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.

BuTrans– Transdermal Buprenorphine

I am the ‘expert’ on a couple forums at MedHelp.org, including the forum for chronic pain;  tonight I was answering a couple posts and came across the name of a medication I was not familiar with: Butrans, by Napp Pharmaceuticals.  After looking up the medication I learned that BuTrans is a 7-day buprenorphine patch manufactured in the U.K. that comes in doses ranging from 5 to 20 micrograms per hour.  I have mentioned in other posts that what is really needed to taper off Suboxone is a lower-strength form of the medication;  buprenorphine is just so potent that when people taper down to a quarter of a tablet they are still taking 2000 micrograms of buprenorphine– which is a significant dose.  The potency of buprenorphine is clear when one realizes that BuTrans is considered a potent analgesic, even though the low-potency patch releases only 5 micrograms– MICROgrams– per hour.  That comes to about 100 micrograms per day, and if we assume similar absorption for skin and mucous membranes that would equal a dose of buprenorphine less than 1/10th of the smallest ‘chip’ of Suboxone a person could reasonably use.
In other words, BuTrans would offer a much-needed low-dose application of buprenorphine;  it comes in several doses and would be an excellent way to taper down in the lower dose range of the medication.  For people who have not read my earlier posts on the potency of buprenorphine, one reason people become so frustrated when trying to discontinue Suboxone is because of the high potency and ceiling effect;  tapering down to 2 mg of Suboxone is relatively easy, and then people tend to simply stop taking it– but they are still taking a dose of buprenorphine that has a high opiate potency– virtually as high as the dose they originally started with before the taper began!  So they are expecting the very last bit of going off Suboxone but instead they are hit with significant withdrawal, equal to the withdrawal from stopping 30 mg of methadone.  That is why I have recommended that people think in terms of MICROgrams instead of MILLIgrams– a quarter tab of Suboxone being 2000 micrograms.  The 5 microgram/hr BuTrans patch is a good illustrator of the medication’s potency.
Unfortunately, to my knowledge there is no way to prescribe BuTrans in the United States– for now, anyway.  My hope is that eventually options such as, or similar to, BuTrans, Temgesic, and other buprenorphine formulations will eventually be available.
SD

Stopping Suboxone– A Bit More Information about a POTENT Drug

I received some feedback after writing about tapering Suboxone here and on my site Sober after Suboxone (soberaftersub.com), and I would like to share the information and suggest a new way to think about buprenorphine during the tapering process.
First… it has already become clear to me that Zofran, or odantreson, is not the big answer for opiate withdrawal that everyone is hoping for.  Oh well…  maybe some day.  As I have said a number of times, some day there will be a medication that prevents tolerance, and I would expect such a medication to affect withdrawal as well, as the two processes are closely related.  On the other hand it is possible that such a medication would actually prolong withdrawal, by preventing the plasticity required for the receptors to return to normal.
The other thing… buprenorphine is a very potent drug.  This is the essential problem when tapering Suboxone;  there is not a low-dose formulation available to taper in the lower dose ranges.  The best way to understand the problem is to realize that buprenorphine is a ‘microgram’ medication– not a ‘milligram’ medication like oxycodone.  When I worked as an anesthesiologist I would give a woman in labor 50 micrograms of buprenorphine intravenously– or 0.05 mg.   Buprenorphine taken orally (trans-mucosally) has a ‘ceiling’ potency at a dose of 2 mg or 2000 micrograms.  If you are taking a quarter of an 8-mg tablet, you are still at the maximum effective dose of buprenorphine!! Whether taking16 mg, 32 mg, or 2 mg of buprenorphine, your tolerance is very high; as high as it would be if you were taking 30 mg of methadone per day.
The standard way to taper a long-acting opiate like methadone is to reduce the dose by 10 % every month.  So if you wanted to do things that way that reduces the amount of withdrawal, you would go from 2 mg or 2000 micrograms of buprenorphine once per day to 1.8 mg (1800 micrograms) per day, and then a month later change to about 1.6 mg (1600 micrograms) per day.  Note that the reduction amount does not stay constant;  each month the dose is reduced by 10 % of the current dose.  So after about 4 months you will be at 1 mg per day, and from there you would reduce to 900 micrograms per day.  The problem?  This 900 micrograms would be 9/10ths of an eighth of a Suboxone tablet!  How do you measure THAT out every morning?


Things get worse;  remember that buprenorphine is very potent. You don’t want to ‘jump’ from that 900 microgram dose, as it is still represents significant opiate tolerance and will result in significant withdrawal.  So you keep tapering… down to 500 micrograms per day… keep going down each month, past 100 micrograms, eventually to 50 micrograms and lower.  Ten micrograms of Suboxone would still have some opiate potency;  this would equal 1/800th of an 8 mg tablet!  Beyond the logistics of working with such small pieces of Suboxone it should be obvious that tapering off Suboxone is best considered a long-term process.
I am going to see what is available in other formulations of buprenorphine and look into the legalities of dispensing buprenorphine from the office.  I should mention that I do not have something like that now, and that any medications in our office are kept in a safe, and that we have security measures that include lethal and non-lethal deterrents, video recording devices… I go a bit overboard with security measures, as I am aware of the motivational power that withdrawal has on some people to do horrible things they would not otherwise do.  When I worked in the prisons I met a number of people who were average students, wives, dads, or moms, before finding opiates and eventually forging checks– or holding up pharmacies using a finger in a paper bag, not realizing that threatening a gun is as bad as having a gun from the law’s perspective.  Nothing like 5 years in prison to help one find a ‘rock bottom’!
One more important point that will help you undertand the withdrawal from opiate medications… the body generally reacts to change in a ‘logarithmic’ fashion, not in a ‘linear’ fashion.  And when responding to change, the relative amount of the change is a more accurate predictor of symptoms than is an absolute value.  To explain my point using opiate effects, the withdrawal experienced by a person is probably similar when changing his daily dose of methadone from 300 mg per day to 100 mg per day– a change of 200 mg–  to the withdrawal experienced when changing from 30 mg to 10 mg — a change of 20 mg.  So at the end of your taper off buprenorphine, even though the numbers of milligrams or even micrograms seem tiny, and you are taking a piece of Suboxone the size of a speck of dust for your daily dose, you may still have a bit of withdrawal when you stop!
Finally, yesterday I had my third patient who stopped Suboxone abruptly and had no withdrawal.  She was taking 16 mg per day–correctly– when her parole was revoked, forcing her into jail where she had to stop Suboxone without any taper.  Like two other patients of mine, she claims she had no withdrawal!  I do not know why that would be the case– I have a couple ideas but will spare us all that discussion at 10 PM on a Saturday night!
As always, thank you for stopping by and reading;  thanks more for subscribing, thanks even more for referring something you like to Stumble upon, digg, or the other services to help keep my ‘page rank’ up there.  If you are a publisher or have access to a book agent, please consider helping me get a collection of my posts into paperback book form.  Finally, drop a 20 in the ‘donation’ box and you will buy yourself an e-mail consult–  I try to answer without the 20 as well, but I get more and more questions and never get to all of them.
Opiate dependence stinks.  I hope Suboxone is helping you deal with it;  if you are struggling, please consider asking for help.  All of us addicts want to do everything for ourselves, and call our own shots.  Look how well that has worked!
You all take care.
SD

As If!

A comment and question from a reader:
How’s it going people thanks for the education dr. I’ve been on Suboxone for 3 months now and am down to 2 mgs a day, I have found that getting physical exercise is such a key to my over sense of well being. I believe that it is one of the major parts in the tapering process because of the addition of natural dopamine release and just the overall feeling of wellbeing of doing something positive and constructive. I do have a question in regards to how I should taper down from 2mils should i keep doing it by halves every week or should i try and take it at 2mils every other day but i know if i get to low then it brings up cravings. Any advice would be great. Me personally I try eating a lot of fruits especially bananas along with good exercise in the sun is really helped me a lot. which when I was on opiates I would have to get loaded in the morning so I didn’t get wds which limited all my activities and made me lazy leading to an overall degraded self esteem and image when I feel so much better being able to feel good about constructive behavior and radiate positive energy to people. But ids rather stay at 2 mgs a day for the rest of my life and be happy, and positive, then go off when im ready. Rather than be in a constant struggle with trying to be happy, feel well and also the cravings. Finally what’s the long term consequences of maintenance Suboxone use I’ve heard rumors it might affect memory or something like that (at let’s say 2mg)??
My Response:
That is great that you are exercising! There is no doubt that exercise will reduce the severity of the withdrawal process—unfortunately people don’t feel like exercising when they are in withdrawal, so they usually don’t. Exercise helps so many things… it will have a positive effect on depression as well. I often tell people to ‘act as if’– a common Recovery phrase that is said in reply to the complaint ‘I don’t feel like it’. Act as if you DID feel like it—and the ‘feeling like it’ will follow.

We have to act ‘as if’ on many occasions as addicts trying to stay clean. An actively using addict does what he/she wants, and that’s that. So it is important to have a goal out in front of us—an image of who we would like to be at some point. When we feel like taking a day off, or doing something inconsistent with Recovery principles, instead we can remember our goal and act ‘as if’ we were that person already. Acting ‘as if’ is one of the little things that I have carried around since treatment that has certainly kept me out of trouble on many occasions. All alone in a relative’s home, where there are certainly going to be pill bottles? Act ‘as if’ I am not alone, or act ‘as if’ I had a urine test later in the day. Nervous about applying for a job? Act ‘as if’ you aren’t nervous. Etc.

Tapering down from 2 mg per day is tough. One thing to do is take a tab every other day for a week, then stop… the problem is that once you get to such low doses, you run the risk of going into minor withdrawal at the end of every dosing interval. Once that starts to happen one might as well just stop completely, otherwise the misery only becomes dragged out. The general mistake I see people make is that they change the dose too rapidly, given the long half-life of the drug. During the early stages of a taper, the dose should be changed no faster than weekly. I usually recommend going down by 2 mg every week, but everyone has their own preferences. But if a person goes too fast, the WD becomes ‘stacked’ up and is as severe as it would be with no taper. To explain… WD takes 3-5 days to develop in an average person on 16 mg. If a person tapers each day, he will be almost to zero per day by the time the WD starts—and will feel as if he abruptly stopped the medication.

I have not seen any credible threat to health from long-term use of buprenorphine at this point. There are plenty of junior scientists out there on the web, extrapolating from studies on mice or tissue culture—there is little relevance to clinical use in humans from what I have seen rumored on the web. There is a decrease in sex drive associated with chronic opiates, and I would assume that buprenorphine would fall into that category. When I have a patient with that side effect I usually treat it with a Viagra-type medication, or sometimes with a small dose of testosterone, particularly if their testosterone level is below the normal range for age.

Many of my patients report similar mood effects as you describe.  I interpret the effects as a bit of euphoria from the opiate action, and maybe something else– maybe the sensation of a more ‘level’ mood because of a reduction in cravings.  Opiate cravings can be manifest by irritability, depression, anger… and since buprenorphine so effectively eliminates cravings, I would anticipate a reduction in those ‘negative’ symptoms as well.

I certainly have many patients who intend to stay on Suboxone indefinitely. There are currently trials looking at other forms of buprenorphine, such as ‘Probuphine’, an implant of buprenorphine intended to last for six months. My prior post refers to all of the ‘Suboxone experts’ out there who use PubMed or another reference site to download articles, then send them to me or other people to try to prove some point—I encourage people to ignore the attempts of others to scare you off of Suboxone—or any medication, for that matter. Speaking as someone who has published a number of scientific articles I can tell you that the people who do that are always much less bright than they try to appear. I have a guy right now who is sending me articles to try to back up his argument that opiates are safe to use long-term– the last set of articles he sent have nothing to do with the issue at all, although a person in a non-science field would be swayed by the sheer volume of material! Don’t let some idiot spouting off with anger about Suboxone change your mind about how to handle YOUR health.