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.