How Low Can It Go….

An entirely logical question:
Soboxdoc,
I am taking 16mg of Suboxone a day – 8mg in the morning and 8mg at night. You state above that Suboxone has a ceiling effect of about 4mg. Does that mean I could take a half of an 8mg tab once a day and it would have the same effect as the 16mg that I am currently taking? Even after the three day half-life? Or should I still cut it down by 2mg a week until I get to 4mg?
That would be great if I could do it right away with the same benefit! Either way I am still left speechless on how much this medication has changed life for me. Thanks again for all the wonderful info.
My Best Guess:
Thanks for writing! The 4 mg level for the ‘ceiling’ is an average for patients overall, and assumes that you are taking the Suboxone in an effective way. My addiction to fentanyl initially relied on absorption across mucous membranes, and in order to get the most ‘bang for the buck’ I brought my best neurochemistry training to study the absorption of lipid-soluble medications through tissues. We know that molecules move slowly through tissues, so when I picture under-the-tongue Suboxone dosing I see a pill dissolving around the periphery, saturating the tissue under the tongue with buprenorphine… and then little rivers of buprenorphine run along each side of the tongue, to be swallowed down the esophagus. I have to think a better idea would be to have a small volume of saliva to dissolve the tablet, making a high concentration of drug to move down its concentration gradient… then spread the concentrated slurry over as much surface area as possible, for as long a time as possible. I do think that this method increases the percent of drug absorbed, and it certainly is faster than leaving a pill under your tongue for 35 minutes!
Even so, I would expect a significant amount of waste, as a large amount of drug will miss getting stuck on the mucosal surfaces. I have one patient who spits it out, freezes it, and reuses it to save money!
Most people who have moved from 16 down to 8 or even 4 mg have had very little withdrawal. The ones with the worst withdrawal tend to be people who have had real bad withdrawal many times, and are expecting it to be horrible again. The people who haven’t had very bad withdrawal don’t find Suboxone withdrawal bad at all. Am I avoiding the question? Maybe… but yes, I would think that you could move to 8 and then 4 mg fairly quickly, and then stop there. I would stop at 4 for several weeks before going any longer just to make sure your aren’t ‘stacking’ the withdrawal from changing too fast (I picture it like the sound waves stack up against the nose of a supersonic jet, just before it breaks the sound barrier!). I would try going from 16 to12 for three or four days, then to 8 for three or four days, then maybe to four…
The mind is the biggest trouble during this period, as you probably have found. The technique that works best is a combination of determination and distraction. It is awfully hard for any addict to be determined for a few weeks! You need something REAL distracting– maybe you could call and see if Angelina Jolie needs a lift anywhere during the time you are tapering, and you could distract yourself by engaging her in witty conversation. Just a thought… Or get the DVD’s of the Cosby Show entire series and watch that. That would be a good distraction too. One of those should work.
The other problem is that as you lower the dose most people start to have more thoughts of using. This is the biggest mistake I see on the way to relapse from Suboxone– people take less and less, and then start wondering if they are still ‘blocked’… then they get the bright idea that it would be ‘good to know if I am still blocked, so I should take an oxy– just to see. You see where this is going. Sometimes it looks awfully suspicious for the ‘addict inside’ planning the whole thing out, from start to relapse. Watch for that– try to take an honest assessment of your thought every now and then, and pay attention to any emergence of a cocky or joking side of your personality– that is usually how the relapse addict inside all of us makes his appearance.
Thanks again– I hope I provided an answer in here somewhere! WAY past my bedtime!