Buprenorphine for low-dose opioid use

A reader wrote with a question that I don’t think I’ve addressed on the blog.

Do you have a threshold for how much narcotic a patient must be using before you will put them on buprenorphine? I am concerned about narcotic addicts that are using 6-10 Vicodin (hydrocodone) a day for example.  Many have very mild withdrawal symptoms, but are never-the-less unable to stop on their own.
This is an insightful question that provokes enough discussion to fill at least one blog post.  I don’t have a simple answer, other than to go on a case-by-case basis and try to determine who, if anyone, might be able to walk away from opioids completely (i.e. a person who I would be less likely to put on buprenorphine, as doing so would drive tolerance higher) vs. those who will need maintenance treatment eventually, even if their doses are not yet very high.

Patients have a right to know if they are having their tolerance increased in my opinion, given the misery involved in bringing tolerance down.  It is also important to tell people with lower tolerances that they are going to get a buzz from buprenorphine for a few days because of the potency of buprenorphine.  This opiate stimulation is likely to occur even with a very small piece of a Suboxone tablet; a quarter tab or 2 mg of buprenorphine has almost the same potency as 16 mg because of the ‘ceiling effect.’  The potent opioid effect may make the doctor liable for a car accident, or could even lead to overdose if the patient combines buprenorphine with other respiratory depressants.

In general,  the ‘break even’ point on the tolerance scale is 80-100 mg of hydrocodone or about 60 mg of oxycodone per day.  In other words, if the person is taking 8-10 of the larger-strength Vicodin per day, I would consider Suboxone to be of about equal potency.

In considering whether a person’s use and tolerance are high enough to call for buprenorphine, some people focus too much on the initial potency relationships, and forget that opioid dependence is almost always a long-term condition.  I’m not sure by your last sentence whether you realize or not that the presence or absence of bad withdrawal is a red herring for acheiving sobriety from opioids.  Many addicts mistakenly think that withdrawal is the primary force that keeps them actively addicted.  In late addiction they find that desperation helps them get through withdrawal over and over, but they continue to relapse– as soon as they feel well!

From a scientific perspective, I have not seen evidence of a correlation between the severity of addiction and the addict’s tolerance level (if anyone has seen such a study, please forward me the reference).  At the same time, I don’t think I would feel comfortable starting buprenorphine in a person taking a couple Tylenol 3’s per day.  Luckily (?), this type of situation has been rare in my experience.   I should do chart reviews and publish the exact numbers, but out of the 500 or so people presenting with opioid dependence over the past 5 years, I would guess that the average tolerance level is approx. 120-150 mg of daily methadone (range of 30-400 mg per day), or approx. 160 mg of oxycodone per day (range of 40-700 mg of oxycodone per day).  Yes, I had two people—interestingly, both women– come in at those upper daily doses of methadone and oxycodone.   The methadone patient had been labeled a ‘fast metabolizer’ of methadone as reason for the ridiculously high dosage.  The reason seemed good enough, until I found, when converting her to other agonists for pain, that her tolerance was ultra-high to ALL opioid agonists—telling me that she was not metabolizing the methadone fast enough to prevent her body’s response to the high dosage, and calling the entire ‘fast metabolizer’ issue into question.  The woman taking the large amount of oxycodone had inherited a tidy sum of money; hundreds of thousands of dollars, all gone after one year of using.