Buprenorphine, Part 2

Changing a patient’s medication from methadone to buprenorphine is trickier than from other opioids, because of methadone’s long duration of action. Patients need to stop the methadone at least seventy-two hours before starting buprenorphine. Since methadone is also a much stronger opioid, the patient should be stable on methadone forty milligrams per day or less. Otherwise, dropping from a higher dose of methadone to buprenorhpine often leaves the patient with feelings of low-grade withdrawal for the first few weeks of buprenorphine.

I’ve had a few strongly motivated patients make the switch from higher doses of methadone than I would recommend, to buprenorphine. One patient was dosing at 70mg of methadone, stopped it for about five days, and then started buprenorphine. He didn’t have a very pleasant first week. I worried it would be too difficult, but he did it. By two weeks he felt pretty good, and he’s done great for the last three years, on a relatively low dose of buprenorphine. Because he also has chronic back pain, he’s decided to stay on buprenorphine as the best solution to both his chronic pain and opioid addiction.

Because buprenorphine is a partial opioid agonist, there’s a ceiling on its effects. This is why it’s now permitted to be prescribed through a doctor’s office, without all the regulations that methadone clinics have. After the buprenorphine dose reaches twenty-four (some say thirty-two) milligrams per day, further increases in the dose have no additional effects. This makes the drug much more resistant to overdoses. However, if mixed with sedatives like benzodiazepines (Xanax, Valium) or alcohol, it can still be fatal.

 Most patients say they “just feel normal,” after taking buprenorphine. When the drug works, many patients have returned to my office on the second visit saying, “It’s a miracle!” They say they feel just like they did before they got addicted. They don’t think about pain pills, don’t feel withdrawal, and don’t feel like they’re medicated. Patients who have been on both methadone and buprenorphine say the methadone is heavier, and they feel medicated, but on buprenorphine they feel lighter.

A dose of buprenorphine can stimulate opioid receptors anywhere from twenty-four to sixty hours, so some patients feel stable when they dose only every other day, though I think overall best results are seen with stable daily dosing. There is no impairment of thought processes or motor function in patients on a stable dose of buprenorphine. These patients can drive, work, and play with no limitations.

I try to temper patients from being overly enthusiastic about buprenorphine. Sometimes patients feel so good on this medication, they don’t realize how much psychological work needs to be done before they can taper and stay off of buprenorphine. Patients feel so good, they minimize their addiction, and are reluctant to get the counseling they need. One of my doctor friends says that the drug’s main problem is that it works so well.

Buprenorphine is ideal for patients with opioid addiction who have lower tolerances, who have relatively stable lives, or who have been using for shorter lengths of time. Buprenorphine is a better drug than methadone for patients who have been addicted less than one year, because methadone is more difficult to stop, once it’s started, for most patients.

 Buprenorphine has the same side effects as other opioids: constipation, sweating, decreased libido (sex drive), and possible weight gain. Usually, these side effects are much less pronounced in patients taking buprenorphine than in patients taking methadone. Unlike methadone, there is no increased risk for fatal heart rhythms, because it doesn’t affect the QT interval. Most patients do complain about the bad taste of the sublingual tablets.

 Buprenorphine doesn’t seem to cause lasting damage to the body, even if it’s continued indefinitely, though elevated liver function tests can be seen in some patients. Liver function blood tests should be checked periodically in patients who are infected with hepatitis C or B.

Buprenorphine can be fatal if taken by children. It can also be fatal in adolescents or adults not accustomed to opioids. Patients should always store their medication safely out of reach, and with a child proof cap. Since buprenorphine is absorbed through the oral mucosa, if a child puts a tablet in his mouth, some can be absorbed, even if the pill is retrieved fairly quickly. Any handling of a Suboxone pill by a child should be viewed as a possible overdose, and the child must be taken to the hospital emergency room immediately.

Why do people snort buprenorphine? I don’t know. I don’t think there’s any difference in the rate of absorption. If anything, buprenorphine probably crosses the thin mucus membranes of the mouth much more quickly than the thicker skin of the nasal mucosa. I suspect people who snort Suboxone and generic buprenorphine are actually more addicted to the act of snorting, rather than getting any true pharmacologic benefit (“high”) from snorting. That’s on my list of things to ask the Suboxone rep to find out for me. Anyone reading this have ideas about why people snort Suboxone?

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6 responses to this post.

  1. Posted by cheryl lindsey on July 27, 2010 at 5:48 am

    Suboxone saved my life. If i could scream off the roof tops of what this drug has done for me I would. I have had neuropathy for 3 YEARS. When I came down with it I was suicidel. The pain was more than I could stand. In and out of the hospital just trying to stop the horrible pain. I was being treated in some of Bostons best hospitals . Every treatment , every different medication know to man some opiates, others like neurontin, cymbalta, lyrica and so on. I became like a zomby. In bed for almost 2 years and still in pain even though I was on so many medications, I decided to detox just to see where I was at, I felt I had nothing to lose as I was in such bad shape to begin with. The Doctor at the detox explained to me about soboxone and felt i was a good canidate, well here I am today one year later, working full time again (I own a large restaurant with 100 employees) taking charge of my business, my family and have lost a lot of weight and exercise every day. It is a miricle drug.. I still have neuropthy but it is manegeable. On days it is bad I stay home and sometimes cry, but the next day when it calms down I am not in bed like a zombie, I am up and out with so much energy. I am still considered handicaped, I ride a scooter most places and limit myself to mostly working and family but it is a beautiful life and I feel everything now. If i could i would talk to more Doctors about this medication, because so many people are out there in this world in so much pain, or so drugged up and this medication is so close and the Doctors don’t even know about it. thank-you cheri lindsey

    Reply

  2. Thank you for writing. This medication is a great option for many people. I’m so glad to hear how much your life improved.

    Reply

  3. Posted by Anon on September 9, 2010 at 4:31 pm

    good for you cheryl, i hope it works for you as long as you need it 🙂 lets all hope this medication is a step in the right direction for those that need it.

    Reply

  4. Posted by jay on May 1, 2011 at 4:31 am

    Hi,

    I started an addiction to opiate ‘agonists’ three years ago.

    My Doctor prescribed buprenorphine 8mg sublingual tablets to help me stop my opiate agonist addiction.

    Within day’s of starting my treatment, I felt absolutely ‘normal’, until I had a chance encounter with an ex prisioner who explained that – “inside”, they crush up the tablets and then snort them!

    Well, as I was allowed to take a prescription home at the weekend I thus tried my first crushed up line!!

    The abuse then esculated to every other day (as I sneaked it out of the chemist controlled room).

    Now my addiction is everyday, however I’m approaching the tapering period (dosage is 0.4mcg)

    Throughout my addiction I had some terrible side affects – eventually – ie, drowsyness, itchyness, myoclonic head twitches, red spots on my skin, palor skin, low haemoglobin, low white blood cell count (3.7) loss of balance, low blood pressure, tingling feet.

    Before the side affects started, the opiate affect is felt and is very addictive and it’s similar to the affect you get from cocaine (just not as intense) it makes me very talketive and confident and I have an urge to learn knew things.

    I hope this answers you question.

    Take care

    Reply

  5. Posted by Eric on October 21, 2014 at 5:42 pm

    I have been on methadone for 3 months my highest dose was 105 mg and I took that dose for one day then went back down to the dose they had me on 95 MG’s. I was taking suboxone before the Methadone and was doing fine but listened to someone that told me methadone would give me more energy and I asked Dr. at clinic and he switched me. I think this was a terrible decision. I have been on xanax for 15 years and the Dr.knew this I have read all the horror stories of people dying on these meds have been in panic mode the entire time. Finally 3 weeks ago after asking the Dr. Several times to tapper down and get back on suboxone I have been tapering down 2 MG’s a day and took my dose this morning down to 52 MG’s tomorrow will be 50 MG’s.How hard will the switch back be.I am a nervous wreck.

    Reply

  6. Posted by Maxim Melamed on September 20, 2016 at 1:24 pm

    Youre absolutely right..its the act of sniffing something that gives the desired reaction. A kind of weird placebo effect that allows the user to trick the brain into thinking its “doing drugs” even though there is no ohysical benefit. This seems to be a passing phase and regular users realize that they get more out of their medication by using it as prescribed.

    Reply

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