I received some feedback after writing about tapering Suboxone here and on my site Sober after Suboxone (soberaftersub.com), and I would like to share the information and suggest a new way to think about buprenorphine during the tapering process.
First… it has already become clear to me that Zofran, or odantreson, is not the big answer for opiate withdrawal that everyone is hoping for. Oh well… maybe some day. As I have said a number of times, some day there will be a medication that prevents tolerance, and I would expect such a medication to affect withdrawal as well, as the two processes are closely related. On the other hand it is possible that such a medication would actually prolong withdrawal, by preventing the plasticity required for the receptors to return to normal.
The other thing… buprenorphine is a very potent drug. This is the essential problem when tapering Suboxone; there is not a low-dose formulation available to taper in the lower dose ranges. The best way to understand the problem is to realize that buprenorphine is a ‘microgram’ medication– not a ‘milligram’ medication like oxycodone. When I worked as an anesthesiologist I would give a woman in labor 50 micrograms of buprenorphine intravenously– or 0.05 mg. Buprenorphine taken orally (trans-mucosally) has a ‘ceiling’ potency at a dose of 2 mg or 2000 micrograms. If you are taking a quarter of an 8-mg tablet, you are still at the maximum effective dose of buprenorphine!! Whether taking16 mg, 32 mg, or 2 mg of buprenorphine, your tolerance is very high; as high as it would be if you were taking 30 mg of methadone per day.
The standard way to taper a long-acting opiate like methadone is to reduce the dose by 10 % every month. So if you wanted to do things that way that reduces the amount of withdrawal, you would go from 2 mg or 2000 micrograms of buprenorphine once per day to 1.8 mg (1800 micrograms) per day, and then a month later change to about 1.6 mg (1600 micrograms) per day. Note that the reduction amount does not stay constant; each month the dose is reduced by 10 % of the current dose. So after about 4 months you will be at 1 mg per day, and from there you would reduce to 900 micrograms per day. The problem? This 900 micrograms would be 9/10ths of an eighth of a Suboxone tablet! How do you measure THAT out every morning?
Things get worse; remember that buprenorphine is very potent. You don’t want to ‘jump’ from that 900 microgram dose, as it is still represents significant opiate tolerance and will result in significant withdrawal. So you keep tapering… down to 500 micrograms per day… keep going down each month, past 100 micrograms, eventually to 50 micrograms and lower. Ten micrograms of Suboxone would still have some opiate potency; this would equal 1/800th of an 8 mg tablet! Beyond the logistics of working with such small pieces of Suboxone it should be obvious that tapering off Suboxone is best considered a long-term process.
I am going to see what is available in other formulations of buprenorphine and look into the legalities of dispensing buprenorphine from the office. I should mention that I do not have something like that now, and that any medications in our office are kept in a safe, and that we have security measures that include lethal and non-lethal deterrents, video recording devices… I go a bit overboard with security measures, as I am aware of the motivational power that withdrawal has on some people to do horrible things they would not otherwise do. When I worked in the prisons I met a number of people who were average students, wives, dads, or moms, before finding opiates and eventually forging checks– or holding up pharmacies using a finger in a paper bag, not realizing that threatening a gun is as bad as having a gun from the law’s perspective. Nothing like 5 years in prison to help one find a ‘rock bottom’!
One more important point that will help you undertand the withdrawal from opiate medications… the body generally reacts to change in a ‘logarithmic’ fashion, not in a ‘linear’ fashion. And when responding to change, the relative amount of the change is a more accurate predictor of symptoms than is an absolute value. To explain my point using opiate effects, the withdrawal experienced by a person is probably similar when changing his daily dose of methadone from 300 mg per day to 100 mg per day– a change of 200 mg– to the withdrawal experienced when changing from 30 mg to 10 mg — a change of 20 mg. So at the end of your taper off buprenorphine, even though the numbers of milligrams or even micrograms seem tiny, and you are taking a piece of Suboxone the size of a speck of dust for your daily dose, you may still have a bit of withdrawal when you stop!
Finally, yesterday I had my third patient who stopped Suboxone abruptly and had no withdrawal. She was taking 16 mg per day–correctly– when her parole was revoked, forcing her into jail where she had to stop Suboxone without any taper. Like two other patients of mine, she claims she had no withdrawal! I do not know why that would be the case– I have a couple ideas but will spare us all that discussion at 10 PM on a Saturday night!
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Opiate dependence stinks. I hope Suboxone is helping you deal with it; if you are struggling, please consider asking for help. All of us addicts want to do everything for ourselves, and call our own shots. Look how well that has worked!
You all take care.