Deaths on Suboxone

I wish I had more time to devote to this topic right now, but I am on my way to a short vacation… so I will not be available by e-mail for at least a few days.  Everyone is pacing around the house right now, waiting for me to finish with ‘that stupid computer’.
I had to to write, though, because of a horrible incident in Milwaukee a couple days ago that took the life of a 15-year-old girl named Maddie Kiefer.  According to news stories, she snuck out from her house in Whitefish Bay, one of Milwaukee’s’nicer’ suburbs– by nicer meaning a place where the houses are kept up, many children grow up with two parents, and the public schools send a high proportion of students to colleges.  The suburb lies just north of Milwaukee, and along with other northern suburbs has seen a significant increase in heroin use by young people over the past 5-10 years.  I live another hour or so to the north, and we are seeing more and more heroin ‘up here’ as well;  the opiate addicts that I treat used to report taking oxycodone mostly, followed by methadone, then fentanyl;  now I am hearing histories of heroin use almost as often as oxycodone.
Most people know about some vague danger of combining Suboxone with ‘benzos’ like Xanax (alprazolam);  the risk is respiratory depression, which can kill a person– and is usually the cause of death in overdose of opiates.  Opiates desensitize the brain’s response to carbon dioxide, causing the person to breathe at a slower rate and allow carbon dioxide to build up.  The high level of carbon dioxide isn’t fatal, but if a person breathes slow enough, or stops breathing altogether, the oxygen level eventually falls… and the low oxygen level either makes the brain stop working– including ceasing the urge to breathe entirely– or the low oxygen level triggers a cardiac arrhythmia that halts the flow of blood, which then affects the brain, causing unconsciousness, apnea (no breathing), and death.
A couple quick points:  Suboxone and benzos are a dangerous combination particularly if a person is naive to both.  If a person is opiate-tolerant, for example is addicted to opiates, then the risk of death from such a combination is very low.  In any case, the risk of Suboxone plus benzos is MUCH LOWER than the risk of combining a benzo with a full opiate agonist, like oxycodone or methadone!  There is nothing especially dangerous about Suboxone in this regard;  in fact, it is much safer than a full agonist.
I suspect that the teen killed in Milwaukee was not used to opiates;  in such a alcase Suboxone alone would almost never be fatal… unless combined with other respiratory depressants, such as alcohol or benzodiazepines.  The story of her death is horrible– it displays the utter lack of concern for others that takes over the soul of a person addicted to opiates.  I will not make any excuse for a person who dumps someone in a driveway who needs life-saving assistance– but I understand how people get that way.  Many opiate addicts do things that are similarly devoid of conscience– and that is behind the ‘split’ that occurs with addiction, where the addict represses the horror of who they have become, and carries a fake outside personna that is cocky, glib, annoying, and easily recognizable to those who understand addiction.
When I talk about tapering, I assume people are working with a physician;  I do not condone the practice of buying Suboxone on the street or sharing it with friends or ‘loved ones’– even out of concern for them.  When people treat themselves, they are fooling themselves;  the addict is firmly in control and there is minimal chance that the person will recover.  People who share or sell Suboxone with others deserve to be incarcerated.  Period.

Getting Off Alprazolam (Xanax): The need for Recovery

A comment on my old blog referred to a discussion about the withdrawal from Xanax, or Alprazolam, a short half-life benzodiazepine:
Clonazepam (Klonopin) actually is not the drug of choice used in benzo withdrawal, rather it is diazepam (Valium). Clonazepam It is not a very long-acting drug, with a half-life of only 18-50 hours; diazepam’s half-life is 20-100 hours, with its metabolite hanging around for twice that long.

Absolutely the worst thing about benzo withdrawal (take it from me) is that it never ends. That is why I still take them.


My Response:

The ‘drug of choice’ for benzo withdrawal depends on many factors beyond half-life. Diazepam (aka Valium) is absorbed very quickly and so the onset of action is as fast as 20 minutes; this is useful in some situations, but is also thought to contribute to the increased addictiveness of diazeapam over clonazepam (Klonopin). Both drugs stick around long enough to accumulate with repeated dosing; diazepam has active metabolites, making the effective half-life even longer than the pharmacologic half-life. But who cares? In either case the person coming off alprazolam (Xanax) can take the longer-acting benzo four, three, or two times per day– even once per day could be sufficient to prevent seizures with either drug, providing the dose is high enough.

It is very hard for most people to get off Xanax… or any benzo. For that reason, the best medication for alprazolam withdrawal may be a non-benzodiazepine anticonvulsant. I have used valproic acid (Depakote) or phenobarbital in patients for treatment of benzo withdrawal and/or alcohol withdrawal. Pretty much anything that works for alcohol withdrawal will work for benzo withdrawal– which is consistent with the fact that alcohol, benzos, phenobarb, and valproate all have actions at the GABA receptor. Other factors to consider when choosing a medication for benzo withdrawal include liver function– diazepam in particular lasts forever in patients with bad livers. Phenobarb affects the metabolism and plasma levels of many other medications. Valproic acid can cause liver damage and tends to stimulate appetite; is also causes heartburn and nausea in many patients.

The biggest problem with coming off benzos is losing the fuzzy haze that covers life and tolerating the harsh glare of reality. Patients complain of ‘anxiety’– many times they are simply feeling what everyone feels all of the time, but they have lost the ability to tolerate the normal stresses of life. This is where 12-step programs come in; working the steps provides everything that is needed for a person to learn to tolerate reality. After 15 years of going to meetings, I am still amazed at the value contained in the 12 steps. EVERYTHING is there! How to tolerate one’s self; how to deal with others; how to cope with rejection or loneliness; how to begin to understand a purpose for living… the answers to all of these questions– questions faced by most drug addicts on a daily basis– are contained in the steps. I strongly encourage, and invite, people learning to tolerate reality to come to recovery and join the others who are looking for the same thing– and finding it at AA or NA.


More Xanax

A Question:
I have been taken xanax for over half my life. initially for anxiety and insomnia. then like most was unable to function or handle the withdraw and remained on it. later because of an injury i was introduced to oxycontin. i became addicted and could not step off. one because of “real back pain” the other because of the withdrawl. i would have to go to rehab and or miss work. which is impossible for me because i am the sole provider for my children and i. also my family is very uneducated with these things and have a “zero” tolerance and would be disowned for sure. i no longer want to take opiates but i do feel i need xanax. will taking suboxone while taking xanax be fatal. or is it possible to combine the 2 until i am opiate free?
My Answer:
Thank you for writing;  I feel for you, and have been there.  It sounds like you recognize where things stand, which is miles ahead of many patients on Xanax who misinterpret the withdrawal as their own ‘anxiety disorder’.  I would first suggest that you never give up the courage to get off of the Xanax.  While it is a difficult thing to do, most people will eventually have less anxiety, less insomnia, less fatigue, and less depression if they can get away from benzos.  You CANNOT simply stop the Xanax, as you probably know, as the withdrawal from that class of medication can be fatal, and includes seizures that can just occur suddenly out of nowhere… while you are driving down a highway for example.
I must be cautious to avoid giving medical advice that has the potential to be dangerous; anyone reading my posts MUST make any treatment decisions along with their own physician.  But for the sake of education, yes, people have died from the combination of Suboxone and Xanax (alprazolam) and other benzos (like lorazepam, diazepam, clonazepam, etc.).   But two points deserve mention.  First, the deaths occur from respiratory depression when opiates and benzos are combined– the respiratory depression is ‘multiplied’, not just added together.  The danger is primarily restricted to people who are not tolerant to the medications.  If a person is used to both medications, the risk of having trouble is not all that significant.  So in your case, I would start the Suboxone and if you feel ‘buzzed’ from it I would have you take only half of your Xanax dose until you are tolerant to the Suboxone.  You could probably resume your regular Xanax dose after a couple days.
The second point is that the danger from Suboxone is much less significant than the danger of combining a full opiate agonist (like methadone, oxycodone, or hydrocodone) with a benzo.  The antagonist action of buprenorphine provides a significant measure of safety that is not present with opiate agonists.
One final comment–  the best way to get off the Xanax is to change to a very long acting benzo– clonazepam is usually the best choice– and then go on a slow taper.  If a person is motivated to get clean, and if the taper is done very slowly (over a period of 6 months) the withdrawal is minimal and can be tolerated without the need for inpatient detox.
Take care,

Suboxone and other medications; Xanax?

Q/A with a person from
I have a question regarding suboxone and i cant figure out how to post comments so i figured i would email to see if i can get my questions answered that way.
1) I know that suboxone has some kind of ceiling effect to where if you take too much it is either pointless or does the opposite, Is this true?
2) I am prescribed to xanax and zoloft as well.Will my anxiety medicine or my depression medicine (xanax/zoloft) not work with me being on suboxone? Does it block out benzos like xanax and valium and soma? Or does it just block opiates?
3) My boyfriend is on suboxone as well but I worry that he is abusing it? Can he get high off taking more than his prescribed amount or is it absolutely impossible to get high off suboxone alone?

My Response:
I encourage you to keep fiddling with the site, using the username and password below– you can change the password on the site if you like. That way you can participate in the discussions. But for now…
Yes, Suboxone has a ‘ceiling’ at a dose of about 4 mg, assuming it is being taken correctly (it has to be absorbed through the mouth; whatever is swallowed is destroyed and inactive). Above about 4 mg there is no more opiate effect; at very high doses (above 40 mg) it starts to ‘block itself’ and have even less effect, so a person can cause withdrawal by taking a real large amount.
The active ingredient in Suboxone is buprenorphine; buprenorphine selectively activates and blocks the mu opiate receptor and will not interfere with xanax or other benzos, and will not interact with soma. BUT… buprenorphine will cause respiratory depression in people who do not have a high opiate tolerance, at least until the person gets used to Suboxone (after a few days). Benzos also depress respiration and there have been deaths from the combination of Suboxone and benzos in people who are naive to one or both of the drugs. Also, Xanax and other benzos cause tolerance even faster than opiates do; the first-line treatment for anxiety is serotonin (an SSRI) and benzos are best avoided by people with addictions. Benzos will reduce anxiety, at least for a few weeks, but they are very addictive in their own way, and the withdrawal from them can be fatal. The early withdrawal consists of severe anxiety, which patients often misinterpret as their own ‘anxiety disorder’, for which they think they need more benzos… and the cycle continues. All of us opiate addicts are too focused on how we ‘feel’, and benzos only reinforce turning our attention inward, when what we really should be doing is trying to ignore how we feel and instead focus on things ‘outside’ of us. You can tell, I’m sure, that I don’t like benzos. But patients sure love their benzos– patients get more attached to their benzos than to any other med in my experience, and it is very hard to get a person to give them up.
As for your boyfriend, a person can get high off suboxone if he/she takes it only intermittently and never becomes tolerant to it. That would be very difficult for most addicts to do, as the person would have to take it and then come down, wait a few days, and take it again. Most opiate addicts would not be able to ‘come down’– they would just keep taking it. I cannot imagine how a person could get a high with regular use, as tolerance would prevent it. BUT… I have had Suboxone patients who (unfortunately) took oxycodone or another agonist while taking Suboxone; they had no effect from the agonist but they still could not stop taking it. It appears silly on the surface, taking something so expensive like oxy and getting no effect, yet not being able to stop. But opiate addiction is complex– it is more than just taking something because it feels good. In fact most addicts will admit that they have not had a ‘high’ in years, but they still have to keep using. Using ‘serves many masters’, and each person may have a different master. For example, a person who is actively using becomes completely absorbed in the drug– finding it, playing with it, using it, worrying about finding it again… Some people after starting Suboxone have a great deal of anxiety– the way I see it is that suddenly they don’t have the obsession with opiates occupying their minds, so they are free to worry about the other things in their lives. One reason for their use, then, is to reduce anxiety… and perhaps that is what is going on with the people I know who are on suboxone but are still using. By the way, I do not keep people in such a state– I may give the person who uses one more chance, maybe with a higher dose of Suboxone, but if he/she can’t stay clean (and after crossing that line, most do not stay clean) then methadone or residential treatment is their only hope.
I am going to answer your question ‘publicly’ but I will take away your e-mail info. Please continue to visit the site, and post when you get it figured out!

Induction, Relapse, Benzo Questions

Some questions about the induction process and my answers:

If I try to just take the oxycodone for a period of time prior to meeting with you would that eliminate some of the problems and complications associated with the transition from methadone to suboxone? If I took only oxycodone for 4 days or 6 days might I be able to go directly to suboxone without that withdrawal period?

Yes, it is helpful to change from methadone to oxycodone for a stretch of time. Methadone is highly protein-bound, and takes forever to leave the body– I like people to be off methadone for at least 4 days, whereas 24 hours off oxycodone is usually sufficient to avoid precipitating withdrawal with suboxone. There is no way to avoid withdrawal completely, however, as a person must be in a bit of withdrawal at the time of suboxone induction. Otherwise the person will get very sick.

Would I be feeling well enough by (specific date) to be physically comfortable enough to be a joy to be around or will I still be suffering? I believe I will need some help just with the driving alone…

Some people start suboxone and go to work later the same day– it depends on the person’s individual ability to handle the withdrawal, and on their tolerance to opiates. A person who takes less than 40 mg of methadone per day (or the equivalent dose of oxycodone) will generally have no problem adjusting to suboxone. I have done inductions on people taking well over 100 mg of methadone per day, and they do OK as long as they have gone without methadone for a few days. If you can change completely to oxycodone and avoid methadone for a few weeks before suboxone, you will do better.

In addition to the methadone I have also been prescribed Clonazopam (a benzodiazepine) that I take with the methadone. I take 3 to 4 mg a day. Can Dr. Junig prescribe me that or a different one and get me tapered off the benzo’s? I really want to be clean and sober as I once was… I stopped going to meetings and I had gone to over a thousand during that time and was pretty darn healthy in all ways; but after I stopped I picked up a drink and eventually narcotics again.

Clonazepam is a dangerous med for anyone with a history of addiction. The tolerance that develops makes the drug helpful only for short-term use, for the most part. I will prescribe it sometimes for a person who is taking the proper medication for anxiety (like prozac or effexor) but who still has breakthrough anxiety, as long as the dose remains stable. 3-4 mg is a high dose, and I would want to try to taper that down a bit if possible.

The part about the meetings is typical. Opiate dependence is a long-term affliction—life-long for most people. People contemplating suboxone have two choices: life-long medication, or life-long meeting attendance. At this point there is no cure. Addicts who stop going to meetings eventually go back to opiates, for the most part. Likewise, it is important for people who stay sober through the 12-steps to avoid all intoxicants. Use of a different drug often results in ‘cross-addiction’ to the different substance, which then often leads back to using the drug of choice.

More Suboxone Information at