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Yesterday someone wrote about the high potency of buprenorphine. He also wrote that it is hard to get off buprenorphine medications. I ended up writing more than I intended, which occurs often and keeps me up too late most evenings. I decided to share my anwer, as the issue comes up often on the forum and in my practice treating patients on buprenorphine medications (Suboxone, buprenorphine, Zubsolv, Bunavail, etc.)
My answer, partially edited:
Yes, buprenorphine is ‘potent’, but that potency is limited. Buprenorphine has strong opioid effects in microgram amounts, which is one aspect of potency. But the potency of buprenorphine is limited to a certain maximum effect, and in that regard buprenorphine is not potent at all. No matter how many milligrams, grams, or pounds of buprenorphine a person ingests, injects, or absorbs sublingually, the medication is NOT more potent than one 80 mg tablet of Oxycontin or five 10 mg tablets of methadone.
Likewise, an adult human cannot typically overdose on buprenorphine alone, even if that person has never used opioids. But it is very easy for adults to overdose from oxycodone or fentanyl. So from the danger standpoint, buprenorphine is not potent at all.
As for the difficulty stopping buprenorphine, the brain has NO idea which opioid drug or medication you are stopping. The brain (more accurately, the neurons in your endorphin pathways) only know that your opioid receptors have a high tolerance, and the activity in those endorphin pathways will come to a halt until tolerance returns to normal.
The degree of misery caused by stopping any opioid is a function of only two things: the degree of tolerance and the rapidness that exogenous opioids are removed. Buprenorphine cannot raise tolerance higher than the effect of 40 mg of methadone, which limits the severity of withdrawal. Almost every heroin addict I’ve met over the past 2 years– about 300 people coming in as new patients in a methadone program– have tolerances much higher than 40 mg of methadone. The average, in my best guess, is 3-4 times higher, judged by the very small effect that 40 mg of methadone has on their withdrawal symptoms.
The severity of withdrawal comes up often, and the reality is very simple. The problem is the change in mu receptors, not anything specific to buprenorphine.
Buprenorphine has features that make it easier to ‘come off’. We always use long-acting agents to taper medications. People coming off Xanax are changed to clonazepam, for example. It is not really possible to taper off something that has a blood level that goes up and down throughout the day. Tapering requires a stable blood level, and that blood level is then slowly decreased. With oxycodone, the blood level goes from very high to zero in 4 hours; with heroin in 8 hours. Medications administered by patch, such as transdermal fentanyl, can be tapered because of the constant blood level that patches provide.
As for the length of withdrawal, it takes 6-12 weeks off exogenous opioids for opioid receptors to return to normal, no matter the opioid. People always remember it differently, not surprising given how memory works. Think back about how long you had pain after your last surgery, or how long you had a bad cough after you had the flu. Unless the memory is pegged to something (like days off work), nobody remembers those types of things. We all have ‘impressions’, formed by what we’ve said or what we’ve read from others. But human memory is not good at remembering how long something happened. That’s probably why women go through pregnancy over and over. They wouldn’t more than once if they remembered the entire experience better!
Thanks for reading, as always. And again, I hope to see you at the Forum!