31 Comments

  1. Becca

    I have a question for someone my husband and myself have been in a Suboxone clinic for 8 months and last week we had a urine test and he tested positive for buprenorphine and negative for naloxone but my tests come out perfectly I took the strip cut so where we can come together I am wondering how this is happening please I need an answer

    • Naloxone does not always show up in urine tests in people taking Suboxone. A very small amount of the naloxone is absorbed, especially if the person is taking it properly (3% is absorbed under the tongue, but 100% is absorbed if injected IV). Naloxone ie destroyed by the body very quickly. So I would not be concerned if no naloxone appeared in urine testing. You probably metabolize the nalone a bit more slowy, or maybe your urine was more concentrated, and that’s why yours showed up but his didn’t. He should NOT be discharged for something like that!

    • One reason the answers vary is because the time varies– between individuals, and depending on the dose, how long it has been taken, and the testing methods. From the start, people metabolize buprenorphine at different rates, depending on the activity of enzymes called ‘cytochromes’. Those enzymes vary by over 100% dependinig on genetics, and they are also impacted by many medications. Buprenorphine is mostly metabolized by CYT3A4, and you can see medications that induce (increase) or inhibit that enzyme’s activity at wikipedia: https://en.wikipedia.org/wiki/CYP3A4.
      One dose of any drug, including buprenorphine, leaves the body quickly– but taking a drug for days causes it to build up in the body, making tests positive far-longer. One dose is usually not detectable after 3 days, but someone who has taken it for months will test positive for a week or more after stopping.
      Finally, mass spectrometry will detect very low levels of a drug, whereas the initial screening, usually by immunoassay, is much less sensitive. Urine concentrates excreted substances, so dilute urine will have much lower amounts of the drug than concentrated urine- which also determines how long it will be detected.
      So even in one person, the time it can be detected will vary greatly. On the short end, with dilute urine and a one-time use, it will probably be gone on a couple days. In that same person but using regularly, without drinking as much water before the test, it could be present for 10 days.

  2. Julia

    Hi, I am on Buprenorphin-Nalox 8-2mgs and I take my meds everyday & when I go to the doctor every month I take a drug test, well this month when I took my drug test my doctor told me that the meds did not show up in my system & I was dumbfounded because I take them everyday & I did not stop taking my meds, I didn’t do anything different. I do not understand why the meds I take everyday just like I’m suppost to didnt show up on the drug test I took and I didn’t do anything or change anything. Do u know what could of made this happen?? I have to go back in two weeks and if its not in my system my doctor will have to discharge me. This is so crazy because if I don’t take my meds I will be sick. I do not know what to do.

    • I understand the frustration. Doctors are taught in med school to ‘treat the patient, not the lab value’… but in these cases doctors do the opposite. Yes, patients with addictions often have secrets. But doctors should be extremely careful before taking actions with risk of significant harm to patients!
      Some possibilities… if you were very well hydrated, the buprenorphine in your urine may have been too dilute for the test to pick up. If you usually drink lots of water, drink less before your next test. Or, your sample could have been mislabeled or mishandled by the lab, causing your result to be confused with another patient. If this happens again, ask your doctor to do a blood test. If it is low in that test, ask the doctor to have you dose in front of the doctor and then repeat the blood test. Ask your doctor what you can do to prove you are telling the truth. There are ways for the doctor to figure out what is happening, and a good doctor will do those things, if there are any reasons to believe that the patient is telling the truth.

      • Pam

        So i am on 2 8mg subutex a day. I’m breastfeeding, i started working out, and drink lots of water. I’ve been going to the same doctor for 3 years. At my last drug test they said my levels were very low which i do try amd take less before a feeding of my baby and they also just switched the testing lab as of last time? Is it me or the new drug tests or is my body metabolizing it out of my system faster? Please help, thank you.

        • I don’t know, as it could be any of those things. In general, though, buprenorphine is metabolized by several specific enzymes, called ‘cytochromes’, that are not affected by exercise or activity. They CAN be inhibited, or activated, by specific drugs or medications. Understand that urine tests are more sensitive for detecting drugs, but are of far less value than blood tests in determining blood LEVELS. So if they are saying your levels are off after urine tests, they are probably using another substance in urine like creatinine, and using that to adjust for urine blood levels.
          There are many, many variables that can throw off blood or urine tests. For that reason I take issue with practices that ‘treat the urine test’ at all costs, no matter what the patient says. I believe that we need to take reasonable steps to detect diversion– but the risks and benefits must always be balanced. For example, we know that deaths from diverted buprenorphine medications are EXTREMELY rare. How rare? Less than deaths from lightning strikes. The number of people who die without any trace of buprenorphine in their bloodstream is literally a thousand times larger than those who have buprenorphine in the bloodstream. And understand that most of those people just happened to have traces of buprenorphine in their system, i.e. they were not harmed by buprenorphine, and would have been saved if MORE buprenorphine was present.
          With that in mind, how does a doctor who supposedly took an oath to ‘do no harm’ throw people off buprenorphine, and back into active addiction, because the numbers are not as expected? I hear of doctors who use abnormal metabolites as the only reason to kick patients out of treatment– and shame on them! This situation has created and aggravated by for-profit labs, who then convince insurers that patients shouldn’t be on buprenorphine if their labs are abnormal. The insurer gets to stop covering buprenorphine, and the patient then relapses, returns to heroin, and is off insurance by the time the overdose occurs– so the insurer doesn’t have to bear the cost of months of neurorehab.
          Sound crazy? How many times would this have to happen before you would get angry? 5 times? 10 times?
          I know, without a doubt, that pain clinics are setting up turnkey labs that bring in huge profits, earning $800 on lab tests that require $5 of reagents and 20 minutes of time. I know, for a fact, that at least two insurers in my are have been convinved to deny buprenorphine in patients who are not given tests for buprenorphine breakdown products. And know of many practices that take pride in catching patients with abnormal numbers. Maybe they watched too many episodes of CSI, and find themselves in the wrong profession.

  3. Julia

    Thank you for your responds! I am going to have to do some deep research to find out why this happened to me, because it is truly not right and not fair that I’m going through this when I have done nothing wrong. I did find out that this has happened to other people at their doctor’s appointments. well I’m going to dig deeper into this cause I have to know. If anybody has any feedback for me, let me know. Thank u From Julia

    • There are a couple reasons. Buprenorphine medications are very potent. It is almost impossible for someone tolerant to opioids to overdose on buprenorphine. But deaths are possible in someone who 1. has no history of opioid use, AND 2. takes a second respiratory depressant. So one reason to check a UA is to make sure the patient is truly using opioids.
      Another reason is to verify what the patient says in his/her history about use of other drugs. I’ve found over the years that many people with isolated opioid dependence do very well on buprenorphine. But the success rate is much lower in people who are also addicted to crack cocaine, methamphetamine, benzos, or alcohol. IF a person tests positive for those substances I would want to let the patient know my expectations– i.e. how long I’ll allow them to teat positive for that substance before discharging them.
      There may be other reasons; some doctors may have concerns if the patient tests positive for buprenorphine. I don’t hold that fact against new patients because I’ve had many patients who tried a period of ‘self-treatment’ before they were able to find a physician.

    • Julia

      You have to take a drug test every month for afew reasons. The doctor needs to know what’s in your system also your doctor tests has to make sure the meds they your are getting are in your system and that your not taking anything else your not supposed to be taking.

  4. Thanks for your reply Jeffrey. ….I know I’m going to test positive to diazapam as I have been suffering alot lately with anxiety……I drink alot and no I have to stop everything when going on this drug….but I’m worried what the side affects are of the drug itself on its own

    • Shoot… I had an answer then accidentally deleted it! The side effects are all based on mu receptor effects, i.e. typical opioid effects. If you have a very high tolerance, you may have mild withdrawal for a few days (just a bit of fatigue and feeling down). If you have a very low tolerance you will feel a bit ‘narcotized’ for a day or two. But very quickly your tolerance will line up, and you’ll feel normal, save for some constipation (in some cases).
      Good luck!

  5. Vanished Sarah

    I have a question for someone. So my husband has been going to one of those pay to prescribe doctors for about 7 months. He is prescribed 2 8mg strips a day. Today his doctor said his levels are really low, about 60, when they should be 300 – 400 (I’m not really sure what he’s measuring). Here is the issue.. We cannot afford for us both to go to the clinic, so he’s been sharing with me. I’m assuming that’s why he’s low, but that’s a lot lower than he should be. If he has an average metabolism, if he takes 1 sub before bed and 1 sub in the morning (his appointment is usually around 11:30) will his levels be okay? I know what we’re doing is illegal, I get that. We’re already paying $80 every 2 weeks for the visit, and about 20 is gas to drive almost 2hrs away to get it. There is no way we can double that. We’re not selling, just cheating the $$ system.

    • I’m not comfortable advising you on this issue, but you’ll find some help at my forum from other readers. Try posting it at http://www.suboxforum.com .
      I will add a couple general comments. It takes a few days for blood levels of buprenorphine to stabilize, so any one-day dose change will not have a big impact. The doctor may also be testing metabolites, which take a few days to build up as well and show if the medication was taken for only a couple doses, vs for several days.
      I hear you on costs, and I realize that there is only so much money available for most working families. I charge less than what you are paying. But you describe costs of $160 per month, or about $2000 per year. Opioid dependence is a horrible, oft-fatal illness that destroys relationships, personal health, jobs and employability. People addicted to opioids often end up with felony convictions, and lawyers cost much more than what you’re paying for treatment. Some people end up with brain damage or lose their lives– and no price can be placed on those things.
      Treating illness with similar morbidity costs much, much more. Treating breast cancer, for example, easily runs over 100 thousand dollars. A heart attack and bypass surgery will also run over $100K. Disc disease leading to spinal fusion can cost even more. Treating opioid dependence with buprenorphine is truly an incredible bargain. Understand that you may find an in-network doctor for those other illnesses, but most people find that many of the charges are not covered by insurance, either because of deductibles or an out-of-network anesthesiologist or radiologist or radiation oncologist.
      And even compared to other opioid addiction treatments, your cost is not that high. I work part time in a methadone program that is covered by medicaid, but NOT by private insurers– so people with jobs pay over $500 per month, every month, per person. My own treatment was mandated by the board to be abstinence-based, and they chose the program. The first 3 months of treatment cost almost $90,000 out of pocket– luckily we owned a vacation cottage in Wisconsin to sell in order to pay. I then had to pay for therapy and drug tests, twice per week, for 6 years– another $700 per month for those 6 years. When I completed the six years I had maxed out a number of credit cards, and since I lost my career and did another residency it took 5 years to pay them off.
      The issue that many doctors find to be the most frustrating is that many people who complain that they can’t afford treatment also smoke cigarettes. I don’t know if you do, but smoking one pack per day costs more than what you are paying for treatment. I realize that everyone needs to have a ‘hobby’– but I gave up a cottage on the lake that my kids used to enjoy, in order to do the right thing… and so I don’t think it is too much to expect people to stop smoking to pay for addiction treatment. If that seems too hard, then the person doesn’t truly understand the reality of the problem being faced. Treatment with buprenorphine will easily have a greater impact on your life than anything else you will ever do. And if you lose it, the financial costs will only be much, much greater.
      I don’t mean to ‘shame’ you, but I do mean to open your eyes, and maybe persuade you. Do what is necessary to keep your buprenorphine doctor. It can really get nasty if that is lost.

      • Vanished Sarah

        There is a fairly big difference between you and I, I will never own a cottage. My husband and I both dropped out of highschool addicted to heroin. Our combined incomes are probably less than how much you paid for your cottage. You know the poverty line? We couldn’t reach it if I wasn’t standing on his head. Let’s break down my necessary expenses. So our combined monthly income is about $1100. We pay $350/month for rent, about $60 for gas and same for electric. We have about $200/month in drug related fines, another $120 in gas BC we drive an old shitty SUV to work. Speaking of work, we already never see each other, in order to avoid child care costs we work opposite shifts. After all that is said and done, we’re left with $280/month not spent on “necessities”. That doesn’t even add in the cost of raising 2 boys, one who goes through jeans and shoes like they’re going out of style. So, yes, my cost is a lot lower than that of a cancer patient. Its all relative tho, isn’t it? You’re not opening my eyes, as you seem to think. You are doing as you said you weren’t, shaming me. I would go to a clinic that accepts my Medicaid, however last I called I was on a 6 month waiting list. The threat of relapse seems too high to just wait. Anyhow, thanks for the info

      • Becky

        So a week ago I took two more strips of suboxone then I was supposed to then today I took 1 1/2 more then I was supposed to. My question is of they come to test me tomorrow and send it to the lab like they always do will it show that I took more then I was supposed to? Please help me!

    • The primary metabolite is norbuprenorphine, which acts as an opioid agonist at the gut but does not accumulate in any amount in the brain. The result is that swallowed buprenorphine can increase constipation, even though it has effect on brain receptors.
      There are lesser amounts of other metabolites.

  6. Emily

    I have been on suboxene strips for 2 and a half months. Today I went in for my weekly appointment and they said every urine test has came back negative for Suboxone. They think I’m selling it and kicked me off the program. I take a 4mg strip 3 times a day. I don’t understand why my klonpin level is coming back positive and my Suboxone level is negative. This program has saved my life and now I don’t know what to do.

    • I’m always irritated by programs that treat urine tests as the ‘gold standard’. Some people break down buprenorphine more quickly than others, and those people have ‘abnormal’ urine tests. Your doctor did you a disservice, but I don’t have any great suggestions other than to find a doctor who at least TRIES to believe the patient, and who looks for reasons for abnormal tests instead of just kicking people out of treatment. Sorry– I don’t know what else you can do.

  7. Debbie

    We have something in common. I take my Suboxone as prescribed and have been going for two years now. I am one of the most trusted patients our clinic has. My last drug screen came back as N/A for naloxone. Because of my level of trust, my doc stated he believed me but I also want a definitive answer because this just simply is not correct and although he states he trusts me, what happens if the same thing happens next time I go. I may have to go more often, etc and not from my own wrong doing. I was recently put on levothyoxine for under active thyroid…. But I noticed we are taking a similar over the counter sleep aid with the same active ingredient… diphenhydramine. I take this almost nightly but failed to mention because it is over the counter. I am wondering if this has anything to do with it because the doc is aware of the thyroid meds. Another thing worthy of mentioning is that I have been taking the exact same dosage for a year with no wavering. You would think my drug screens would be consistent.

  8. Evalena

    I have been taking suboxone for about 10 yrs for pain management. I have never had a problem with my urinalysis. I recently changed doctors and had a urinalysis come back positive for codeine of which I fervently denied and still deny taking. My pharmacist says that codeine can be something called a metabolite of suboxone. Is this what is causing me to show a positive result?

    • Codiene cannot be created through metabolism of buprenorphine- at least not in the human body. But there are two primary types of tests. The first is an immunoassay, that detects certain patterns of atoms and their charges to identify certain drugs. This is a very specific test, but about 5% of the time the antibodies miss their mark and focus on something that has similar charge characteristics but is a completely different molecule.
      The second test is mass spectroscopy and is 100% accurate. Again, I don’t know a way for codeine to get there from buprenorphine, but maybe it was the first type of test, and the test deteted parts of the buprenorphine moleccule that were shaped similar to part of the codeine molecule. This is interesting

  9. Jrod

    This happened to me on Monday!! I don’t get it I take 4 a day
    Everyday he asked if I was selling wtf!! I said I’ll take a sub pee for you do blood work do something anything and like your doctor mine wasn’t having it made me feel like crap!! I’m calling his boss to make a report

  10. Dear Dr. I have taken buprenorphine 8mg since 3007. Just recently I have had to find a way doctor. Ive seen her weekly for the past month and a half. She has done urine testing for me weekly..all came out clean. This last one they called me to say they wanted me in therapy and weekly visits . All this will cost me $770 for a month. It was on a weekend I received this info..I have the doctors personal email so I wrote her..I told her since 2007 have I never had a dirty urine test. She asked me if I used ketamine or kratom? Oh my I wrote her saying gosh dr. I didn’t even know you knew anything about kratom ? But my answer is yes I tried kratom for mood and energy benefits. But it is not working..she wrote me back saying thank you for your honesty. It could be the kratom affecting your urine sample. Stop kratom . She said come to therapy and we are doing a urine sample to.. I told her I have nothing to hide and the reason I can’t do therapy for a long time is I’m on a fixed income my husband just retired and we do not have the money as we did before. I don’t think what will become a this. But gosh was I surprised about all this. I don’t even know what ketamine is. By googling this I found out somewhat what it is but still truly dont know. Any feedback thank you

  11. The health care system, especially in Indiana, is lacking in general medical knowledge. The government has screwed up the health system works leading to 5x the opiate/opioid death rate. Since patients can’t get safe pain medications we used to, some patients turn to the internet and streets to get relief, and then die from deadly drug overdoses. In my suboxone program it isn’t even covered by Medicaid yet! They want me off my clonazepam, which I take for severe OCD anxiety and partial seizures. It is only a dose of .5 twice daily which is less than a starting dose. I had taken 4-6mg of clonazepam for15 years or more! Doctors just go by the book instead of using the patients self history, which is supposed to account for 95% of how to treat the individual. They think they know your body better than you do, and we all react the same to medications, which is so wrong. Doctors need to learn to treat patients as individual situational cases! So now I am going to have seizures and severe, unbearable anxiety due to my psychiatrist and sub doctor don’t understand finite medicine, and how much medication the patient needs and is safe. I take Luvox and it is a CYP450 3A4 enzyme inhibitor, so buprenorphine will take longer to metabolize into norbuprenorphine due to less of that enzyme. The tests are not accurate. If a doctor does not know what interacts they need to look it up. They need to keep up with current research, while using the old medications that work well, like klonopin. It truly helped me. I gained a tolerance to all medications for seizures and anxiety, except clonazepam. They are following current FDA restrictions and CDC advisements, which could kill me from withdrawal from a long acting, non addictive or me benzodiazepine which works so well for me. I studied Neuroscience at Purdue University, and it sad to see so many doctors scared to prescribe life saving medication. They do not have any true experience, like we learn on the streets and net a they need to actually listen to Most doctors dont study about medication like us addicts do. They should use patients self history, use medical and common sense, and treat the individual patient. Do not just throw ssri’s, snri’s, ssnri’s combined with antipsychotics meant for schizophrenia! There are many better treatments that are non narcotic, but long acting benzodiazepines of 1mg 3x day with opiates and opioids including suboxone are safe if the patient is not abusing them, which a good doctor can plainly see. It is sad I have to wait to wait to see are doc, because my psych says he can’t! Then after I get a reference for a neurologist it takes 3 months to get in. I should be all seizured out by that time. Suffering as many patients are. Hopefully the gov will let doctors be doctors, and leave the bullshit politics for the statehouse. Lol, not really. All the doctors out there need to fight against the government making health care worse resulting in patient suffering, and in some cases I have seen, death. I pray for all the doctors and patients out there. Doctors and patients keep pushing for a better health system. One understanding of mental disorders, including addiction, and treating each individual patient under the circumstances, in with a decent bedside manner. Please do what is right for the patient.

  12. Nick Richter

    If taxpayers would like to save money, then we need to put a stop to putting addicts in jail and dcs causing them problems, instead of getting them help. Especially Indiana needs to decriminalize marijuana to stop jail overcrowding and taking money out of taxpayer pockets for non criminals to sit in jail while you feed them. Talk to your local congressional representatives please.

  13. They keep telling me my lebels are low, yet i take my suboxone as prescribed. On monday they want me to do a supervised dosr. I have to stay 4 hours. Thry will discharge me if my levels are higher than they think it should be. Do you have any advice on what qurstions i should ask? Should i ask for a blood test? Like others, they just look at me like im lying, and just another addict

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