Yes, you heard it here fir…. fourth… it is hard to stop Suboxone. As anyone pausing at this website knows, it is hard to stop ANY opiate. There are many forces at work against you when you are tapering off opiates; physical withdrawal, mental withdrawal, cravings for opiates, and the unconscious mental effects of addiction– the conditioning of your mind to see opiates as the solution to all of those uncomfortable feelings. With all of that going on, it is no wonder that most ‘opiate tapers’ end unsuccessfully, leaving the addict more discouraged than he was before.
Suboxone is different than other opiates, and the differences profoundly influence the tapering process. I have mentioned several times how the ceiling effect of the drug affects the tapering process; there is minimal withdrawal going from 16 to 12 to 8 to 4 mg, but then the withdrawal kicks in during the last part of the taper. This is probably why people leave messages here and there on internet health boards about Suboxone being ‘the worst thing to stop’; the early stages are a cakewalk, and then the person tapering the drug gets hit with a brick at the end of the process.
What we really could use, to help people taper off Suboxone, is a tablet that is as large as the 8 mg tablet, but that contains less buprenorphine. It would be helpful to be able to dose people with 1 mg, then 0.5 mg, then 0.25 mg, then 0.125 mg, then off. Buprenorphine is a very potent drug; when used for pain relief it came in solution for IV administration in microgram doses, and a dose of 50 micrograms was a potent dose; the smallest pill form available is 2000 micrograms! So tapering requires the use of tiny chips of a tablet during the final stages, making accuracy impossible. If you wanted to do a proper taper with the drug you would want doses of about 50 micrograms each… and that amount is in one-fortieth of one-quarter of an eight mg tab. Do you know anyone with tiny tiny fingers and macroscopic vision?
Since we don’t have a formulation that allows a slow, accurate reduction in dose, we are left with doing the best that we can under the circumstances. I think it is useful, to know what to expect, so you don’t become too discouraged when hit with the withdrawal at the end. One thing that seems to be different about Suboxone is that people seem to have less ‘pull’ to take more during the taper. I don’t know if that is a real difference in the drug, or if it is just that people coming off Suboxone in my practice have taken it long enough for the conditioning that is so prevalent during active use to have faded.
I believe in medicating the taper off Suboxone; I was criticized on one site for suggesting the medication Vyvanse to deal with the horrible fatigue. But there is a ‘balance of risks, and I believe that it is safer to use everything we can to get a person through the taper without re-igniting all of those thoughts and memories of using, even if it means using a stimulant or benzo for a week.
People need to understand that the issue with addiction, and with all of these things related to addiction, is NOT THE DRUG… THE ISSUE IS THE RELATIONSHIP WITH THE DRUG. Some people hear the word ‘amphetamine’ and they go crazy– ‘that’s addictive!’ they say. Yes, it is. So is clonidine, when used in the prison environment. There are safe ways to use addictive medications; unfortunately, modern medicine demands ten-minute appointments, where safe prescribing is an impossibility. Why do patients keep putting up with it? Shouldn’t it take longer to figure out your problem and educate you, than it takes to make a hamburger?
The problem with any opiate taper, including Suboxone, is the loss of motivation after a few days of pain, weakness, and depression. You all tell me– would motivational tapes help? I have mentioned my web site sober after Sub, where I have tapes describing the state of mind you want to be in… you can get in that state of mind in a few ways that I know of, including going to meetings. I am eventually going to have tapes that will hopefully help a person feel support during the four or five days at the end of the taper… the days when everything appears hopeless and the clock moves in half-time, or even slower.
As for medications, I have been surprised at the effectiveness of gabapentin in relieving the ‘hot flashes’ that are such a pain during withdrawal. Clonidine is helpful, but it is such a drain on energy that it is sometimes hard to decide if a person is better with or without it. I tend to recommend it for nighttime use only. And then there is Vyvanse, an interesting molecule consisting of lysine bound to amphetamine… it is impossible to abuse, and a short course can help a person keep working.
For those people who have a problem with the use of a stimulant, picture my patient in the final few days of tapering off Suboxone. He is tired and discouraged, and despite my encouragement, I know that the ‘addict inside’ is now awake, and about to use self-pity to turn the person away from his good intentions. That is what happens, by the way– the addict inside the person waits for these opportunities, and once active the addict inside will change a person’s insight! And once it changes, it is impossible to change it back… at least not until there is some negative consequence that wakes the ‘real’ person. Crazy description, I know…. but addicts will recognize what I am saying. I strongly recommend all addicts learn to recognize their own ‘addict inside’. One value of twelve-step groups is that you get to hear about everyone’s addict inside, and you learn that the addict inside everyone is the SAME PERSON– the SAME ADDICT. Watch it in others, and learn about it in yourself.
Where was I…. this patient of mine is on the fence, and I am in danger of losing him? He won’t go off and relapse, but he will go back to the full dose of Suboxone for another six months before trying again. So if instead of all that, I can give a week of a stimulant to get his energy and mood up a bit, and help him kick through those last few days… where is the harm? As it turns out, many opiate addicts have ADD as well; they were on that common path of students identified by the school and parents as having trouble keeping up, leading to anger, shame, discouragement, and drug use. And so I have seen a number of patients start reading for enjoyment for the first time in their lives… pretty cool.
I think I’ve covered the major points:
Yes, it is hard to stop Suboxone… just like anything else. The ceiling effect results in the withdrawal symptoms being ‘backloaded’– all at the very end of a tapering process. It is very hard to taper because of the potency of buprenorphine; a tiny fragment of a tablet of Suboxone contains a very potent amount of buprenorphine, which is usually dosed in micrograms when used to treat pain. Remember when tapering that stopping 16 mg of buprenorphine is like stopping 30 mg of methadone… and stopping 2 mg of buprenorphine is like stopping… 30 mg of methadone! That is the ceiling effect in action– great for holding addiction in remission, but a pain when it comes to eventually tapering off Suboxone.
One last comment: tapering off the opiate is the EASY part; the hard part is not picking back up again. And that takes a great deal of work over the rest of your life. Before Suboxone, getting clean required changing one’s personality. I honestly don’t know if people going through a year on Suboxone, learning some things, then tapering the drug will be able to stay clean long-term. I try to offer things that I believe will help, things I picked up through a long residential treatment and years of twelve-step immersion. I hope I am helping at least some people- not only helping them feel ‘not alone’, but also helping them keep opiates from destroying their lives. BUT… if you are not doing well, don’t rely on my blog to turn it around. Do what I did, and open your mind and ask for help at a treatment center. I will say this again because if you hear it I will save you tons of money you would otherwise waste: open your mind before stepping in the door. Treatment is NOT education– it requires you to change and to do that you must drop all of your resistance to change. Avoid thinking that you have the answers; after all, it was your own best thinking that got you to where you are today.
daveprince13 · February 17, 2009 at 11:38 am
I get what you mean. I’m at 4mg and wondering if I can safely go off cold turkey and how long the WD’s will last. I’m thinking I’ll be out a week of crap and another week of not feeling great but the reason I’m wanting to do it is because a.) I’m ready. b.) I’m in a good support group and c.) I’ve got outside influences motivating me off the drug.
When you said it’s easy to go to 4mgs and then hard to go down from there, it makes me think I’d just rather jump and get it over with. It’s just that the doctor I’m seeing isn’t nearly as smart as you. I asked him “If I go cold turkey (I was at 8mgs) how long will the WD’s last.” He tells me “2 days, 3 max.” He even asked me if I knew anyone that he could treat with Subox because he didn’t want his open slots to go to waste. Anyway, I’m ranting. The point is, I know that you’ve been through it and know that you have a great sense of what it is that you’re talking about Jeffrey. That’s why your blog is so helpful. I bet half the people on here are seeing doctors that don’t know what they are talking about but it’s nice to hear some advice from one that’s actually felt our pain. Thank you.
johnpal716 · February 18, 2009 at 9:39 pm
I’m John P, a recovering addict in Buffalo, NY. I am thrilled to have stumbled on your site. I was originally looking for some wisdom as to what to do about having to stretch a significantly less than sufficient amount of 8 mg tablets out till my next doctor’s appointment but after reading your notes on maximum absorption in the mouth and just being generally made to feel at ease, coupled with some common sense, I can see i’m just going to have to tough it out and that it probably won’t be as bad as my expectations.
I had a pretty severe opiate habit that cost me my partner, career, life in NYC, and almost my life when I moved home and decided to get clean. I went through a week of neverending hard withdrawals ONE LAST TIME and then went on Suboxone. A few days into withdrawal I began attending 12-step meetings (I got my yellow nine month tag last week) at the suggestion of my father, as he saw my grandpa get sober through AA. I have encountered a lot of static in the rooms for being on suboxone and quickly decided to keep it between me, my sponsor, and a few other trusted people. While I have come to believe that it is certainly the Suboxone that gave me the luxury of feeling physically better so soon (even after horrible physical withdrawal complete with the bizarre hallucinations and other goodies I never want to feel again) it is definitely definitely meetings and the steps and the whole program that is working in my life and the true solution.
I see so many people come into meetings (or before, outpatient counseling) with a false sense of “CURE” fresh on Suboxone, talking about getting jobs, mates, money, a car, etc, with no interest in examining where the real problem is (“drugs are just a symptom”) go back out and use and never return. They are either using, dead, or “cured”, god bless em. I applaud your mentioning of 12-stepping on your site, because strangely enough, on all of those “HELP I RAN OUT OF HYDROS” messageboards I keep running into in the search for knowledge, I haven’t seen a single mention of meetings or steps, probably the reason for all the negativity on there.
Anyway, that’s all I have. Just wanted to share my thoughts, and thank you for instilling some optimism in this formerly hopeless dope fiend.
Thanks for letting me share,
SuboxDoc · February 19, 2009 at 7:30 pm
Thanks for your comments. We learn more about using Suboxone as time goes by; I have to be careful myself, as I am well aware of the ‘cures’ that have come and gone over the years— in contrast to the 80 years of success and growth by the 12 step groups around the world. My life was saved twice– both times by the steps. I encourage, but do not require, 12 step attendance by my Suboxone patients; I feel that forced attendance is a waste of time– although sometimes I wonder if even forced attendance would result in SOME wisdom rubbing off on the person! You might notice that I tend to mention recovery programs more than I used to… I have been getting back to the ‘roots’ of recovery more and more in my discussions with patients, realizing that blocking cravings alone will rarely result in longstanding sobriety. Congratulations on your newest chip, and I hope you accumulate many more. Keep spreading the wisdom– I have come across the same nonsense out there that you are describing.