I often answer questions about Suboxone that require the qualification ‘if it is being absorbed properly’. If a person asks how long it take for Suboxone to wear off, or at what dose does the ceiling effect occur, I need to be sure that the person is taking it in a way that maximizes absorption; otherwise all bets are off. If a person simply swallows the tablet, for example, the level of buprenorphine in the bloodstream will be much lower than if it is taken correctly. How can one optimize the absorption of Suboxone?
The usual instructions for taking Suboxone are to place a tablet under the tongue and let it dissolve. It is important that Suboxone be taken once per day, in the morning; this instruction is included in the course for physicians but is too often ignored. I will talk another time about the philosophy for dosing once per day; the basic reason is to extinguish the behavior that has been conditioned as part of the addiction. But the point of this post is the absorption of buprenorphine from the tablet into the bloodstream, and how to maximize that absorption. It is important to maximize absorption, particularly if one is trying to save money by reducing the daily dose of Suboxone.
From my experiences as an anesthesiologist and as a PhD chemist, I consider three factors when maximizing absorption. The first is the concentration of buprenorphine in the saliva, as the drug diffuses into tissue down it’s concentration gradient; this is maximized by having a small volume of saliva. I recommend that a person start with a dry mouth, place the tablet in the mouth, and crush the tablet between the teeth until is is dissolved in a small volume of a concentrated solution.
The second factor that affects absorption is the amount of surface area; buprenorphine is absorbed through all mucous membranes (the tissue lining the inside of the mouth), passing through the surfaces and entering capillaries, the route into the bloodstream. So the concentrated solution should be ‘painted’ repeatedly over all of the surfaces inside the oral cavity; the inside surface of the cheeks, the tongue, the roof of the mouth, under the tongue, the back of the throat… swished around in the mouth over and over, repeatedly bringing the concentrate into contact with new areas of mucous membranes.
The third factor is time– the longer period of time, the longer for the buprenorphine to make contact with the mucous membranes, attach to the surface, get absorbed into the tissue, and enter the capillaries. The initial process will be the saturation of the surfaces of the mucous membranes, and the slower process will be the passage into the tissue; that is why the amount of surface area has such an important effect on absorption.
The onset of action of the drug suggests that fifteen minutes is sufficient for most of the absorption to occur; there may be drug remaining that is attached to the surface but not yet fully absorbed, and so I recommend avoiding eating or drinking within another fifteen minutes or so.
If you pay attention to these principles you will maximize absorption of the drug. The ceiling effect will occur under these conditions at a dose of about 2-4 mg; the long half-life of the drug will guarantee that if you take over 4 mg or so each morning, you won’t have any significant withdrawal for over 24 hours– allowing once-per-day dosing. Yes, early in treatment patients will feel as if they need to dose more frequently– but that is not because of too little buprenorphine, but rather because of conditioned behavior.
A person early in Suboxone treatment will have feelings or minor withdrawal in the late afternoon or evening after dosing in the morning; those minor withdrawal sensations will go away in about 15 minutes if the person takes more Suboxone, and will also go away in 15 minutes if the person doesn’t take Suboxone. If the person takes more Suboxone, it will reinforce the sensations and the person will get stuck on dosing twice per day. If, on the other hand, the person uses distraction and avoids dosing, those minor withdrawal sensations will completely disappear in a week or two, as the conditioned behavior is extinguished.
1 Comment
blc · February 4, 2009 at 11:14 pm
I’ve been reading your blog posts for several weeks now and finally feel compelled to register and comment. While an email would probably be more appropriate, I was unable to find a link or address. Please excuse me for being off the subject of this particular post.
I am a recovering addict with a twenty-seven months free from active addiction. I’ve been able to put this time together only with the help of Suboxone, which I’ve been taking daily for these twenty-seven months. I was a garbage can addict, addicted to everything for most of my life, but the last seven (worst seven) were those final ones where had a heroin and cocaine habit. I got clean traditionally, with severe withdrawals by locking myself in my house and going to two-three NA meetings a day, and my first try managed to stay clean for eight months. Then I battled… in and out of the rooms for four months, relapse for a week, then two months, relapse for a week, again and again and again. I thought it was hopeless. I tried Revia and ended up in an ER when I cheeked my dose, used, then took it again.
Anyway, I’m rambling… I wanted to thank you for your posts. I find them very reassuring and helpful. I couldn’t agree with you more. I am like many on suboxone a cash pay patient and while the medication combined with the monthly doctor’s visits cost nearly $600/mo, even just financially it is a great savings over active addiction not even considering the freedom it affords me. I hope you continue to post. I just found some of your vlogs (videos) and have enjoyed as well. I don’t even bother telling people at meetings anymore and share my suboxone secret (it feels that way sometimes) with only a few that won’t judge me, and those newcomers that I think may benefit. I switched sponsors over this about a year ago.
Well, now that I am registered I suppose I’ll comment in the future. (hopefully more on-topic) Thank you again. Really, I hope you know how much you are appreciated, by me and I’m sure countless others who you’re helping.