit to feeling a bit annoyed when people write about being ‘stuck on Suboxone.’ I’m not sure why it bothers me as much as it does; I don’t receive kickbacks from Reckitt Benckiser, and I certainly had no part in inventing Suboxone. If I put words on my annoyance, it would be something about looking a gift horse in the mouth—a saying that nobody seems to say anymore.
Suboxone didn’t cause your problems; YOU caused your problems, or perhaps Percocet did. Suboxone bailed you out; it allowed you to live to fight another day, rather than go down the tubes and end up in prison or dead, from oxycodone addiction. People often write the same thing— about being stuck– on my forum, and I have the same reaction there. It seems to be so unappreciative or irresponsible, to blame the very thing that kept you alive.
For the people who write ‘I should have just stopped oxycodone without taking Suboxone’, I point out that it is clearly easier to stop Suboxone than oxycodone. How do I know? I know because we are having a discussion about tapering Suboxone! Nobody addicted to opioids tapers off oxycodone (everyone tries, but nobody is successful). At least SOME people CAN taper off Suboxone. Don’t believe me? Think it would have been easier to taper off oxycodone? Then you can just change to oxycodone and get on with the taper! NOTE—I do NOT recommend doing so; oxycodone is MUCH more addictive than buprenorphine, and much more likely to kill you!
The other reason the attitude bothers me is because after treating people addicted to opioids for the past 7 years, I’ve watched so many people from utter despair to stabilized on Suboxone, and then become convinced that they aren’t ‘clean enough’ on Suboxone. I’ve watched them taper off, and I’ve seen their obituaries a few years later, or received desperate emails describing the loss of a 70 K per year job because of a recent felony conviction. Meanwhile I have a number of patients who are content to treat their addiction for years, as their lives get far better than they ever dreamed.
For those still reading, I’ll explain why half-life is not a big contributor to the duration of withdrawal. If we took any person on any opiate, then suddenly and completely removed the opiate from the body, the brain pathways that are stimulated by opiates (the endorphin pathways) would suddenly become quiet. As those pathways stop firing, the person feels horrible. After all, the pathways help keep everyday-sensations from being painful and help elevate mood, so the opposite happens when they stop.
As the person used higher and higher doses of opioids over time, tolerance developed at the receptor level. In essence, the receptor for opioids became less sensitive to ALL opioids. Receptors that are not sensitive to oxycodone, are also not sensitive to hydrocodone, and not sensitive to the brain’s own opioids—endorphins. In a withdrawing person, there is little or no activity in opioid pathways because the receptors, where endorphins usually act, are no longer responding to endorphins.
In order for withdrawal to end, the body must make NEW receptors, and implant the receptors in the cell membrane. That takes weeks to occur. The process is initiated by withdrawal itself. When the neurons in endorphin pathways are not firing at their normal rate, the neurons respond to that lack of firing by turning on the machinery involved in making new receptors. In other words, the pain of withdrawal MUST occur, if receptor renewal is to be triggered.
The duration of withdrawal is a function of how long the body takes to make new receptors– NOT the amount of time to clear the body of the substance. Some people mistakenly think that withdrawal ends when the drug is gone– and that it is ‘stuck in the bones’ or things like that. All of that makes interesting reading, but it is not what is going on. It takes 8-12 weeks for the body to make new receptors, so that is how long opiate withdrawal usually lasts.
Suboxone DOES have a long half-life. That long half-life causes the initial withdrawal to be less severe because instead of turning off instantly, the opioid pathways become less and less active over days. So instead of the sudden onset of severe symptoms, the misery takes several days to peak. This may result in the entire process lasting an extra day or two, but that extra time is not relevant compared to the weeks that it takes to generate new receptors.
I imagine that people get different impressions of withdrawal because of the different patterns of misery from different opioids. When I came off fentanyl, I was very, very sick for the first few days. I could not walk, literally, and my systolic blood pressure never got above 90. A week later, I could walk, and so things seemed a lot better. But I still got winded after 20 feet, and I couldn’t eat for many weeks. I lost 30 pounds in the process, and I was skinny to start! Buprenorphine withdrawal starts more slowly, but then ramps up higher after a few days, and then slowly goes down. I see people come off all sorts of opioids; the pattern of misery varies, but the total misery is about the same in each case.
Specific to the writer, one should anticipate 2-3 months of fatigue and loss of appetite after stopping buprenorphine, similar to other opioids. The first few days are a bit less severe with buprenorphine than with, say, oxycodone, because the drug is leaving the body more gradually.
A final comment—I worry whenever I read that a person’s strategy for staying sober involves being ‘smart’ or ‘strong’. The only way I know to stop opioids is by coming to the full realization of one’s powerlessness over them, as in the first step of AA/NA. Being too strong or smart only gets in the way of that realization. In my opinion fear is the best approach, as in ‘if I try, even once, I will die— and it will ALWAYS be that way.’
I wish you well,
J

Withdrawal from Suboxone

I often receive e-mails asking for advice on tapering Suboxone, or asking how long Suboxone withdrawal should last.  People who read my blog know my approach to stopping Suboxone; I see it as an exercise in futility even in the rare cases where the person is successful, because of a relapse rate that verges on 100%.
A couple myths to get out of the way… there is NO evidence that withdrawal becomes more difficult the longer a person is on buprenorphine.  In fact, from my experience the opposite is true.  The feelings and emotions during withdrawal are aggravated by the guilt and shame of active using, and the further from active using a person gets, the less the suffering during withdrawal—and the better able the person is to keep some perspective on what is happening, rather than drowning in despair.  I believe that the severity of withdrawal is subject to a ‘kindling effect’, a phenomenon that affects seizure disorders and other neural activity as well.  In other words, the pathways of the brain that are used the most frequently are the pathways that are most likely to fire again.  So a person who has been through very severe withdrawal is likely to experience withdrawal as very severe, no matter what agent the person is stopping.  It would make sense that the more time that goes by in between episodes of withdrawal, the less powerful would be the kindling effect—sort of like ruts in a muddy road being erased by repeated cycles of weather over time.
Many people write on blogs or forums that Suboxone withdrawal is worse than coming off opioid agonists.  This is simply ‘poppycock!’  I have seen many, many people go through opioid withdrawal, and have experienced it myself (gratefully, many years ago!).  People going through withdrawal from agonists are very miserable; they tend to stay in bed, getting up only to race to the bathroom because of severe diarrhea.  Their legs shake involuntarily—a very uncomfortable experience that is similar to severe ‘restless legs.’  The mental effects are perhaps the worst; most people have severe depression and thoughts of suicide.  Eventually, when the person attempts to get out of bed, he/she faces weeks of profound fatigue and weakness.  During my own detox ten years ago I remember my family visiting after a week or two, and being able to walk about half a block before needing to sit and catch my breath.  Appetite is gone for weeks as well, and most people lose significant weight during detox.
Withdrawal from buprenorphine, on the other hand, rarely forces addicts into bed for more than a day or two.  I’m not saying that they don’t FEEL like staying in bed, but they will still usually get to work and engage in the activities of daily living—eating, showering, getting dressed, etc.  A simple look at the forums shows a profound difference between Suboxone and agonist withdrawal; people coming off Suboxone write about how bad they are feeling, whereas people coming off agonists are nowhere to be found— and are certainly not able to sit at the computer and type!
There are two basic approaches to stopping Suboxone.  One is to taper slowly, and the other is to just ‘jump’ and handle the withdrawal as best as possible, sometimes with the help of clonidine, benzos, or other substances.  Some people find that THC helps, but I can’t really recommend that approach—at least not in states where there are no laws allowing the use of ‘medical marijuana.’  There are a couple taper methods described here and there on the web; I described something called the ‘liquid taper method’ on the forum that uses tiny doses of dissolved buprenorphine, administered by an eye dropper.  As I mentioned in an earlier post there is a new transdermal buprenorphine system hitting the market soon, and that should make things considerably easier.  The main problem with any taper is that the person usually gets to a certain point and then realizes that a full dose would cause a ‘buzz’—and that buzz is almost impossible to say ‘no’ to, especially after being in minor withdrawal for several days or weeks!  The transdermal approach is appealing because it would allow the person to get rid of all tablets that could be used to bail out of the taper.  I can’t imagine that there is much chance of success if the person has 8 mg of tablets stashed away in the house somewhere!
Because of the tendency to bail out of a taper, most people who start out tapering end up ‘jumping’ at some point—raising the question of whether people should just jump from the start, planning to be miserable for a good few weeks, and then just tolerating it.  For those taking that approach, the main thing is to STICK WITH IT.  In order for your receptors to return to normal, you MUST be miserable— that misery is what causes the neurons to manufacture new receptors.  If you take a break from the misery by using for a day, you turn off the forces that are moving you toward feeling better, delaying the process by days to weeks.  To be direct, the quickest way to stop Suboxone and get back to zero opioid tolerance is to avoid opioids completely until you feel better.
Again, in my opinion, all of this is folly because the chance of staying clean is low. At minimum, a person must be completely free of any contacts who are using or who have access to opioids.  The person should be actively involved in some time of recovery program.  The person should have someone in his or her life who can act as a ‘reality check’ to speak up if the person starts to harbor resentments, or if the ego begins to grow out of control.  If you don’t have these things at a minimum, consider just sticking on buprenorphine.  You will save yourself a great deal of money, time, embarrassment, and who knows what else.
If you do stop buprenorphine, expect withdrawal to peak at about 4-7 days after you finally discontinue taking Suboxone, followed by slow recovery that accelerates each week.  By four weeks, you will be done with the creepy crawly legs, and your energy will be starting to return.  By two months, your sleep should be coming back—unless you are also stuck on benzos, which make sleep a big problem if you use them for more than very short-term.
By three months, you should be back to normal—assuming that you did not use opioids at all.  And you will recover fastest if you get some exercise, eat right, and stay as active as possible, even when you don’t feel like it!

My ebook guide to Buprenorphine/Suboxone

I have talked about the book I am working on– I decided at some point to come out with two things. I receive so many questions about Suboxone– apparently many doctors don’t come up with suggestions for dealing with surgery, pain, etc. So I have produced an e-book that describes my approach to dealing with all of the little things that can become big things without proper guidance. The e-book is called ‘A User’s Guide to Suboxone’, and can be downloaded for $9.95 using the links below.
This book is all very practical– not theory.  It discusses how I handle planned vs emergency surgery, pregnancy, inductions from high tolerances, tapering…  I don’t want people to use this as the final say, but rather to use the information to spark conversation with their physician.
The other book is still a ways away, and is more like 300 pages long– it contains a number of theoretical discussions about Suboxone, including a great deal of info from my blog that has been cleaned up and organized better.
I hope you like what I have produced;  The guide contains the topics that people ask about the most when they send me e-mails.  As always, thank you for placing your trust in my opinions.  If there are topics not covered in this handbook that you would like to see covered, please leave a comment with your suggestions.
Thanks!
JJ
Again, the e-book is my ‘User’s Guide to Suboxone’, and the cost is $9.95.  After purchase you are immediately taken to a page with a download link, and also e-mailed the link.  There is a 4-letter code sent at the same time that is needed to open the e-book.

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User's Guide to Suboxone
User's Guide to Suboxone

How Long to Take That Stuff?

I ended the ‘85% off’ sale of the recordings listed to the right of the blog;  they are also listed at the web page ‘Sober After Suboxone,’ along with some other useful recordings about opiate dependence.  I have received good feedback about the recordings, and I think that the ‘how long’ one is the most useful for the people reading this blog;  people at other stages of opiate dependence may find other recordings more useful, such as the one that discusses opiate dependence treatment options.  The treatment options are NOT just a list of the different options available;  they are a list of the options from the perspective of someone (i.e. me) who has dealt with my own opiate addiction for 16 years.  They take into consideration the fact that few people will commit to residential treatment, and more importantly they take into account the relapsing nature of opiate dependence in SPITE of residential treatment options.
The ‘how long are you going to take that stuff’ recording is for the people who are always on your case about Suboxone– the people who think you are still getting high, or the people who say you have ‘substituted one addiction for another’ (you haven’t, by the way).   I take on these and other issues, such as the fantasy about being ‘clean of all substances’ that comes from NA programs from time to time.  I haven’t fully decided on the title of the book I am almost done with, but I like ‘dying to be clean’, as it captures the folly of going off life-sustaining medication to chase after a shame-based goal to be ‘completely clean.’  For parents who keep harping on their children to stop Suboxone, will you feel better when your son or daughter has died from an overdose while trying to avoid the Suboxone that would have kept him or her alive?  DROP THE IDEA OF BEING OFF EVERYTHING.   Opiate dependence is a horribly fatal illness;  if Suboxone is working, count your blessings and appreciate life.  Finally, addiction is not the ‘use’, it is the ‘obsession’.  Suboxone is unique among opiates in that it addresses the obsession.  THAT is what gives you your son or daughter back.
As I said I stopped the 85% off sale, but I did keep a 50% off sale– not actually a sale, but more a permanent 50% price reduction.  I hope you will continue to use the recording, either to arm yourself with knowledge or to share the information with others.
As I have said before, consider the $10 purchase as a donation to the cause.  I really appreciate those of you who have already purchased one or several of the recordings.
Thanks!

Hard Knocks, Talwin, Tapering: Q and A from SuboxForum.com

A new feature on SuboxForum.com is the ‘Q and A,’ where I select a question to answer in detail.  I will post my answer here as well.  I won’t post the original question, but it is embedded in my response so I think everyone will figure it out!

There are really a number of questions in your post, so I will do my usual thing and answer them as we go through the message. As always, these are my opinions; consult your own doctor before changing anything about your dosing or medication.

The message/my responses:

Thanks. I feel obligated to pay, and will–but I’d rather pay when the time is right for me to go thru w/d off subs. My problems are more than just getting off this suboxone. I now know I need to be in better stable frame of mind to go through this—everything I read on the blogs says be prepared to go thru this weaning.

Donations are appreciated and helpful, but don’t feel obligated, please. If someone is comfortable helping to support my time here and the site in general, please consider a donation. If you are going through hard times, take care and don’t sweat it! Two comments though: First, as you know my ‘big thing’ is recommending people STAY on Suboxone. Yes, it is expensive—but not NEAR as expensive as using, even if things go well. Throw in unexpected consequences like an arrest and the costs really go up! But my second comment is to agree with you. If you want to taper off Suboxone, you need to start at a time when things are great—because the process takes a lot out of you.

Talwin made my chest tight and my legs felt weird. And I went into full W/D by the 3rd day off suboxone. It was last Sat so I called the after-hrs nurse and told her what happened. She contacted the Dr who had my RX avail within the hour. I was fine within minutes of taking 4mg. But I had a really hard time getting back on any dosing schedule all this last week. Is this psychosomatic or something? I mean relief was immediate.

It usually takes a few days for withdrawal from buprenorphine to become severe, due to the long half-life of the drug. Relief from resuming buprenorphine usually isn’t immediate, so some of the relief may have been psychologically based. The uptake starts at about 20 minutes and is pretty much complete at 90 minutes. I remember your other letter—you were recommended Talwin, of all things, to taper off Suboxone. That was poor advice. Talwin doesn’t even bind to mu receptors, which are the receptors that buprenorphine works through. Talwin contains naloxone and pentazocine, the latter is a kappa and sigma agonist, and we all know what naloxone does! The naloxone in Talwin would if anything make you more sick during your withdrawal; pentazocine is a nasty drug that has been abused in years gone by (combined with Ritalin, for example) and that can cause seizures, hallucinations, and other dysphoric states. I do not recommend using Talwin to taper off Suboxone.

I read so many horror stories online about others who quit at 2mg who suffered for months. When I first went on suboxone I was miserable and unable to function for at least 3full weeks–out of work a whole month. My Dr says that shouldn’t be. Well be or not it was. My back was killing me–all I could do was lay around on the couch and try to get up and move as much as possible–the terrible loss of clear vision/runny eyes and dilated pupils, goose bumps, achy all over–the only help the suboxone was fast on was the desire to take more Vicodin and the diarrhea stopped.

You don’t mention the dose of opioids that you were taking at the time that you started Suboxone. What you describe sounds like ‘precipitated withdrawal’—if your total daily dose of opiates was greater than 30 mg of methadone, or 50 mg of oxycodone, or 70-80 mg of hydrocodone, then I would expect you to feel sick when starting Suboxone—unless you went a few days without any opioids and got your tolerance down a bit.

If you say it shouldn’t take too long to wean off, then why are so many people having such a hard time and taking so long with so much misery to get off either the opioids or the suboxone? I got a taste of suboxone w/d last week and it was not pretty.

Opioid withdrawal stinks! No doubt about it. I am well aware of the complaints about Suboxone withdrawal, but I have witnessed withdrawal from buprenorphine and from agonists many times (and experienced it as well!) and I know the truth of the matter—that there is no comparison. Methadone withdrawal always lasts for months—always! Fentanyl, oxycodone, and heroin withdrawal are violent—legs kicking, diarrhea and nausea, extreme weakness… I often say that the reason you read about how bad Suboxone withdrawal is, is because those people 1. Can go off Suboxone, and 2. Can still function enough to write on the internet. Neither is the case with agonists– people cannot taper off, and if they are forced off they are not able to type messages about how they are feeling! I have argued this point with the people who post ‘Suboxone w/d is the worst ever’, and they insist they are correct. All I can say is that I have seen both many times. I do notice one thing to explain the discrepancy: people ALWAYS think that their current is their worst misery. Pain experienced is worse than pain remembered.

Is it really true that .5mg suboxone is as potent as 30mg hydrocodone or 10-20mg methadone?

The kinetics are not ‘linear’. So if taken in an optimal manner, 2 mg of buprenorphine is as potent as 4, 8, 12, 16, or 32 mg of buprenorphine. They all are at the ‘ceiling’ potency, and all are equal to about 30 mg of methadone, 50 mg of oxycodone, or 70 mg of hydrocodone. Your numbers are about right.

Have I been taking huge amts of narcotics (albeit diff than full receptor opioids) for 2years now? I read up on suboxone when I started, but then haven’t paid any attention since then—too much else going on. Now I’m freaked about going off of em if they really are equivalent to pretty high doses of opioids.

Again, you do not say what you were on before the buprenorphine. But yes, to some extent you are correct in your statement. I wouldn’t say ‘huge’ doses, but I would agree with ‘high’ doses. To put things into perspective, methadone clinics officially shoot to have addicts on at least 60 mg, but usually have them at 100 mg or more. Most oxy addicts I see take two 80’s per day or more— 160 mg of oxycodone at a minimum. The largest dose I have seen taken by an addict was 700 mg of oxycodone per day—she had inherited $300,000 and it was all gone after one year. So in comparison, 30 methadone-equivalents of a partial agonist is not ‘huge’, but it does represent significant opiate activity.

I now know I have to wean to less than 2mg a day to go off this stuff, and I am planning to set aside 3weeks from work to go through this. You say the worse thing to do is lay on the couch–keep moving. I’ll do whatever I can to make it better, but I cant go through last week again until I have time off from my frantic life! And my frantic life —no real sleep for 15months..isnt going to end until I get out from under my financial mess. So I will plan a good 3weeks minimum to get over this stuff.
And now I read about others that are weaning way way back to tiny slivers of subox to quit and still going through hell when they finally do.

Three weeks is not enough. But that is not the fault of Suboxone; three weeks isn’t enough to get off any opiate! I mean, REALLY! Look what you, and other people, are asking for! You haven’t mentioned what you took but some people will use for ten years… then go on a year or two of Suboxone, and if everything isn’t perfect in three weeks—THREE WEEKS!!!—they complain about Suboxone?! Talk about expecting miracles! Talk about expecting an easy way out!! My active using lasted several months—that was it!! I was in detox, sick as sh…, then in residential treatment… for 14 weeks!! I then was in aftercare for 6 years, going to AA several times per week, PLUS group therapy twice per week. And while I treated my addiction aggressively, there were and are many, many people who treat it as aggressively or more! In the place where I am medical director, we send many people to a year of living in a sober community—a halfway house, essentially—and that is AFTER six weeks in residential treatment and three months in a halfway house. And that amount of treatment, in my opinion, is a bit light!

I have to repeat this because people don’t seem to get it. I used for several months– Adding 1993 and the 2001 relapse together, my total opiate use was less than one year! And my treatment was 14 weeks in residential AFTER detox, then six more years of meetings and group therapy—THAT is how you get clean before the world of Suboxone!!

As for the ‘tiny slivers’… read about ‘micrograms’ on my blog so I don’t have to repeat it. Two mg is way to high to ‘jump’ from. The withdrawal from quitting two mg is about the same as the withdrawal from 16 mg, for reasons I mentioned above. One person on the forum is in the process of tapering down to the low micrograms and writing about it—he uses a technique I have written about (but that I didn’t invent—it was sent to me by a reader) where the buprenorphine is dissolved and taken with an eyedropper.

Do you not see that these people that are going through pure misery to get off of this stuff?

Yes—and I’m sorry, but I consider those people fools. Their lives were saved once—they might not be so lucky the next time. And for the vast majority, there WILL be a next time. That is just the fact of the matter. They all have the same fantasy—a fantasy I once shared—of being ‘normal’ again. It ain’t happenin’, folks. I’m sorry to break it to you. All the misery you are going through tapering off Suboxone… some day in a few years you will be saying to yourselves, ‘why the heck did I stop that med, when everything was going so well?!’

I found one plan that says to cut back 25pct for 4days and if no problems keep cutting back till it’s over. If I dont make it, take a sliver to stop the w/d then start that 4days over. I saw you have 2 tapes explaining your “tried and true” method to detox from subs…
I will order your tapes when I’m ready to go off the subs. ( I have 6weeks off starting Sept 1 this year)
.

My tapes aren’t magic, and the method isn’t ‘tried and true’. I don’t say that. I wouldn’t say that. It is very hard to taper off any opiate, INCLUDING SUBOXONE. My tapes describe what I have seen to work the best. I provide all of the same info as on the tapes in the blog itself—so if you have read through the blog, don’t worry about buying the tapes. I do try to give some extra motivational stuff, but the techniques, the meds, the ‘how to tell when you are ready’… I’m sure I have covered it in the blog itself by now. But if you want to save some time and provide me some support at the same time, by all means purchase a tape, with my thanks.

Right now I am facing extreme pressure having to sell my home and everything I own and quit my job of 31yrs and move back home to Iowa to live with my mom. I’m 54yrs old and have lost everything–even my credit. All cuz of a steady stream of bad luck (dont blame the drugs–I wasn’t on them till I was recovering from my last accident) It’s very humiliating and disheartening to work so hard and so long and then nothing worked out and I have to start over at my age.

I’m sorry for what you have been through. All the more reason, in my opinion, to keep the Suboxone going if you can get it paid for. Look into Medicaid. Ask the doc if his patent assistance plan is full (every doc gets a couple spots). You don’t need any more problems right now, so KEEP YOUR ADDICTION TREATED.
You got your pictures in the paper for being a hero (cool eh)…

Thanks for noticing—the high point in my life for sure. Posted on my site at wisconsinopiates.com.

I got mine in for bad luck (I just moved into a home I built myself and the next month it flooded–the local County bought it and tore it down-top story on local TV showing them bulldoze all my hard work down in about 8min. –then a frikkin tornado hit down and only damaged two homes–my two rental houses that are next to each other–the paper reported it as a freak tornado–we don’t have tornadoes in WA.) Then the injury accidents –fell off a rental house roof–then fell down a spiral staircase, then got rear-ended by a huge Ford Econoline that lost his breaks..Then fell fixing an awning on my new home up on a hill away from flooding rivers. But I got over it…I was doing great–my shoulder and neck surgeries were healing very well ….went on my first vacation in a long time and my brand new car hit a soft spot on a dirt road (the Idaho Sheriff called it a freak accident) and my car plummeted down a steep cliff and crashed into a tree that saved me from drowning in the river below—still got over that –but 9mo out of work forced me to refinance my home to a subprime because I was financially strapped being on a medical leave without pay—but I was determined to get back to work–I paid extra loan origination points to buy down this awful loan to 1year-no prepay penalties–and I worked very hard to have good credit so I’d refinance into a nice 30yr fixed in a year. But a year later I had no house to refinance.

A freak windstorm knocked a tree down and totaled my home on the hill.–I’ve have to live in hotels, rentals, my RV and now back in the home that insurance finally fixed–I couldn’t refinance after my 1yr because the contractors were jerks and went on vacation and left my house with nothing but a few walls left (it was a total rebuild)…no bank will refinance if an appraiser can’t find a house to appraise. By the time I finally had a house again, and was signing the last page on my refinance loan 4months later— it was too late–the bottom had fallen out on the real estate market—even my good credit didn’t matter—no refinance—no one was loaning. That was 15months ago. I haven’t had a good night’s sleep since then. I work full time and still have to drum up double what I make every month to pay that subprime mortgage loan each month. It is killing me. And of course just when I really need my roommate (male companion) to come through for me and pay more than his pathetic tiny amount each month…he has no work and no money at all) The only way out is to sell. And the contractors screwed up and left a zillion things that weren’t done so I have had to do that too. Plus sell everything of value I owned. I’ve been to every counseling service looking for help and there is no one out there who can help me save the home…..all the same advice–dump the deadbeat guy and sell the house. So I am.
I tell you this cuz I’m angry everyone thinks all those people who took out subprime loans were greedy and bought more than they can pay for and now we’ve ruined it for everyone else. I’m angry there is no help out there for someone like me who has worked my whole life and now my credit is ruined (can’t pay hardly anything except that huge mortgage–I pay more than a house that’s for rent right now near Bill Gates mansion on Lake Washington–it rents for 2950.00mo….my mortgage is 3400.00 mo! for a tiny 2b 1ba 1150sq ft house) So tell everyone there are some that took those crappy loans for a short term catastrophic event and worked VERY hard to have great credit to get out of the loan–but couldn’t because of bad misfortune, not greed.

You just told them yourself. Gosh, I’m sorry. You have had a horrible series of events. But you are here, and you are a survivor, and for that I give you a great deal of credit. It sounds like time to just live each day, and to do your best to avoid looking too far forward. And remember—once things are gone, there is nothing they can take from you anymore. I know it hurts, but try to avoid feeling like a bad or evil or worthless person. You have done great things to last through all of this—that is your heroic record.

Then what…My sister got cancer, my dad died, a coyote got my cat that was the love of my recent life.
I GIVE UP. I’M GOING HOME to my mom in Iowa. She’s all alone now, and I need to quit whining about myself and help her so I feel useful in this life I have. My last day at my airline job is 31Aug09. I need to be off this suboxone no later than November. I hope to use the first part of Sept to get over it. I hope your tapes show a way that is painless—if my house does sell I have no idea where I’ll be in the interim before moving to Iowa.

Why do you have to stop the Suboxone? Pretty much all of my patients have jobs, and many get drug tested—it hasn’t shown up yet. If it does, tell them the truth—that you are taking it for chronic pain because it doesn’t ‘mess up your thinking’ like ‘REAL’ pain pills do.

There is NO painless way to withdraw in a few weeks. My tapes recommend reducing very, very slowly over a number of months, to a very low, microgram dose.

Sorry for the ramblins…if you dont read it that’s ok…it’s just another hard-knock story.

You only asked about Talwin..it SUCKS===dont recommend it. That’s probably why it’s hard to find at most pharmacies–no one uses it. I can’t go thru any w/d right now–I just finished the interior floors in my house–it’s almost ready to sell–took me 15months to do all the stuff that didnt get done by contractors–so I HAVE TO FOCUS on selling this place now.
What do I want—I will get your tape for w/d from suboxone. And I need to learn to let go of anger, regret and fear. Easier said than done. Do I use positive repetition to retrain my thoughts to quit worrying so much?

That would be ‘CBT’, and another long process. For now, you take one day at a time and do a daily inventory at the end of each day, reflecting on the good things you have done and giving yourself some credit. If you REALLY need to be off Suboxone by September, the time to start weaning is now—but you do it so slowly that the w/d is very small. Ten percent reduction every couple weeks.

I truly wish you the best. I will send you a link to download the tapes without charge; maybe that will be the start of your luck turning around.