Ending Constipation from Suboxone and Buprenorphine

Constipation is one of the few potential side effects caused by buprenorphine medications, including Suboxone Film and Zubsolv. Fortunately, ‘binding up’ can be managed by making minor changes to your lifestyle.

Constipation from buprenorphine is caused by activation of mu opioid receptors in the small and large intestine, reducing the sequential squeezing and relaxation (called peristalsis) that pushes bowel contents forward. All opioids have similar effects, mimicking our natural endorphins throughout the body. Endorphins are released during trauma to naturally block pain and to divert blood flow to areas where it is needed most — and the bowel is relatively shut down during those periods to conserve energy.

Constipation problems from buprenorphine (I’ll use that term for Suboxone, Zubsolv, Bunavail, or any other form of buprenorphine) often occur in people who are already having some constipation problems, where the medication makes things worse. The first few ideas I’ll offer will help anybody, regardless of whether they take buprenorphine or other opioids.

Diet and Hydration

The function of the large intestine is primarily to reabsorb water. The amount of water reabsorbed is related to the time that contents spend in transit. This will be a bit graphic… but that’s why the first part of a bowel movement is generally hard and drier than what follows. That first part has been through the ascending colon, the transverse colon, the descending colon, and the sigmoid colon, and has hardened into something like adobe bricks. After that has been pushed out of the way, the remaining stool passes through more quickly, with less drying.

The most important step to avoid constipation is to keep things moving. If nature gives you a chance to go, take it! If you manage to skip the chance, it would only be harder to go tomorrow.

Many people fail to drink enough liquids, especially those who live in hot environments. If your body is relatively dehydrated, your colon will work harder to conserve water. Staying hydrated — to the point where you urine is light-colored — will reduce constipation.

Diet, of course, plays an even larger role. Those of you who work with concrete know that certain additives will make the mix more strong or dense. Throw in a bale of hay, and the opposite happens. So add food to your diet that contains fiber, which reduces concretion and adds bulk, making it easier for you colon to compress and push the mass forward.

Certain foods like prunes and plums have chemicals (as well as fiber) that keep the bowel moving. Other foods — e.g. cheese and processed foods — can slow things down.

Medications

Add medications only when the ideas listed above aren’t working. Consider softening agents first, as they have less effect on colon function and are less likely to create a dependence. Medications with docusate pull water into the feces to soften them. Drugs that contain sorbitol, magnesium, or polyethylene glycol pull water back into the colon, increasing the volume of feces which then stimulates a bowel movement.

Senna and bisacodyl stimulate the colon to increase peristalsis. I usually recommend Senokot to my patients, as it comes in liquid form that can be added to juice in measured amounts. With all of these over-the-counter products, be sure to follow the directions on the bottle. ALL of them can do harm if taken in excess. Stimulant laxatives and cathartics can also create tolerance and dependence, so avoid using that approach for more than 2 days in a row.

Nothing Works!!

It is possible for constipation to block the colon completely. The last things on the list are enemas and suppositories, which work from the other end of the obstruction and aren’t, obviously, something to use routinely. Glycerin suppositories lubricate and also stimulate the colon. Bisacodyl suppositories stimulate the colon to provoke a bowel movement. Enemas stimulate peristalsis, lubricate, and soften feces. Many people, though, are uncomfortable doing enemas at home.

If you are completely blocked up, stimulant cathartics will cause pain and vomiting. In that case, you may have to bite the bullet and go to the ER.

if none of the convenient options are working, you might consider ‘dosing and spitting’. At the liver, buprenorphine is metabolized to norbuprenorphine, an opioid agonist that does not cross into the brain. When you take 8 mg of buprenorphine, about 30% of the dose is absorbed into the bloodstream and the other 70% is swallowed and metabolized to norbuprenorphine. If you dose for 10 minutes and then spit out the remaining saliva, you will reduce the formation of norbuprenorphine, and reduce constipation. It takes about 5 days to start seeing results because norbuprenorphine builds up in your system over time. The practice might turn off your friends so try to do it in private!

Keep in mind that solving the constipation problem will require making a change that you can continue going forward. Drinking more water and eating more fresh fruits and vegetables are great places to start.

Dr. J

Stopping Buprenorphine in Three Steps

Readers will sometimes ask for my thoughts about buprenorphine. I’m always happy to respond, time permitting. I’ve described how my patients taper off buprenorphine in prior posts, but the interest out there warrants revisiting the topic.

Most people who become dependent on opioids become very fearful of withdrawal. That fear continues on buprenorphine medications like Suboxone, Zubsolv, and generic buprenorphine. Patients should strongly consider using buprenorphine to keep their addictions in remission for at least a year or two before starting a taper, and those prone to relapse to opioid use should consider life-long medication. Doctors regularly use medications with higher risk-profiles than buprenorphine to prevent illnesses with lower associated morbidity!

But some people feel trapped by their fear of withdrawal. Such an attitude is completely unnecessary, because most people can taper off without too much trouble. Over the years, hundreds of my patients have tapered off buprenorphine.

Are You Ready?

The first thing to do is to consider whether you are ready to taper. Stopping buprenorphine IS difficult when tried too early, before the mental connections to opioid use have faded. To assess readiness, I make sure that the patient has been dosing once or twice per day, ‘as needed’, which reinforces the behaviors that treatment aims to eliminate. You should be doing well with prescriptions, and not running out early.

Make sure the odds against relapse are running in your favor. Several studies have shown that relapse rates are very high – over 95% – in people who have been on a maintenance agent for less than 12 months. Relapse is also more common in people who are frequently exposed to their drug of choice, so if you’re still hanging with the same crowd, consider staying on buprenorphine. Finally, your odds are improved by being busy. If you’re not working, consider holding off on tapering until you are.

Just Do It!

If you’re ready by those standards, I recommend dosing twice per day during a taper.  Dosing twice, rather than once, will be helpful when you get to blood levels that dip below the ‘ceiling effect’ during a 24-hour day.

So you’re taking 8 mg in the AM, and 8 mg in the PM.  They don’t have to be 12 hours apart;  many people choose around 7 AM and then around dinnertime.
The first step is to remove 2 mg from the PM dose.  Take that amount, 14 mg/d, for two weeks.  Then remove 2 mg from the AM dose and stay at 12 mg/d for the next two weeks.  Then remove another 2 mg from the PM dose, wait two weeks, and then remove another 2 mg from the AM dose.  It takes about 2 months do do all that, and now you’re at 8 mg/day.   Unless you have an unusual metabolism, you won’t have significant withdrawal during this first part.

The second half of the taper takes more time, and works best if you have the film.  You do the same as you did in the first part – i.e. remove a little bit from alternating doses – but you will need to remove less than 2 mg.   There are three things that make the second half of the taper more difficult:

  1. It is harder to consistently divide smaller pieces.
  2. The dose/response relationship is now a steep diagonal line rather than the horizontal line present at ‘ceiling effect’ doses.
  3. Your body’s response to a dose reduction is based on percent change, not the change in amount.   Taking 2 mg from 16 is 12%, but taking 2 mg from 4 is 50%.

As you start the second half of the taper, tear off about 40% from one end for the morning dose.   At night, tear off a similar amount.  Keep doing that amount for 2 weeks, then change to tearing off a little less. Repeat.

Within a couple months you’ll be down to about 2-4 mg buprenorphine per day.  At this point you will want to get more precise.  Get a razor or a sharp scissors and cut the film into quarters, lengthwise.  Now when you tear off pieces, the pieces will be 25% of the dose that you would get from tearing an entire strip.  Better yet, have your doc prescribe the 2 mg films.   However you do it, you just keep slowing reducing the dose, and keep dosing twice per day.  ALWAYS wait a couple weeks between dose changes to allow your body to adjust.

When you get down to less than 0.3 mg per day, you can ‘jump’ without too much discomfort.  Some people taper lower, but if you’ve been at 0.3 mg for at least a couple weeks, you shouldn’t have too much trouble.

There will be times when you find that you have reduced by too much too fast.  When those times come, go back a tiny amount, but avoid giving up all of the gains you made.  And now and then, give yourself a reward – maybe get a massage (if that even happens during a pandemic!), or go out with a friend and get a good meal.

Tapering off Suboxone will NOT be the hardest thing you’ve ever done.  As you make progress you’ll see that all of those people on the internet were wrong when they said ‘it is the hardest opioid to stop’! Good luck, and check out the forum too (suboxforum.com)!

Dr. J

Considering Suboxone in NE Wisconsin? Study Enrollment Ends Soon

I have talked a number of times about the fact that Suboxone is only a part of recovery from opiate dependence.  I have been one of the docs recruiting patients for a study that looks at an additional component of treatment that is provided by telephone.  Patients starting Suboxone for the first time for treatment of opiate dependence, or patients who have taken Suboxone in the past but not for at least three months, are eligible for the study (there are a couple other conditions that are relatively minor).   What’s in it for you?  If you participate for the full six months, you are paid a total of $225 by the organization doing the study.
Recruitment for the study will end at the end of 2008.  So if you are ‘on the fence’ about starting treatment, or waiting until after the holidays, here is a reason to start your new life sooner rather than later.
Besides, I can promise you that you holidays will be much more enjoyable if start now, and give up the miserable life of active opiate addiction.