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PostPosted: Fri Sep 05, 2014 3:50 pm 
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Hi,

I've been on a once daily 8mg dose of subutex for about 50 days now, at first I felt like everything was going fine the last few weeks have been a different story though, I really feel as if I need to go up to a higher. I just don't feel like its working like it did at first, i usually dose around 8am, and usually around this time i start feeling really crappy. For the first time in 2 months my cravings have returned and i'm just really afraid of relapsing and I'm worried about asking for an increased dose, I don't want the nurse or my counsuler to think less of me or anything like that. I'm basically wondering if they would increase my dose at this point after being on 8mg for nearly 2 months now. I've never given them any problems, I've never failed a drug test or missed a dosage. Do you build a tolerance to subutex, why am I feeling this way now, I'm just starting to get really worried...

I usually start feeling this way about 8 or so hours after dosing, its 4 pm here.


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PostPosted: Fri Sep 05, 2014 4:25 pm 
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I don't think it would be out of line to ask for an increase of dosage. Just say what you said here and be honest. Some people have a faster metabolism than others so your body may be processing it too quickly. And no, a person does not build up a tolerance to Sub/Buprenorphine. It is usually the other way around. From my experience and reading what others have posted here, it seems like the effect gets stronger the longer you ingest it so we tend to taper down to a level that we feel normal at. Again, everyone's system is different.

No harm in asking. All they can do is say no. Just make sure you mention the cravings.

rule

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PostPosted: Fri Sep 05, 2014 4:26 pm 
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I hear this from many if not most folks starti gvsub. Around the 6 week mark, we want more.
I did. It dosent seem to matter what the dose is, just wanting more.
You could ask the dr. Some drs will some wont. Dont feel badly about asking. Its your recovery although they control the script.
Or, as I did, try dosing later in the morning. Say at 10 or 11 am. This way you could feel better though the afternoon.
Or.., you could spilt the dose. 4 in the am, and 4 in the pm..
However, we are trying to break the habit of reaching for something to feel good, or better. .
There are some choices, an just my 2 cents...razor


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PostPosted: Fri Sep 05, 2014 6:24 pm 
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I'm early in my treatment as well, 4 weeks to be precise, and I feel that I need to increase, although I'm at 4 mg so I know I'm below the ceiling by mid afternoon and that would even be the case if I didn't have the rapid metabolism that I have. I'm going to ask for an increase to 8 mg on Monday when I see the doctor because I want to avoid dosing twice a day because the more I dose, the more I'm thinking about taking something and that's the habit and lifestyle that I need to break.

As far as increasing beyond 8 mg, I have a hard time seeing how doing so would bring you any real physical benefit, understanding that the ceiling of maximal intrinsic activity (opioid effect) lies between 4 and at most 6 mg. It's extremely unlikely your metabolism is sinking your blood level from the equivalent of 8 mg below the equivalent of 4 mg in 6 hours (from 8 AM to 2 PM you said); I'd even say it would be unlikely to do so in 18 hours, though I won't say it would be impossible. I would say 6 hours would be though so that to me indicates that it's predominantly if no solely psychological. It's VERY common (and I've already noticed it myself) to feel a "sense of withdrawal" in the evening or late afternoon, even with people at doses of 24mg! The truth is, at 8 mg once in the morning, if that's enough to help your withdrawal immediately after you take it, it will definitively prevent you from having actual withdrawal in the evening. That "sense of withdrawal" is a psychological need to take something that your body is trying to reinforce with the sensation of "pain". Funny how backwards addiction is. We take opioids to relieve pain (pain as a stimulus) until we become addicted. Then our body creates pain (lack of drug as a stimulus) so that we will take opioids. Dr. Junig has mentioned that when these false feelings of withdrawal occur, the best thing to do is distract yourself for 15 or 30 minutes until they go away and they almost always do, as confirmed by myself and others.

Anything beyond 8 mg just will not physically help you more; it will only provide you temporary psychological relief until your mind tells you that you need to up your dose again. As far as tolerance goes, your opioid receptors WILL develop tolerance to buprenorphine, however, the level of tolerance is limited by the ceiling effect. Your brain will become tolerant to buprenorphine up to the level of 4 - 6 mg and the tolerance will stop as the other effects stop at that ceiling. This is actually beneficial though because you will still get an effect of buprenorphine at that very last degree of tolerance that the ceiling effect prevents you from ever getting past so once you've taken 4 mg or more, no matter how long you're on buprenorphine, your tolerance will remain fixed and not increase.

When you say that you feel crappy, exactly what are you feeling? Is it an almost uncomfortable mental sort of itch that just makes you feel only slightly and briefly restless? or would it be enough to prevent sleep?

At 8 mg once in the morning, it is slightly possible your metabolism could be tearing through enough for your brain to notice it in the evening but it wouldn't do so at 1:50 PM as you mentioned. I would mention everything you said that is bothering you as far as why you're considering a dose increase and then just ask him if those are things that you think a dose increase will fix and let him decide. Don't ask him for permission for a dose increase. It can't really hurt because of the ceiling effect so you won't gain tolerance to that increase anyways.

I typically wouldn't recommend anyone to dose more than once daily because it's so crucial not to think about dosing and reaching for something when we feel any difference in our mood at all however, if what you're doing now isn't working 100% and the sensations and cravings that you're feeling are strong enough that you genuinely fear they will cause you to relapse, then that's a case I'd condone dosing twice daily. You're certainly better off just splitting your Suboxone dose and otherwise sticking to the same regimen where you're stable and not spending anymore of your money.

I hope some of this is helpful. Let me know how it goes!

Taylor


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PostPosted: Fri Sep 05, 2014 7:21 pm 
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I think the decision on whether or not to increase your dose should be up to you and your doctor. Now if you've already tried the distraction method that Dr. Junig recommends, and after 15 minutes or so are still feeling physically bad and craving opioids, then I'd say perhaps you do metabolize sub faster than others, and a dose increase or split dose is in order and perfectly acceptable to ask for. As rule said,the worst the Dr. can say is no, in which case I'd read Dr. Junig's article at his blog about optimizing absorption of buprenorphine, and give that method of dosing a try. That could make a big difference. Even if the need IS more psychological than anything, this early in your recovery, an increase in dose or split dose could be the way to go to avoid a disastrous relapse, and it certainly can't hurt, and later on when you're feeling more stable in your recovery, you should be able to easily reduce your dose back to eight milligrams,without any wd symptoms, especially if it's significantly higher than the ceiling. Many studies show higher retention rates in treatment when patients are taking sufficient doses to stave off cravings and withdrawal. It is highly individual. Some patients do benefit from higher doses than others. There's a blog by a Dr named Jana Burson, that you'll find by googling her name. She discusses this and many other facets of recovery. Read some of her entries if you have time. They're very interesting. She specializes in this field of Medicine, operating her own suboxone practice, and is the director of an opioid treatment program, and has been for many years,so has seen the benefits of split and higher dosing for some patients. Also visit http://www.suboxonetalkzone.com to read Dr. Jeffrey Junig's (owner and founder of this forum) blog. Enter the key words in the search box, "optimizing absorption, to read the article I referred to earlier. Both blogs are full of tons of useful and accurate information about medication assisted recovery, and addiction in general.


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PostPosted: Fri Sep 05, 2014 7:24 pm 
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lizzieshug2013 wrote:
I think the decision on whether or not to increase your dose should be up to you and your doctor. Now if you've already tried the distraction method that Dr. Junig recommends, and after 15 minutes or so are still feeling physically bad and craving opioids, then I'd say perhaps you do metabolize sub faster than others, and a dose increase or split dose is in order and perfectly acceptable to ask for. As rule said,the worst the Dr. can say is no, in which case I'd read Dr. Junig's article at his blog about optimizing absorption of buprenorphine, and give that method of dosing a try. That could make a big difference. Even if the need IS more psychological than anything, this early in your recovery, an increase in dose or split dose could be the way to go to avoid a disastrous relapse, and it certainly can't hurt, and later on when you're feeling more stable in your recovery, you should be able to easily reduce your dose back to eight milligrams,without any wd symptoms, especially if it's significantly higher than the ceiling. Many studies show higher retention rates in treatment when patients are taking sufficient doses to stave off cravings and withdrawal. It is highly individual. Some patients do benefit from higher doses than others. There's a blog by a Dr named Jana Burson, that you'll find by googling her name. She discusses this and many other facets of recovery. Read some of her entries if you have time. They're very interesting. She specializes in this field of Medicine, operating her own suboxone practice, and is the director of an opioid treatment program, and has been for many years,so has seen the benefits of split and higher dosing for some patients. Also visit http://www.suboxonetalkzone.com to read Dr. Jeffrey Junig's (owner and founder of this forum) blog. Enter the key words in the search box, "optimizing absorption, to read the article I referred to earlier. Both blogs are full of tons of useful and accurate information about medication assisted recovery, and addiction in general.



Immensely informative!! Thank you!


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PostPosted: Fri Sep 05, 2014 8:59 pm 
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lizzieshug2013

Thank you so much for your response, I read the article you mentioned, and i'm certainly going to try the technique listed there in, and thank you to everyone else that responded, see i have to go to a clinic where I pay 11 dollars per dose for subutex, and I'm at the point now where they're going to let me sign up for what they call a state exception program, which will allow me to pick up my meds for the entire week and then i'll be able to dose at 4mg's twice a day, rather than once at 8mg. See, as things are now I have to drive 30+ miles every single day in order to dose, I live in the middle of no-where by the way, and it's a major financial drain, and in that setting I always feel rushed along by the methadone patients, who dose in 2 seconds, so i end up waiting for it to turn to paste and swallow it, and the nurses there told me there was nothing wrong with that. I look forward to trying the new technique in the AM thank you all again.

And to thair7391, its usually around the 8 hour mark, thats why i said it was nearly 4 here when i posted that, and I'm guessing I have decent metabolism, I'm 6 foot 200 pounds, but having read that article, i think i was taking it all wrong, thanks for the response though and good luck with your recovery.

Thanks again all!
MG


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PostPosted: Fri Sep 05, 2014 10:05 pm 
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so glad you found it helpful, Dr. Junig is a really clever guy. I just bet that using that technique will help you a lot! I totally understand about living in the middle of nowhere too, I'm 45 mins from the nearest real grocery store, and closest Walmart lol! Almost 2 hours from an actual mall! Also I drive over two hours one way every 2 wks to see my sub doctor in a bordering state, since there are so few prescribers in my state and the ones within two hours are full with long waiting lists. Buuuut, he's a great psychiatrist, & he's worth it! I had no idea how much therapy would help me! I'd been to counselors/therapists before, but always thought it was stupid or boring or otherwise not worth my time. It's different now though,I think because I really want to succeed whereas before I was going because others demanded it or I just wasn't ready...idk, either way. I'm feeling healthy, happy, and clean enough on 12 mgs!


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PostPosted: Wed Sep 10, 2014 3:15 pm 
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MG85 wrote:
lizzieshug2013

Thank you so much for your response, I read the article you mentioned, and i'm certainly going to try the technique listed there in, and thank you to everyone else that responded, see i have to go to a clinic where I pay 11 dollars per dose for subutex, and I'm at the point now where they're going to let me sign up for what they call a state exception program, which will allow me to pick up my meds for the entire week and then i'll be able to dose at 4mg's twice a day, rather than once at 8mg. See, as things are now I have to drive 30+ miles every single day in order to dose, I live in the middle of no-where by the way, and it's a major financial drain, and in that setting I always feel rushed along by the methadone patients, who dose in 2 seconds, so i end up waiting for it to turn to paste and swallow it, and the nurses there told me there was nothing wrong with that. I look forward to trying the new technique in the AM thank you all again.

And to thair7391, its usually around the 8 hour mark, thats why i said it was nearly 4 here when i posted that, and I'm guessing I have decent metabolism, I'm 6 foot 200 pounds, but having read that article, i think i was taking it all wrong, thanks for the response though and good luck with your recovery.

Thanks again all!
MG


I'm glad you got it all straightened out. I think improper administration and hence absorption is probably one of the most common, yet most unaddressed issues that plagues many people on Suboxone. The instructions only tell the patient to dissolve the dose in the mouth or under the tongue. Those instructions alone don't exactly explain how crucial it is that the medication is actually dissolved in a way that allows or promotes absorption. Most people just throw their tablet or film strip into a saliva saturated mouth and as soon as the dose disintegrates, they swallow and that's it.I doubt most patients really understand that the medication is instructed to be taken that way because it isn't absorbed well or at all when swallowed. They probably just assume it's done for maybe convenience or to dissuade the habit of "swallowing pills" but that otherwise, it all gets in the system either way which is unfortunately not the case. Physicians should obviously instruct their patients on the matter but unfortunately I don't find this largely to be the case. There really should be a campaign for proper Suboxone administration. It would save many patients probably almost half of the cost of their medications if they doubled their absorption and just took half of the dose!


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