A question and answer session with someone who is considering stopping buprenorphine. His message first, with identifying information removed:
Hi, I just sent a donation through PayPal.
I used Norco 10/325 since 1999, about 20-40 per day for the past five years. A month ago I went on 2 mg Subutex but don’t like the feeling of being drugged. The next day I went down to 1 mg/day, and have been at that dose since. I liked the Norco because I could still function, and could “feel”, including joy. Now I have no feelings of joy at all, just feel drugged all the time. I meditate and exercise 30 min/day, have done that for years, so maybe that kept me grounded.
Q: What is the quickest and most comfortable way for me to taper? Should I use Ativan to help with restless legs and sleeping? I don’t mind a little discomfort, but if it’s too much I am afraid I will relapse to the Norco.
Thank you
My response:
Thank you very much for the donation.
(note to readers: most days I receive from 3-6 e-mailed questions– sometimes very lengthy questions. I answer when I can, and of course the laws of capitalism apply– i.e. a donation tends to make me feel guilty if I don’t respond! I provide formal telephone consultations for those who need or want such a discussion, at a rate of $100 per 30 minutes. The sessions can be set up by contacting me at the phone number provided at my home page, at fdlpsychiatry.com)
Most people who take high dose buprenorphine (HDB) have no feeling of being ‘drugged’. It sounds like your mind is made up about stopping buprenorphine, but as an FYI, the reason that you are likely feeling drugged is because your dose of buprenorphine is too LOW. I’ll try to explain…
If you look at the dose/response curve for buprenorphine, at low doses the ‘curve’ is essentially identical to the plot of an opiate agonist. It is only at very high doses that the ‘curve’ flattens out in the shape of the well-known ‘ceiling effect.’ With HDB the goal is to keep the brain levels of buprenorphine high enough so that even at the end of the dosing interval, the opiate stimulation remains above the ceiling level. If brain levels of buprenorphine stay that high, the opiate effect remains constant over time, allowing brain opiate receptors (and the brain in general) to become completely tolerant to the effects of buprenorphine. Once completely tolerant, the person on HDB feels no opiate activity at all from taking buprenorphine; the only thing that is potentially felt is withdrawal from a lack of opiate stimulation if the brain level of buprenorphine drops below the critical level where the ceiling effect occurs.
If a person takes an amount of buprenorphine that does NOT push brain levels above the ceiling level, the person will feel the same response to buprenorphine as he would feel from an opiate agonist. The degree of opiate stimulation would change as the buprenorphine level goes up and down, never reaching the ceiling level where constancy is achieved. Because the receptors are not fully stimulated, they would not become fully tolerant to buprenorphine. The person would not, then, feel ‘normal’ because he will never gets to the point of full tolerance. Making things even worse, the effective half-life of buprenorphine becomes much shorter at the low doses you describe, requiring multiple dosing to avoid episodes of minor withdrawal between doses.
But back to your question, and taking the last one first, the biggest risk for relapse from what I have seen isn’t so much during the taper as it is a couple months later, when the person finally starts to feel better. Being sick during withdrawal helps the addict remember just how horrible opiate dependence has been, serving as a motivator for sobriety. But when the person feels better, those thoughts start coming back… that just a tiny bit would be OK. Always remember your weakness for opiates, as your weakness for opiates will surely remember you for the rest of your life.
I have no problem with a short course of benzos during the taper of buprenorphine. Some people argue, simplistically I think, that since benzos are addictive they must be completely avoided by addicts, no matter the reason. In general I hate benzos, and think that they do more harm than good in most cases. But opiate withdrawal is so horrible that a small amount of lorazepam or clonazepam would not have to be the end of the world. Besides, one could argue that making the withdrawal a bit milder might lessen the pull back into the world of active using. Clonidine is of course the classic medication for easing opiate withdrawal, and I have also had some success with gabapentin in some individuals. I would like to set up a trial someday with the old medication ‘proglumide,’ which has been rumored to reduce opiate withdrawal for a number of years. But I do not know where the medication can be found—in or outside of the US.
The main thing about tapering is to go slow—on the order of 10% every 1-2 weeks at the fastest. During a taper off buprenorphine you will want to think in micrograms, not milligrams—i.e. 2 mg equals 2000 micrograms. Remember that buprenorphine is a potent narcotic in doses as low as 10 micrograms, and European trans-dermal buprenorphine delivery systems release as little as 5 micrograms per hour! You will want to taper down to 500 micrograms per day or less before ‘jumping’ from the medication. I have written about the ‘liquid taper’ method both on the blog and on the forum, and you will find the experiences of many people with that method described at the forum. The basic idea is to dissolve 8000 micrograms of buprenorphine in a milliliter or two of water, then dose with a graduated eyedropper or a tb syringe (without using the needle!).
Finally, remember that the half-life of buprenorphine markedly decreases as the dose is decreased, so as you taper down, you will need to divide the daily dose into multiple fractions.
Thanks again for your generous donation. I hope to see you around the forum!
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5 Comments
src4 · May 23, 2010 at 2:37 am
Hello everyone! I just finished my spring semester of my junior year. I go to a great school and now that summer has come I am going to quite taking Suboxone. I purchased the audio version of Quitting-Suboxone by Dr. Jeffrey Junig. This has helped me a great deal and i am using the audio books advice and I am going to start my taper next week and from that week on until I get down to 2 mg’s. At that point I am going to quite and use some of the meds recommended by Dr. Junig and another Dr. that I work with. What I am wondering is can I taper a bit faster in the first three weeks instead of what the audio says? or would that be setting myself up to fail? I am now taking 16 mg’s per day and I have been taking subs for about one year. I plan on being completely off of it in 6 -7 weeks from now. Once I get through the two weeks of withdrawls I plan on going to 90 meetings in 90 days and then go to a meeting per week after that. I feel very confident in my ability to do this because I have three months off of school and I will be working minimal hours and I am allowed time off when needed. Once I get to my 2mg’s every other day I am going to pack up all of my meds that I have prepared and we are going to my family cabin for 9 days without any suboxone. I will be there with my dad and he will be the one giving me my doses. I trust my dad 100% and I know that once I get there with him that I will not be leaving until I am clean. I am going to start a blog for anyone who would like to follow through my next 8 week journey.
I want to thank Dr. Junig for all of the help and motivation that he has given me and he doesnt even know who I am. And please feel free to change anything about by plan that you may not like. I need help so anyone that has any advice for me, I am all ears.
SuboxDoc · May 23, 2010 at 8:19 am
Thank you for your comments– I wish you all the best!
hatmaker510 · May 26, 2010 at 9:15 am
SRC4 – Have you been to the suboxforum.com? It’s Dr. Junig’s forum/companion to this blog.
There are MANY threads about stopping suboxone and referring you there would be best instead of going into all of it here, but I will say you might want to consider a slower, longer taper and getting below 2 mg before jumping off.
Good luck!
slipper · September 13, 2011 at 9:39 pm
LACK OF GUILT?
JUST WONDERED IF ANYONE ELSE FELT NO GUILT WHEN USING..I MEAN WHEN ACTUALLY GETTING YOUR DRUG OF CHOICE..I WOULD SAY WELL..I NEED IT MORE THAN SHE DOES AND TAKE MY FRIEND’S ENTIRE BOTTLE FROM HER MED. CHEST….. THE THING I DID…29 YEARS OF ADDICTION TO HYDRO’S 20 10MG. A DAY TRYING TO GET IT GOING TO DRS. PHARMACY..TRYING TO KEEP UP WITH WHO I WAS IN THIS TOWN” (HAD A STORY FOR EVERY DOCTOR” COUNTING, RECOUNTING..HIDING THEM AND REHIDING THEM MY GOD IT WAS WORK…I FINALLY HEARD ABOUT SUBUTEX AND WENT TO DR. ON 16 MG. AND A MIRACLE HAPPENED…I’M SOBER….I DON’T EVEN THINK ABOUT HYDRO’S ANYMORE…I HAVE MY LIFE BACK…5 TREATMENT CENTERS..20 PLUS YEARS OF AA (IT WORKS IF YOU WORK IT..OBV. I DID NOT)….BUT NOW I DO FEEL GUILT FOR ALL THE HORRIBLE THINGS I DID TO GET IT…THIS IS MY FIRST POST…BEEN READING ALL OF YOUR POSTS AND THEY ARE SO HELPFUL…I AM A NURSE RN/TEACHER WITH A BS AND MS DEGREE AND I NEARLY LOST ALL OF THAT BECAUSE I MAINLY AM AN ADDICT…………..JUDY
slipper · September 13, 2011 at 9:45 pm
OH AND BY THE WAY I HAVE BEEN MARRIED FOR 41 YEARS TO A MAN WHO HAS STAYED WITH ME THROUGH ALL THIS SHIT….ANYONE ELSE WOULD HAVE BEEN LONG GONE…AND TWO WONDERFUL BOYS AND 4 GRANDCHILDREN…SO MUCH TO BE THANKFUL FOR ….BUT I STILL FEEL THIS GUILT NOW FOR ALL THE THINGS I DID TO MY FAMILY AND MY FRIENDS AND TO PEOPLE I DIDN’T EVEN KNOW ….. I EVEN TOOK MY MOTHER’S PAIN PILLS WHEN SHE WAS DYING WITH CA.—I HAVE ASKED GOD TO FORGIVE ME BUT I DON’T KNOW HOW TO FORGIVE MYSELF…HAVE ANY OF YOU HAD THESE FEELINGS?? THANK YOU SO MUCH