Ending Constipation from Suboxone and Buprenorphine

Constipation is one of the few potential side effects caused by buprenorphine medications, including Suboxone Film and Zubsolv. Fortunately, ‘binding up’ can be managed by making minor changes to your lifestyle.

Constipation from buprenorphine is caused by activation of mu opioid receptors in the small and large intestine, reducing the sequential squeezing and relaxation (called peristalsis) that pushes bowel contents forward. All opioids have similar effects, mimicking our natural endorphins throughout the body. Endorphins are released during trauma to naturally block pain and to divert blood flow to areas where it is needed most — and the bowel is relatively shut down during those periods to conserve energy.

Constipation problems from buprenorphine (I’ll use that term for Suboxone, Zubsolv, Bunavail, or any other form of buprenorphine) often occur in people who are already having some constipation problems, where the medication makes things worse. The first few ideas I’ll offer will help anybody, regardless of whether they take buprenorphine or other opioids.

Diet and Hydration

The function of the large intestine is primarily to reabsorb water. The amount of water reabsorbed is related to the time that contents spend in transit. This will be a bit graphic… but that’s why the first part of a bowel movement is generally hard and drier than what follows. That first part has been through the ascending colon, the transverse colon, the descending colon, and the sigmoid colon, and has hardened into something like adobe bricks. After that has been pushed out of the way, the remaining stool passes through more quickly, with less drying.

The most important step to avoid constipation is to keep things moving. If nature gives you a chance to go, take it! If you manage to skip the chance, it would only be harder to go tomorrow.

Many people fail to drink enough liquids, especially those who live in hot environments. If your body is relatively dehydrated, your colon will work harder to conserve water. Staying hydrated — to the point where you urine is light-colored — will reduce constipation.

Diet, of course, plays an even larger role. Those of you who work with concrete know that certain additives will make the mix more strong or dense. Throw in a bale of hay, and the opposite happens. So add food to your diet that contains fiber, which reduces concretion and adds bulk, making it easier for you colon to compress and push the mass forward.

Certain foods like prunes and plums have chemicals (as well as fiber) that keep the bowel moving. Other foods — e.g. cheese and processed foods — can slow things down.

Medications

Add medications only when the ideas listed above aren’t working. Consider softening agents first, as they have less effect on colon function and are less likely to create a dependence. Medications with docusate pull water into the feces to soften them. Drugs that contain sorbitol, magnesium, or polyethylene glycol pull water back into the colon, increasing the volume of feces which then stimulates a bowel movement.

Senna and bisacodyl stimulate the colon to increase peristalsis. I usually recommend Senokot to my patients, as it comes in liquid form that can be added to juice in measured amounts. With all of these over-the-counter products, be sure to follow the directions on the bottle. ALL of them can do harm if taken in excess. Stimulant laxatives and cathartics can also create tolerance and dependence, so avoid using that approach for more than 2 days in a row.

Nothing Works!!

It is possible for constipation to block the colon completely. The last things on the list are enemas and suppositories, which work from the other end of the obstruction and aren’t, obviously, something to use routinely. Glycerin suppositories lubricate and also stimulate the colon. Bisacodyl suppositories stimulate the colon to provoke a bowel movement. Enemas stimulate peristalsis, lubricate, and soften feces. Many people, though, are uncomfortable doing enemas at home.

If you are completely blocked up, stimulant cathartics will cause pain and vomiting. In that case, you may have to bite the bullet and go to the ER.

if none of the convenient options are working, you might consider ‘dosing and spitting’. At the liver, buprenorphine is metabolized to norbuprenorphine, an opioid agonist that does not cross into the brain. When you take 8 mg of buprenorphine, about 30% of the dose is absorbed into the bloodstream and the other 70% is swallowed and metabolized to norbuprenorphine. If you dose for 10 minutes and then spit out the remaining saliva, you will reduce the formation of norbuprenorphine, and reduce constipation. It takes about 5 days to start seeing results because norbuprenorphine builds up in your system over time. The practice might turn off your friends so try to do it in private!

Keep in mind that solving the constipation problem will require making a change that you can continue going forward. Drinking more water and eating more fresh fruits and vegetables are great places to start.

Dr. J

Stopping Buprenorphine in Three Steps

Readers will sometimes ask for my thoughts about buprenorphine. I’m always happy to respond, time permitting. I’ve described how my patients taper off buprenorphine in prior posts, but the interest out there warrants revisiting the topic.

Most people who become dependent on opioids become very fearful of withdrawal. That fear continues on buprenorphine medications like Suboxone, Zubsolv, and generic buprenorphine. Patients should strongly consider using buprenorphine to keep their addictions in remission for at least a year or two before starting a taper, and those prone to relapse to opioid use should consider life-long medication. Doctors regularly use medications with higher risk-profiles than buprenorphine to prevent illnesses with lower associated morbidity!

But some people feel trapped by their fear of withdrawal. Such an attitude is completely unnecessary, because most people can taper off without too much trouble. Over the years, hundreds of my patients have tapered off buprenorphine.

Are You Ready?

The first thing to do is to consider whether you are ready to taper. Stopping buprenorphine IS difficult when tried too early, before the mental connections to opioid use have faded. To assess readiness, I make sure that the patient has been dosing once or twice per day, ‘as needed’, which reinforces the behaviors that treatment aims to eliminate. You should be doing well with prescriptions, and not running out early.

Make sure the odds against relapse are running in your favor. Several studies have shown that relapse rates are very high – over 95% – in people who have been on a maintenance agent for less than 12 months. Relapse is also more common in people who are frequently exposed to their drug of choice, so if you’re still hanging with the same crowd, consider staying on buprenorphine. Finally, your odds are improved by being busy. If you’re not working, consider holding off on tapering until you are.

Just Do It!

If you’re ready by those standards, I recommend dosing twice per day during a taper.  Dosing twice, rather than once, will be helpful when you get to blood levels that dip below the ‘ceiling effect’ during a 24-hour day.

So you’re taking 8 mg in the AM, and 8 mg in the PM.  They don’t have to be 12 hours apart;  many people choose around 7 AM and then around dinnertime.
The first step is to remove 2 mg from the PM dose.  Take that amount, 14 mg/d, for two weeks.  Then remove 2 mg from the AM dose and stay at 12 mg/d for the next two weeks.  Then remove another 2 mg from the PM dose, wait two weeks, and then remove another 2 mg from the AM dose.  It takes about 2 months do do all that, and now you’re at 8 mg/day.   Unless you have an unusual metabolism, you won’t have significant withdrawal during this first part.

The second half of the taper takes more time, and works best if you have the film.  You do the same as you did in the first part – i.e. remove a little bit from alternating doses – but you will need to remove less than 2 mg.   There are three things that make the second half of the taper more difficult:

  1. It is harder to consistently divide smaller pieces.
  2. The dose/response relationship is now a steep diagonal line rather than the horizontal line present at ‘ceiling effect’ doses.
  3. Your body’s response to a dose reduction is based on percent change, not the change in amount.   Taking 2 mg from 16 is 12%, but taking 2 mg from 4 is 50%.

As you start the second half of the taper, tear off about 40% from one end for the morning dose.   At night, tear off a similar amount.  Keep doing that amount for 2 weeks, then change to tearing off a little less. Repeat.

Within a couple months you’ll be down to about 2-4 mg buprenorphine per day.  At this point you will want to get more precise.  Get a razor or a sharp scissors and cut the film into quarters, lengthwise.  Now when you tear off pieces, the pieces will be 25% of the dose that you would get from tearing an entire strip.  Better yet, have your doc prescribe the 2 mg films.   However you do it, you just keep slowing reducing the dose, and keep dosing twice per day.  ALWAYS wait a couple weeks between dose changes to allow your body to adjust.

When you get down to less than 0.3 mg per day, you can ‘jump’ without too much discomfort.  Some people taper lower, but if you’ve been at 0.3 mg for at least a couple weeks, you shouldn’t have too much trouble.

There will be times when you find that you have reduced by too much too fast.  When those times come, go back a tiny amount, but avoid giving up all of the gains you made.  And now and then, give yourself a reward – maybe get a massage (if that even happens during a pandemic!), or go out with a friend and get a good meal.

Tapering off Suboxone will NOT be the hardest thing you’ve ever done.  As you make progress you’ll see that all of those people on the internet were wrong when they said ‘it is the hardest opioid to stop’! Good luck, and check out the forum too (suboxforum.com)!

Dr. J

Suboxone Forum Upgrade

Regular readers know that I’m a psychiatrist and addiction doc – not a computer guy. When I started writing about Suboxone and buprenorphine twelve years ago, there were few other people writing about the medication. Of course heroin addiction was just taking off, and fentanyl was confined to operating rooms.

I put together a couple sites that skyrocketed in readers. The most-used was SuboxForum, where we discussed controversial issues like ‘is Suboxone a drug for a drug’, and ‘do the films hurt your teeth?’

I did not work on SEO stuff, because (in case I didn’t say) I’m a psychiatrist. I watched my sites fall below sites that had almost no content, that only advertised spa-like treatment programs that have been proven not to work for treating opioid addiction. Many web sites ‘scraped’ my posts and content, or took feeds from the forum, and posted them as content on their own sites – that scored above the native sites.

Google always says ‘don’t worry about SEO; just have good content and we’ll find you!’ I can attest that in this corner of the internet, they don’t do a good job of separating the posers and scammers from real content.

There are a couple other forums out there that were big in the past, and now sit dormant or dead. They still rank for questions about buprenorphine. I’ve decided that I need a hobby, so I’m going to try to get the numbers up at SuboxForum. If you haven’t been there for a while, stop by! We are still at the same place, with some software upgrades… but we have many of the same people you knew years ago. Our main mission, of course, is to help the newcomer learn about an important medication… so if you’re wondering how the medication works or other questions, stop by.

I’m a psychiatrist (if I didn’t say that before). So I don’t collect info and sell it to spammers. The software needs you to give your email to sign up, but get a free anonymous one and use that.

Hope to see you there.

THIS is the last time….

My computer expert ‘JJ’ added something interesting at the forum; now you can comment directly on anything from the blog in a ‘give and take’ fashion. It is at the bottom of the page at suboxforum.com. I also want to thank those who signed up; over 30 new people in the past 24 hours!
One last thing… please don’t hesitate to share your knowledge. The best way to share is to emulate an NA or AA meeting, where one will give advice by describing his OWN experiences. For example instead of saying ‘you should…’ people say ‘I don’t know if this would work for you, but in my case I found that….’ A small distinction, but the sort of thing that makes others more receptive to your ideas.
Again, thanks everyone,
Jeff

New Design: Please Comment.

I have had a number of requests to lose the ‘shooting’ picture, so I tried out some new designs today and liked this one. I wanted something simple and ‘to the point’. Please post feedback in the comments section; as I have mentioned, I don’t have much of an eye for design. Ideally the design will encourage people to click on the ads every now and then… please comment on that as well, if you have experience with ad placement.
Thanks!
SD

Get the party started…

A quick plug for publicity… if you enjoy the blog, please spread the word about it in any way that you can– if you like a post, please take a minute and hit the icon for StumbleUpon, Digg, or whatever your favorite social networking site. Likewise, please spread the word about SuboxForum.com— that could really be an interesting place if we can generate enough momentum. There are now so many people out there with questions about Suboxone; the forum would be a place to share your experiences and knowledge with those looking for info, and would hopefully be a place where you could discuss Suboxone without getting blasted by someone else.
Yes, I am making about $2 per day in adsense revenue from this blog– for some reason, opiate addicts seem to have a real aversion to clicking on links! My desire to spread the word about this blog and the forum is more about the fame than the fortune, I guess… just in case that matters.
Let this be the day that you take a minute and send the links to someone, mention the forum somewhere online, submit a post to Stumblers… I really appreciate it.
Jeff J
SD/STZ

Farewell, Paris

I am hitting the road today, homeward bound!  No offense to Paris, but it will be so nice to get back…  I have a new appreciation for anyone who doesn’t speak the language of the area, and for those who suffer subtle snobbery in any environment.  For example standing in a line at a store and trying to make change with unfamiliar coinage, while the people in line sigh loudly, or roll their eyes as they glance at each other.  If I catch myself doing that back in the States I promise to quickly apologize!
A few people wrote to me over the past few days– I received the messages, but for the most part I cannot e-mail back.  I don’t know how to get Outlook to ‘inferface’ with the hotel’s wifi, and my computer struggles lately with every task– so I will take the time to log on to my mail server and write something only to have the computer suddenly crash and lose everything (!)    I will try to reply to people when I get back, but understand that I am far behind in several areas of work right now.   I am also trying to make a new resolution to work less, as I realized the past week that I no longer have the capacity to relax;   I don’t even know what the ‘relaxed me’ feels like anymore!  Since this is a ‘recovery blog’, I should add that the situation I describe is NOT healthy!
I received a plaintive note from ‘mifight’– I will write on Sunday when I get back, but please understand that I am just a one-man show;  I do not have attorneys or special connections, and I cannot help you get your children back.  I am posting this here so you see it–  the best thing you can do, when working with Social Services, is demonstrate recovery–  that means demonstrate a regular schedule, a job, a certain degree of composure, and even patience–  hard to do when fighting for one’s children, I am sure.  But the only alternative is to fight through the courts, and that is a fight rarely won–  it is very easy to make a person look ‘unstable’, where the more the person fights, the more unstable the person looks!  Again, when I return I will post your message without ID and see if anyone else has any ideas.
I am looking forward to seeing all of you– my ‘regular patients’– and to getting back where I belong.
To France–  Au Revoir!

The Catacombs of Paris
The Catacombs of Paris

PS:  I have to add this…. on our last day we went to the Catacombs, a network of tunnels that became the final resting place for thousands (hundreds of thousands?) of skeletal remains…  I will leave it to Wikipedia to describe the place better than I would, but what an experience…  to imagine the monks moving the bodies and bones to this location far below ground, and arranging the bones and skulls in decorative fashion (as they still are today)…  A ‘must see’, in my dark opinion!

Do me a small favor…

I just checked my stats– I like to see the numbers go up, as it provides more impetus for me to write. In the ‘shameless plug’ department… I have a couple harmless requests:
-First, look to the top of the right column, just above the PayPal seal, and click to ‘tell your friends about Suboxone Talk Zone’. Please send the message to anyone you know who is taking or considering Suboxone.
-Second, move down the right column to just below the ‘blogroll’, and click to subscribe to the blog. If you have never subscribed to a blog before, click on one of the services you are signed up for, or just click on ‘RSS’ and you will automatically get each new post in your outlook. More subscribers are detected by Google, and my blog will move up in the search results when people search under ‘suboxone’.
-Third, if you have a blog or web page of your own, please give me a plug and link to me. Let me know if you have a site related to the topic, and I will like to you as well.
Thanks all– I’m done for the night!

Special Price for Informational Download

Special Price

I have been selling a recording over on the right side of this web page–  the recording describes the treatment options for opiate addiction and the philosophy behind Suboxone treatment.  I recommend it for anybody taking Suboxone, considering Suboxone, or even for anyone who has a family member or even a boss who asks them about Suboxone.  When they ask,  ‘What is that stuff, anyway? Are you still on drugs?’  you can e-mail them this 75-minute audio file and tell them to listen to it on their way to work– and to quit asking you so many questions!!
I am lowering the price as a marketing experiment–   It isn’t going lower, but it will go higher again to some point as I figure out the right price.  I did spend considerable time and effort putting it together;  for those of you who don’t know me ‘in person’ and who wonder what I am like, check out the recording and let me talk to you.  I hopefully will make the whole idea behind Suboxone more clear in your mind.

Was $19.99;  now $9.99–  even less than a ‘Kenny G’ CD!  That’s a BARGAIN, man!

SD