Buprenorphine Plus Hydrocodone

I often receive emails with requests for my opinion about various aspects of buprenorphine treatment.  A recent exchange, for what its worth:
Hi Dr. Junig,
I hope you are well.  I know you have written a lot about this, and I have read most of it.  But I still needed to ask your advice on my particular situation.  I will give you all the pertinent details and you can feel free to keep the answer succinct.   I know you do not have a lot of time on your hands. 
I have been successfully using Suboxone for over a year. My current dosage is three 8mg strips of Suboxone a day.  
After a recent traumatic injury I was given an Rx for  20 x 10/325 norcos.  I knew it was tricky to implement this into my Suboxone routine, but I also knew that it WAS possible to do so successfully, and that I really needed to try for purposes of comfort.   
Anyhow, my last doses of Suboxone were yesterday: 1 strip @ 7am, 1 strip @ 1130am.  
I then waited 4 hours and took 2 of the norco, followed by 2,   later, and another 2, 4 hours after that.   I took 2 at 9am this am today, followed by 3 at 1pm today.  And now I am having some serious concerns and reservations about this.  I just feel like shit now. 
And I don’t know if it’s because I am in withdrawal from the Suboxone, or because the Suboxone is still bound and the norco isn’t working?  
My current symptoms are headache, dilated pupils, restlessness, anxiety.  I just don’t feel *right*, and I suspect it’s the opiate situation that is doing this.  I don’t feel comfortable taking more norco at this point, for obvious reasons, but I am also apprehensive about taking any Suboxone right now.  
I appreciate your time and your opinion immensely.  Any guidance (opinion, gut feelings) you can provide me with would be valuable to me.  
Regards,   XXXX
My Response:
My best guess is that you are experiencing early withdrawal from reducing the buprenorphine/Suboxone, and that hydrocodone is not strong enough to replace the buprenorphine you’ve discontinued.  I say that because in the multiple times my patients have had surgeries, I always do the same thing—  continue the buprenorphine at a reduced dose of about 8 mg, once per day, and  add oxycodone, 15 mg every 4 hours, for pain control.  I’ve never seen precipitated withdrawal when starting an agonist when buprenorphine is already established.  Precipitated withdrawal comes when a person is on an agonist, and then takes buprenorphine—not the other way around.
With that in mind, if you were my patient I would cross my fingers, and have you restart Suboxone at a dose of about 12 mg per day— for example 8 mg in the morning, and 4 mg in the evening.  For pain I would give you 15 mg of oxycodone.  If you are like most people, you would get pain relief, without any of the euphoria that you used to get with opioids.
My advice to you would be the same.  I have some concern that you are feeling ‘lousy’ now, when you should still have plenty of buprenorphine in your system after only one day away from it.   But maybe the misery is psychological, or from some other random viral illness.
I have some patients with severe chronic pain, including a firm diagnosis and a solid pain history – i.e. not people with moderate pain, but people who are suffering greatly who other doctors had abandoned.  I start them on 8 mg of buprenorphine per day, and when they are tolerant to buprenorphine I add oxycodone, 10 or 15 mg every 4 hours.  The several people I’ve treated with that approach think I’m a miracle worker because they get pain relief from far lower doses of narcotic than they used before, and never (at least for a year or two that I’ve been doing this) develop tolerance.  Based on those experiences, I would think you would be fine resuming a half dose of buprenorphine, and taking an agonist on top of it.   I don’t know if you can get to an effective dose of hydrocodone and stay safe with the acetaminophen though; hydrocodone may not be potent enough to displace buprenorphine.
Good luck!
Jeff J

A Save with Suboxone?

I’d like to share a recent email exchange with a reader. The post is long, but there are several interesting aspects to the discussion. I’ve removed the conversational parts, as well as the identifying information.
The initial message:
I was an intravenous heroin user for three years. After treatment I was able to stay clean for 6 months… Well apparently to most people I was not clean because I was on Suboxone, but to me I was clean. People are so very discouraging when you tell them you’re clean and they find out you are on Suboxone. It hurts because of how much hard work you put in. I did well for six months, but then I relapsed and used for 5 days. After a short binge I again stopped, continued Suboxone and used once more for one day alone.
All of these relapses were with my girlfriend, and she used one extra time while I was working. She overdosed all three times she used. Her mother found her the second time in her room almost lifeless, and I was with her the other two times. I acted very quickly, giving her CPR immediately and calling 911 without the least bit of hesitation, as did her mother.
My girlfriend) is not on Suboxone, but I stayed on every day other than the times we used. I am pretty educated about opiates in general and I understand that she overdosed because of her lack of tolerance. I have read something you said before: A person on Suboxone maintenance has the tolerance of someone who takes 100mg of oxycodone a day. I need to know, for the sake of her life, my life or someone else’s life, if ever in a dire, life threatening situation and for some crazy reason 911 isn’t an option, could you melt down a Suboxone strip and inject the overdosed person and use it like Narcan if you absolutely had to? Or do you think I’m nuts for even asking?
One more topic… I obsess over heroin every day. It’s so bad that I sit with a calculator and tell myself, “alright, if I stay clean for these next two years and I finish my degree and start my career making this much salary then I can spend this much a day on heroin and it will total x amount of dollars a year and subtracted from my salary I will still have more than enough to survive.” How sick is that? It’s disgusting. It’s an absolute obsession of the mind. I seriously convince myself that with the right amount of steady income I could actually be a functioning addict.
Thank you so much for your time. I appreciate it so much.
My Reply:
Your email shows the incredible danger associated with use of intravenous opioids. I remember how impressed I was, when I was a resident in anesthesiology, over how the human body is SO strong and restorative, that we can survive and recover from horrible injuries… yet how fragile we are, that a lack of oxygen for only several minutes can cause death. Injecting opioids is a very effective, targeted way to kill a person. Doctors and nurses do not inject narcotics unless the patient is being monitored, usually using a ‘pulse oximeter’ to monitor the level of oxygen in the blood. Yet people with far less training are injecting the same drugs, not only without monitoring, but even in the absence of a non-impaired observer. It is no wonder that there are so many deaths from opioid dependence.
You probably know how I feel about being ‘clean’; people on buprenorphine are clean enough, in my opinion, to be considered sober. People on buprenorphine become fully tolerant to the effects at the mu receptor; there might be very minor effects at the kappa receptor, that may or may not have very minor cognitive effects…. but people take chronic medications for MANY illnesses, and some degree of sedation occurs with most of them, including medications for high blood pressure, migraine headaches, and seizure disorders. Should we consider all of THOSE people to be ‘not really clean’ too?
The question about using Suboxone to reverse overdose is very interesting– and shows that you have a good understanding of what is going on with medications like buprenorphine (in Suboxone).
One of my patients has described how he saved his girlfriend’s life by injecting Suboxone. He says that she was unresponsive and barely breathing, and out of desperation he put an 8 mg tablet of Suboxone in her mouth. When she didn’t respond after a minute or two, he quickly dissolved a tablet of Suboxone and injected it into her arm. He claims that she woke up 30 seconds later.
I’m glad his girlfriend survived, but I do NOT recommend that anyone rely on this approach to save a life. The most appropriate action, of course, is to do whatever one can to find appropriate treatment, and stop accepting the huge risks associated with IV injection of opioids. If a person has overdosed, call 911 immediately. The brain starts to die in about 3 minutes. Some parts of the country have instituted programs that provide naloxone injection kits for people addicted to opioids; injecting a pure antagonist like naloxone (Narcan) is much safer than injecting the partial agonist, buprenorphine.
The outcome after injecting Suboxone depends on a number of factors, including the person’s tolerance level and the presence or absence of other respiratory depressants. If a person has only used opioids– no benzodiazepines or barbiturates or alcohol— then in theory, injecting Suboxone would rescue the person from overdose. Both parts of the medication would contribute to reversing the effects of opioids; the naloxone (to a small extent) and the buprenorphine, which would have most of the effect. The ceiling effect of buprenorphine should prevent respiratory arrest in any person, as long as no other respiratory depressants are around.
But– one CANNOT expect the ceiling effect’s protection in the presence of other respiratory depressants. If other depressants are present, opioid tolerance becomes a big issue. I’ll describe two cases to demonstrate:
– Let’s take the low-tolerance scenario, with a person who has never used opioids or benzodiazepines, who ‘sniffs’ 40 mg of oxycodone and 10 mg of alprazolam. The risk of overdose would be high in that situation. And if, during overdose, someone injected Suboxone, the opioid effects of buprenorphine would be as great, or greater, than the opioid effects of oxycodone— so the person’s condition would likely worsen. (Note that I’m ignoring the effects of naloxone. Naloxone’s clinical effect last only about 20 minutes. That effect might help the person in this scenario, but it is hard to predict whether the naloxone would out-compete the buprenorphine that is also being injected. People who have injected Suboxone in the past tell me that they found are no difference between injecting Suboxone vs. injecting plain buprenorphine. That wouldn’t surprise me, given the high-affinity binding properties of buprenorphine.
– For the high-tolerance case, let’s take someone who is using 150 mg of oxycodone per day, but on this occasion took an amount of heroin equal to 300 mg of oxycodone. Let’s assume that there are no other depressants on board. In this case, injecting buprenorphine would be expected, theoretically, to block the effects of heroin, and not only wake the person, but precipitate withdrawal. Even if other respiratory depressants are on board, the buprenorphine would likely save the person from overdose, because the opioid effects of buprenorphine are significantly BELOW the person’s tolerance level, and below the effects of the heroin that is causing overdose.
Essentially, the high-affinity binding of buprenorphine displaces other opioids, causing an opioid effect equivalent to 60-100 mg of oxycodone. If the person’s tolerance is higher than that, the result will be precipitated withdrawal. If tolerance is lower, the result will be greater opioid intoxication.
I will stress, again, that the thing to do in case of overdose is to call 911. An even better thing to do would be to get help for anyone you know who is injecting heroin, and get help NOW—as the risks of IV drug use are very high, and nobody believes that he/she will be the next person to die. If you are in a situation where someone else is overdosing, and you inject that person with Suboxone or any other substance other than Narcan, you will likely be prosecuted, and convicted, for manslaughter.
The obsession described in your message is typical, and is the hallmark of opioid dependence. In my opinion, we (psychiatrists) should see ‘obsession’ as the primary defect in cases of addiction, as obsession is what destroys personality, undermines self-esteem, and crowds out other interests and interpersonal relationships. As I’ve written before, buprenorphine’s unique properties allow it to reduce or eliminate the obsession for opioids. Buprenorphine, I believe, is an effective, targeted way to treat opioid dependence.
His message back:
Being a psychiatrist, what are your thoughts on that obsessive thinking? I hate meetings and the 12-step programs. I lived in a half-way house for a month and a half that required 3 meetings per day. I agree with you that they create a fabricated sense of happiness and self-worth. Do you recommend staying on Suboxone for an extended period, especially during a time where i am still having these thoughts? And because of the way I feel toward meetings should I seek a psychiatrist and try to explain my thought process in order to try and change it? What would you recommend to someone in my situation who obsesses to that degree, and hypothetically plans his future around heroin?
Me Again:
I have seen SO many people who stopped Suboxone, then relapsed years later and lost a great deal. I’ve seen obituaries of former patients who used to be on Suboxone. If a person can take the medication without too much hassle— i.e. has a doctor who allows ‘remission treatment’ without making the person feel like a second-class citizen– then long-term Suboxone provides for the best chance of doing well in life, in my opinion.
Other than buprenorphine, the best ‘treatment’ for the obsession, in my opinion, is fear. Step programs tap into that fear, by emphasizing powerlessness— the realization that using even one time will definitely, without a doubt, lead to your destruction. Every thought about using should be confronted with that reality— that if you use, you will die. Relapse often starts with the idea that maybe the person can get away with it, maybe just once… so to stay sober, the person must KNOW that there is no way to try it, even once. That is a bummer, but not the end of the world! Humans love to feel powerful, but attendance at meetings helps reinforce the reality, and the value, of powerlessness. I’ve written about my own experiences back in 1993, when the realization of my powerlessness caused my desire to use to suddenly disappear. If only I could have remembered that powerlessness, even as my life got better!
I do not think that psychotherapy is all that helpful for obsessions. In fact, I think that psychotherapy can be dangerous, if it leads to the thought that you have everything figured out— a thought that the addicted personality loves to run with!
The challenge when treating with buprenorphine is to instill and reinforce the knowledge of powerlessness, even while treating the obsession for opioids with a highly-effective medication. The thought process becomes a little more complicated, but not impossible to grasp.

Avoiding Precipitated Withdrawal

I received the following question earlier today:
Hello Dr. Junig, I am opiate dependent or rather an opiate addict. I want to seek treatment because I can’t continue this life style. I have questions about treatment. Do I have to be in full withdrawals when I go to see a doctor? Is it true that most doctors probably won’t see me because they have too many patients already? I know Suboxone works for my withdrawals. I’ve stuck in this rollercoaster for at least four years and now I know it’s time for me to seek help.
My thoughts:
My comments, as always, are intended to increase general knowledge about buprenorphine and to promote discussion between patients and their doctors.  They are not intended to take the place of a relationship with a ‘real’ doctor!
The appropriate waiting period before starting Suboxone– ‘induction’– depends on the person’s opioid tolerance, and on the specific opioid that the person has been taking.  An opioid-free delay before induction reduces the amount of opioid agonist bound to the receptor, and lowers tolerance to some extent.  Starting Suboxone or buprenorphine is likely to cause precipitated withdrawal when either 1. There is agonist binding at the mu receptor, or 2. There is very high opioid tolerance.
It is hard to give exact guidelines, as every person reacts a bit differently.  But in general, people match up well for Suboxone induction if they are taking about 60-80 mg of oxycodone equivalents per day.  Someone on that amount of agonist, who waits over 12 hours, will generally do well at induction, unless the person has been taking methadone.  In that case, a longer waiting period is beneficial.  How long?  As long as possible, and at least a few days.  Even so, the transition from methadone to buprenorphine is difficult, often causing headaches or minor withdrawal symptoms for several days.  The best response to precipitated withdrawal is to take the prescribed dose of Suboxone/buprenorphine each day, without trying to overcome the symptoms by taking more of an agonist or extra Suboxone.  Doing so only lengthens the period of withdrawal, and considerably increases the risk of death.
If a person is taking a very low dose of an agonist, or taking a weak agonist like hydrocodone, the problem at induction isn’t withdrawal, but rather opioid intoxication, causing respiratory depression and nausea.  Nausea during induction is much more likely to signify relative overdose, NOT withdrawal.  Patients who have nausea and vomiting from buprenorphine or Suboxone should NEVER take a second respiratory depressant or sedative!  When in doubt differentiating between withdrawal and opioid intoxication, the pupils are a good guide.  Withdrawal comes with LARGE pupils.
If a person is taking a very high dose of agonist each day– over 150 mg of oxycodone or methadone, for example— that dose should be tapered down over time, to the equivalent of 40 mg of methadone per day.  Unfortunately, some people cannot carry out or tolerate such a taper.  In those cases, it may be better to have the person in a controlled environment, and wait as long as possible before induction.  Even if tolerance is very high, a person will often do well if off opioids completely for 4-5 days or more.  Of course, that’s easier said than done!
There is a cap on the number of patients that doctors can treat for addiction using buprenorphine.  Doctors can have up to 30 patients at first, and can petition the DEA to increase to 100 patients after a year.  It is frustrating to keep people who are desperate for help on a waiting list— especially when there is no limit on the number of pain patients that a doctor can treat using opioid agonists!
Suboxone relieves withdrawal symptoms when taken properly.  But the main function of buprenorphine/Suboxone is to eliminate the obsession to take opioids, and to allow patients to move forward in life without substances.  People do best if besides Suboxone, they focus on other principles of recovery, determined with their physician or with a counselor.  The point of Suboxone, in my opinion, is to learn to tolerate ‘life on life’s terms.’  That includes dosing at most twice per day, and learning to say ‘no’ to the minor cravings that most people have, even on Suboxone.
I’m glad you are looking for help– and I wish you the best!

Precipitated Withdrawal– Now What?

I saw this question on another board– I didn’t want to add my reply to the other five answers already listed, so I’ll put it here for hopefully the next unfortunate person in ‘precipitated withdrawal’ to find.
For those who don’t know, precipitated withdrawal occurs when a person’s level of opiate stimulation is suddenly reduced by another medication blocking the receptor site.  This occurs when an overdose patient is given an opiate antagonist such as IV naloxone.  As soon as the naloxone hits the receptors in the brain, the oxycodone, methadone, heroin, or other agonist is ‘displaced’ and the receptor is ‘blocked’ by the naloxone.  I actually did this to myself on several occasions back in my using days; once by out of desperation and stupidity using an unmarked syringe that contained naloxone, and two other times by ingesting naltrexone, an orally-active opiate blocker, in attempts to make myself ‘get clean’.  Those experiences lead to my first comment about precipitated withdrawal:  you won’t die… but you will wish that you did!
The active ingredient in Suboxone, buprenorphine, will cause withdrawal if a couple things are present: first if the person has taken an opiate agonist recently enough so that there is still agonist drug bound to the receptors, and second if the person’s tolerance is greater than that associated with about 30 mg of methadone– equal to the opiate-stimulating activity of Suboxone. If a person just took his first 20 mg of oxycodone, I wouldn’t expect the buprenorphine in Suboxone to induce withdrawal because at his tolerance level, his receptors will see buprenorphine only as an agonist– not as an antagonist. The rules are not ‘hard and fast’, but depend in a complex manner on the interaction between recent use, half-life of the recently-used drugs, and the person’s tolerance. For example, if a person is used to 600 mg of oxycodone per day, but hasn’t used for 24 hours—long enough to get most of the oxycodone out of the system—I would still expect the person to have precipitated withdrawal– because even after 24 hours without using, the person’s tolerance level will still be quite a bit higher than the ’30 mg of methadone’ level of stimulation caused by buprenorphine. There is a bit of an art to avoiding the withdrawal, but sometimes it can’t be avoided. For example, in the 600 mg oxycodone case, I could tell the patient to go without using for three days;  that would be enough time for their tolerance level to drop closer to the ’30 mg methadone’ mark… but the person will feel utterly horrible during that time, and sometimes it is obvious that there is NO chance the patient will stay clean that long. So there are two choices; schedule an induction in three days and then cancel when the person breaks down and uses something the night before the induction, or shoot for 24 hours of clean time and let the patient know that he/she is going to be a bit sick at the induction.
I should mention that the ‘proper way’ to manage the patient taking 600 mg of oxy per day is to taper the person down to the equivalent of 30 of methadone per day.  This never works;  first of all, it is illegal for any doc to taper opiates for the purpose of treating opiate addiction, unless the doc is part of a registered methadone center– and methadone centers, in my experience, are not interested in doing the work of tapering people off opiates.  They tend to do what they want, and that is to increase the dose of methadone– not decrease it.  But even if the patient found a doc willing to break the law and schedule a taper, the tapering schedule cannot be followed by the addict.  I suddenly think of the old joke…’if I could walk THAT way, I wouldn’t need the talcum powder!’…  as I think in a similar vein, ‘if I could do a taper, I wouldn’t need an addictionologist!!’

The good news is that precipitated withdrawal is much shorter than real withdrawal.IF you have precipitated withdrawal, all is not lost—providing you do the right things.First, understand that you are going to be sick for about 24-48 hours no matter what you do.Your choice, at this point, is: after you get better, will you be on Suboxone, or will you be using?

If you have PW (I’m sick of writing out Precipitated Withdrawal), the most important thing is to FINISH THE INDUCTION! Complete the dosing of Suboxone, as quickly as possible—take the full 8 or 16 mg. If you stop the induction early, after only 4 mg, you will likely end up using later in the day to try to overcome the block.  That gets real dangerous, and only prolongs the misery– and in a few days when you finally have the Suboxone out of your body you will still be using. On the other hand, if you complete the dosing of Suboxone– take the full induction dose of 8 to 16 mg– you will be at a place where no amount of using will overcome the block (so don’t even try!).  Try to deal with the withdrawal in the usual manner (clonidine, immodium, warm bath) and the next morning take another 16 mg dose of Suboxone. Keep dosing each morning—DON’T mess with multiple daily doses as they won’t help and they can potentially make it worse (if you take very large doses of Suboxone it becomes a pure antagonist). If you just keep dosing 16 mg per day each morning, by day two you will be much better, by day three you will be 90% better, and by day 4 you will be out of withdrawal. It’s fast—unless you play with it.

By day 4, you’re done with the misery and on Suboxone. Your addiction will be in remission, provided you do the other things required to get better—things which are usually fairly easy to accomplish if you have some level of desire for the sober life. And it is wonderful to have the chains removed! Once you are at this point, KEEP TAKING THE SUBOXONE! I read the comments at some sites about ‘coming off sub’—it is important that you understand that virtually ALL of those people—the ones who go on Suboxone, get their lives back, but then believe some idiot ranting that ‘they aren’t really sober’ and go off Suboxone— will only be using again, probably in a matter of weeks. It is so unfortunate… people go to these message boards and read ‘support’ and ‘encouragement’ to ‘get off Suboxone’, usually doing the taper wrong, suffering through unnecessary withdrawal, and blaming their misery on the Suboxone…  Then they write with excitement how they are now ‘really clean’… But in a week they are gone from the message board, too busy to write, scrounging up money to buy dope—or more likely, selling their computer for the money for dope. It doesn’t work, people.

Is it ever possible to get off Suboxone?  Yes– if you are willing to treat your addiction with something else, usually twelve-step-oriented recovery.  Suboxone alone is not a cure– it is a means to induce remission of opiate addiction.  For someone who got clean ‘the old fashioned way’, the glass is half full!

Waiting for Suboxone after Heroin

How long do you have to wait before taking Suboxone, if one had been using heroin for almost a year? What can one take to ease the withdrawal symptoms in the meantime while waiting? Are treatment centers effective places to go to as a start or just start out with a qualified Suboxone doctor? Any feedback would be great! Thank You.
Hi, and thanks for writing.  Once a person has been on something for a couple months it doesn’t matter if it is three months or three years– the tolerance and risk of precipitated withdrawal are more a function of dose and type of drug than of time.  For example, methadone and high-dose fentanyl have long elimination half-lives and therefore take longer to leave the body before starting Suboxone, whereas low-dose fentanyl or crushed oxycodone have short half-lives and leave more quickly.  Heroin is somewhere in between, longer acting than oxycodone but shorter than methadone.
As soon as you start withdrawing, your tolerance will start to fall.  It falls the fastest initially and then slows down a bit after the first couple days.  For heroin, people who go three days without using will do great– that is more than enough time.  If your daily dose is on the low side 24 hours is sufficient to avoid precipitated withdrawal;  if your dose is real high you might want to try to go a bit longer, say 36-48 hours or so. Treat withdrawal symptoms by treating the individual symptoms.  First, take clonidine– that will reduce all of the symptoms by about half.  It requires a prescription but most docs will prescribe it, as it is pretty safe.  You can take the skin patch, but i prefer the pills because they can be controlled more easily to increase or decrease the dose.  I give 0.1-0.3 mg every six hours or so; stop it if you get light-headed when standing up quickly.  It is a $4 med at Wal-Mart. For the diarrhea and cramps, take immodium, sold over the counter.  For body aches take ibuprofen and tylenol (both if your liver and stomach are in good shape– avoid the tylenol if you have hep C).  A small dose of ativan or valium goes a long way in the evening;  the clonidine helps with sleep as well.  If you don’t have either you can take some benadryl– it will make you sleepy and might reduce your anxiety a bit.  Keep warm by soaking in a hot bath as much as possible– that will also relax your muscles.
Some detox centers use Suboxone, but some don’t– be sure to check.  Likewise different providers have different styles.  The local hospital by me makes Suboxone patients spend the night before induction!  Not sure how the insurance companies let them get away with that.  But some docs around here make people wait longer before starting Suboxone– I have heard some descriptions of other places that sound a bit silly, like ‘just don’t take anything for a week’.  Hmmm. Reminds me of that old joke where the guy goes into the pharmacy and asks for talcum powder and the woman says ‘sure– walk this way’.  As she walks away the guy says ‘if I could walk like that I wouldn’t need the talcum powder!’   (sorry– working on a Sunday does that to me…)

Precipitated Withdrawal

thank you anyway for replying.. So when i do get into seeing a doctor, i must be in withdrawal? I am so confused on this issue.  I am taking suboxone, but most likely have to take the lortab when it is out of my system because of the pain i do have. The lortabs are a prescription that i have been on for over a year.  I just know that i can’t stop taking them on my own, thats why i tried the suboxone.  I researched how to take it and it works wonders for me.
My Answer:
The primary issue with precipitated withdrawal isn’t so much being in withdrawal, but instead has to do with your level of tolerance.  Tolerance goes up with every dose of an agonist, and plummets when a person is in withdrawal.  In predicting precipitated withdrawal one looks at whether a person’s tolerance is higher or lower than it would be taking 30 mg of methadone per day.  A person taking 100 mg of methadone per day who didn’t start withdrawal will have severe withdrawal during Suboxone induction;  A person taking 10 mg of methadone per day who didn’t start withdrawal may actually get a mild ‘high’ during methadone induction.  Lortab includes hydrocodone, the active ingredient in Vicodin.  Hydrocodone is metabolized to a more potent drug—hydromorphone or Dilaudid—to varying degrees in different people (I am about to post something about that), so it is hard to predict the tolerance level in a person on hydrocodone.  The tolerance depends on how their genetics make them metabolize the drug.  For that reason one cannot simply say that 50 mg of vicodin per day won’t result in precipitated withdrawal.  These metabolic relationships occur with other opiates as well and explain why some people say they have never had precipitated withdrawal, and other people do have it, despite taking the same doses of the same opiate.

It is impossible to guarantee that precipitated withdrawal won’t occur, but one can make it exceedingly unlikely by reducing their use of opiates a bit as the induction approaches and then getting good and miserable before starting the induction by discontinuing use for 24 hours or so.  People on super-high doses of a drug like methadone (which tends to stay around in the body for awhile) have the highest risk for precipitated withdrawal, but can make it unlikely by stopping use for 3-4 days, as tolerance drops the fastest in a person who completely stops using.  For what it’s worth, I had precipitated withdrawal myself back in my using days on at least 3 occasions;  twice, in desperation, I took oral naltrexone (an opiate blocker) thinking it would help me stop using;  a third time I injected IV narcan by accident.  The naltrexone incidents were the worst, as that drug lasts for 24 hours or so.  It was pretty horrible, but I did live through it, and the experiences certainly gave me a stronger desire to stay clean!
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