A question from a person caught out of town without Suboxone:

Hello doc – After weeding out all the misinformation on Suboxone which can be found on the ‘internets’, I now I read your blog pretty much exclusively. I have an important time-sensitive issue here and could use your advice.

How to increase level of Suboxone?
Ran out of Suboxone?

I have been on Suboxone/Subutex in some form since March 2008, after a 3 y/o long affair w/opiates and dangerous amounts of Tramadol. I recently went rapidly down from 20 mg/daily to 8-10mg/daily. Feeling not too bad – just sleepy w/lack of energy. I’m pretty much maintained at 8 mgs right now and hoping to stay that way until I go down to 4 mgs and stay there for awhile.

I will be w/o the subs for 2 days here (took my 8 mgs today and am out of town, like a dumbo cannot get my hands on my rx until Sunday.) I do however have access (per my dr) to methadone. I plan on maintaining w/as little as possible (30 mg max) for the next 2 days, and then going back to my Subutex, 8 mg/daily. I was wondering if you could give me any info you may have on taking an intermediate dose of methadone during subutex/suboxone maintenance tx?

Basically, my concern is whether i will have to wait the requisite 48-56 hrs (or longer!!!) you would normally have to after stopping the methadone (on Sunday — after taking it only Friday & Saturday) before transitioning back to the subutex? I’ve heard if you are stabilized on the Subutex beforehand, then you shouldn’t have to wait as a long as if this were a typical ’sub induction’ when only taking a couple days worth of methadone between – but I’m not sure?

I’ve tried to contact my sub doctor but have not yet heard back. I really do NOT want to jeaporadize my recovery w/a drawn out w/d and possible relapse (which is the reason I got on the subs in the first place – always relapse w/cold turkey) – so I do feel this is a matter of not only my recovery, but of life and death. I know I need to speak to my doctor – do you have any advice for me? I wonder if I’d be better waiting it out cold turkey until Sunday? I just know how awful I feel when I miss my usual sub dose – going through the emotional roller coaster I’ve been on, and needing to work over the weekend, I feel like my recovery will be at risk! Any advice? thanks!

Understand that there is no ‘set’ way to do things; only some general ideas based on the science, that may or may not work as expected:

The good news is that you won’t get sick when you go in the direction of subutex to opiates like you do in the opposite direction. If you take the methadone too early it will only be blocked and wasted—but it won’t make you sick. If it were me, I would stop the subutex when it runs out and then go as long as you can, using the methadone only when needed to treat withdrawal, in as small of a dose as needed. And when it is time to re-start the sub, stop the methadone until you get into some good withdrawal, and then re-start. If you stop for about 24 hours you should be fine for several reasons:

First, methadone has different actions when taken for a long time than when taken for a few days. After just a few days of use, it doesn’t accumulate in the body as much and will wear off much more quickly. Second, if you don’t go over 30 mg methadone per day, you won’t be at a tolerance much higher than the strength of Suboxone… so when you start on Suboxone you won’t have significant precipitated withdrawal.

If you DO get precipitated withdrawal, it shouldn’t be too bad—it tends to be shorter-lived than the real thing. You want to just proceed with the Suboxone each day, taking the full dose each morning.


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