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 Post subject: Is my dose right??
PostPosted: Fri Sep 25, 2009 8:14 pm 
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Hi all,

I'm still learning my way around the forum and reading posts, best I can in my condition so please forgive me if I'm answering a question that has already been asked and answered....

I'm a 10 year opiate addict, the past two years using 100 mg. Fentanyl patch every 48 hours with Norco for breakthrough pain - it was sucking the life out of me so I decided to stop using Suboxone as I've tried traditional detox several years ago and relapsed.....

So I found a Sub doctor relatively close to my home (one hour, 15 minute drive) and she started me on 2 mg. of Sub, repeat in 4 hours, then every 6 hrs, for a total of 8 mg. per day. On my second visit I was honest and told her I was not feeling that great and not sleeping at all, she prescribed Seroquel for sleep and kept my dose at 8 mg. I take 4 mg. in the morning and 4 mg. 12 hours later. She said I can take it once a day, or twice a day, my choice. I have not tried the full 8 mg. dose in the AM, would that help?

I still don't feel well! Is this expected or is my dose not right? I don't see her until Tuesday after next, so time is going by SO slow, I'm getting discouraged. Yes, it hasn't been that long I want to be reasonable and give this medicine a chance to work its powers but the more I read it seems most people are on a much higher dose of Sub then I'm taking......even double? I'm confused.

I would appreciate any information or opinions you all can share.

Thanks!


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PostPosted: Fri Sep 25, 2009 9:23 pm 
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The doses you are taking seem small to me, especially coming from where you were for how long you were there. I mean 100umg Duragesic every two days and Norco on top of that seems like a very large, gorilla sized, monkey on your back. Personally I think starting you off at such a small dose is near negligent. How long have you been on the Suboxone and off of the Duragesic patch? I imagine that the Suboxone would be barely working for you at that small of a dose when you are coming from such a large dose of a very powerful Narcotic.

I take 1 8mg every eight hours throughout the day, and that for me is coming from between 40mg and 60mg of OxyCodone per day for the past six months.

Contact your doctor seems like he/she is being very conservative in your treatment.


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PostPosted: Fri Sep 25, 2009 10:27 pm 
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Sky Queen,

The Fentanyl you were taking is fairy strong stuff, and you have a long addiction under your belt. As a non-medical professional, I can tell you that if you are not feeling well on 8mg daily, you may need more. It should remove practically all of your withdrawal symptoms. If that is not true, then you likely need a higher dose. One thing to keep in mind is that right now it has hard to trust your head, are you hurting because you are hurting? Or are you hurting because we as addicts want MORE. We want to be high, to change the way we feel. I take suboxone now, and I do NOT feel my dose. I did the first few days tops, where I felt a bit 'up' when I took it, but I believe that was just me contrasting to feeling down because of the withdrawal symptoms. If you are STILL feeling withdrawals, go see your Dr. immediately, and please do not take more than prescribed, that is fast way to get dropped by a Dr. ok? Good luck.

Tacet,

Did you have any opiate addiction before the oxys a few months ago? 40-60mg daily is not very much in terms of what many addicts get to. In contrast to you saying that her dose is small, I would say I think yours might be a bit high. Now take it for what it is worth, and no one knows your situation like you do (after all, this is the internet) but taking that amount of oxy for a short time such as you did, may not require so much suboxone. Subs are very powerful, and if you haven't been on long, I would check into your dose honestly. At 8mg every 8 hours, is that 24mg a day?? see below:


8mg---16mg--24mg---next day
|--------|--------|--------|
8am-- 4pm-- 12am----

I would feel really strongly at this being 3x what would be needed for a habit (in MY body, everyone is different) of that size....

Take it for what it is worth, we really don't want to over do it, because when it comes time to lower our dose... etc


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PostPosted: Fri Sep 25, 2009 10:34 pm 
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Thank you for your response, I've been reading all day and trying to educate myself, I've not read one story so far from anyone who was started on the low dose that I'm on, yet at the same time I've read that many people feel a dose above 8 mg. is not really effective. This medicine seems to be truly unique.

Sigh...I just know I'm not feeling good and it is giving me thoughts of relapse, I do not want that and I will not tolerate it, you put it quite perfect when you said I had a gorilla on my back, boy did I ever. I would not recommend that patch to anyone, ever. I put my last 100 mg. patch on Saturday Sept. 12th in anticipation of my first appointment with the Sub doctor on the 15th, that patch got to where it didn't even last the 48 hours for me. Anyway, I wanted to be in definite W/D for my appointment. Saw her again on the 22nd and told her I wasn't sleeping and all of my symptoms yet no change in the Sub, just added the Seroquel for sleep and an appointment in two weeks.

Anyway, don't want to ramble, just wanted to thank you for the reply - someone is out there! Yes! I just need encouragement and more important I need the right dose of Sub, seems that is very important.

Thanks again.


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PostPosted: Fri Sep 25, 2009 10:43 pm 
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Rationale,

Thank you also for the response, I appreciate any and all opinions I get here! You make a good point, I'm not thinking clearly and I don't trust myself, I want to stop that addictive behavior and thinking, I really need meetings which I plan on adding next! I know I will need it to break this negative thinking and behavior.

I really do think my dose might be a tad low, but at the same time I (more than ever) want to trust the doctor for once in my life - my doctor is an Indian female, nothing at all wrong with that but there is a little communication barrier and I don't want to seem like a desperate addict in her office. I just really thought from the reading I've done that I would be feeling better, I basically cannot function to do much of anything, even showering is a chore for me. I just hoped to feel a little better on the Sub, but I'm giving it a chance and I will just keep being honest with her, I'm keeping a daily log of my symptoms, etc.

Thank you both so much for responding, it's awesome to actually "talk" to other people who understand what I'm going through. Husband doesn't get it at all and has unreasonable expectations.


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PostPosted: Sat Sep 26, 2009 12:17 am 
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Fentanyl is a tough med to leave for a Suboxone induction-- I think that is probably your main problem. It saturates fatty tisssue and takes literally weeks to be metabolized fully by the liver. The half-life is misleading because it is strongly dose-dependent; in isolated small doses fentanyl wears off quickly (during IV use), but after prolonged use of a patch the half-life is very long. I rarely do inductions straight from duragesic any more- I put people on oxycodone or a different short-acting opiate for at least a week before induction. Even so, fentanyl usually doesn't have as great a response-- people just don't feel as 'great' when making the change.

A couple things about dose-- the half-life of buprenorphine is also dose-dependent. When used IV for pain, it is used in microgram doses, and the half-life is a matter of several hours. At very high doses (about 2 mg, which is 2000 micrograms) the enzymes are overloaded and the half-life is around 50-70 hours. What that means is that you could easily dose the medication every other day, and there would be no difference in discernible blood levels. This is especially true because of a second factor-- the ceiling effect. As long as the blood level is higher than that 'ceiling', the effect will be about the same.

All of my patients initially think they need a second dose late in the day for 'cravings'; I work hard to get them to trust me and dose once per day, in order to put to rest the relationship between dosing and 'feeling' that all addicts have. If a person makes the change to once per day dosing, those cravings almost always go away in a few days as they are extinguished, and the person then gets the biggest benefits from Suboxone-- the person is no longer 'checking in' with himself all day, wondering if he needs more or not, or unconsciously waiting for that next dose. Instead the person takes the morning dose and doesn't thing about being an addict at all until the next morning when he takes another dose. The goal is to avoid taking Suboxone 'when you need it'; the use should be automatic to help eliminate that addiction conditioning.

Finally, in the past 6 months there has been more and more pressure to limit doses to 16 mg per day. I posted a 'best practice' mailing on the STZ blog that talks about this issue; the receptors are all bound up by 12 mg or even lower, and the higher doses are thought to be a function of inadequate absorption (that can be improved upon) or a placebo effect. Of course, there will be outliers--but doctors, pharmacists, and licensing boards are all being sent info from the groups that are trying to prevent diversion that any prescription over 16 mg per day should raise warning flags about the prescriber and should be a very small fraction of the doc's patients.

I know that people talk about using different doses depending on the dose of narcotic used, but there really are no studies or guidelines showing that the induction dose should be related to the tolerance. I base the induction and maintenance doses mostly on the need to completely block any potential use-- i.e. if the person is more likely to 'test' the block with an agonist, I will use a higher maintenance dose. In people who are clearly more desperate and in the very late stages of addiction-- when they tend to stick with their decision to avoid opiate agonists-- I will maintain with lower doses. The advantage to lower doses is that if the person needs an agonist for surgery or injury, it is possible to overcome the block much more easily than if the person is taking 16 mg.


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PostPosted: Sat Sep 26, 2009 1:09 pm 
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Ok, wow - this is what I needed. I guess in the back of my mind I wondered about the Fentanyl...what I needed was for an expert, someone who KNOWS what they are talking about to tell me straight up, real talk - what I'm going through is normal, it's going to be hard and you aren't going to feel good like these other people...I just needed the facts so I can deal with this. I wish my doctor had just told me right from the start what this would be like, but maybe she doesn't know or didn't feel it was in my best interest to tell me. I just feel so lousy I needed to know this was normal, sounds like it is considering what I've been doing to my body for quite a while. This helps me to deal with my situation a little better, knowing there might be light at the end of the tunnel for me.

I can't thank you enough for this reply to me. Also, last night I found your article you wrote for Men's Health - the Junkie in the OR...this gave me a little more insight to Fentanyl and what I'm going through and I feel so much better.

I'll quit rambling now, thank you so much for the fast reply, I so needed it. I'm enjoying your articles, I'm so glad I found you. I'm going to start taking my 8 mg. tomorrow morning all at once, keep reading and hang on for the ride.

Best Regards.....


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PostPosted: Sat Sep 26, 2009 1:38 pm 
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Well it's hard to add anything else to what Dr. Junig wrote but I would like to point out that those who have some troubles at induction almost start feeling better within a week or two. I'm currently taking 8mgs for coming up on 3 years here soon and I can tell you that it sure seems to do what it was supposed to do. I'd also like to point out that everytime I've quit using I'd always seemed to have lost the ability to tell what feeling "normal" felt like after being so used to either feeling great or dopesick and ready to die. Finally I've heard several of our members and guests here post about having a somewhat rough time the first few days after starting Suboxone (especially those on methadone) but they all seem to have started feeling alot better within several days so just hang in there I promise things will get better :)
Please keep us up to date on how you're doing :lol:

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PostPosted: Sat Sep 26, 2009 1:49 pm 
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There's also a post somewhere on the forum that Dr. Junig put up about how to achieve "optimal absorbtion" when dosing. I'll try and find it here quick but the point is you want to make sure that you're allowing the Suboxone to disolve and not swallowing anything for about 15-20 minutes and then not eating or drinking anything or brushing your teeth after for another 20 minutes. When I first found this forum I'd been dosing very quickly in the mornings and not allowing the medication to dissolve and then immediately brushing my teeth after and needless to say I wasn't absorbing much of the medication at all. If your induction was anything like mine my Dr. didn't give me any instruction whatsoever on how to dose but it really is important and there have been people on here who've said after making some changes in how they dose they were able to get by on less Suboxone.

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PostPosted: Sat Sep 26, 2009 1:54 pm 
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Thank you so much Matt2, this is all exactly what I needed to hear. I felt that maybe I wasn't doing as well as the other people here because of my dose...I can totally accept the truth in that I'm not doing as well because of my addiction history with the Fentanyl and I just need to stay on course and hang in there, that I can deal with! I'm all alone in this, with a husband who does not understand and is complaining he is not getting enough attention right now, I SO need to be part of a group with other people who truly understand what I'm going through. As soon as I trust myself to drive I'm going to find a local group to participate in.

This forum and the replies I have gotten are invaluable, can't thank you enough.


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PostPosted: Sat Sep 26, 2009 1:58 pm 
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Here we go :) This was Dr. Junigs advice on dosing from another post he wrote awhile back

As for dosing, the technique I will describe does not affect the amount of absorption as much as it affects the speed of absorption; it still takes the same period of time to get into the bloodstream so I am NOT referring to getting a 'rush' or buzz (that is not possible with chronic use, as you all know), but rather it affects the time you have to walk around with something in your mouth. We all know that the minute you put it under your tongue, your wife is going to start a conversation or your phone is going to ring-- so it helps to make the time as short as possible.

Three things affect absorption: concentration (as that drives diffusion), surface area, and time. So the best absorption requires a very small amount of saliva, repeated painting of the solution over all mucous membranes (all surfaces in your mouth-- including cheeks, roof of mouth, tongue (both sides), gums, etc, and finally, you want ot keep it in your mouth for a good 10-15 minutes. While in solid form, the medication is of NO use to you; it cannot be absorbed until it is in solution, so I DO recommend crushing and dissolving the medication immediately, in a very small amount of saliva. Paint it all over for 15 minutes, then spit or swallow-- either one is fine. People who are sensitive to naloxone-- those who get headaches for an hour after dosing-- sometimes do better to spit out the naloxone, rather than swallowing it. I also recommend spitting it out if you have had a gastric bypass or any surgery that bypasses the proximal intestine, as if naloxone gets to the distal intestine it can be absorbed outside of the portal system and avoid breakdown by the liver. The result would be minor flashes of withdrawal for an hour or two after each dose of Suboxone-- not after Subutex.

As for the concerns in the prior message, the exact level of buprenorphine in the bloodstream is not critical. In fact, most people will do fine on a wide range of doses, from 2 mg per day to 32 mg per day. The important thing, in my opinion, is to take enough that you remain over the 'ceiling' level for 24 hours after dosing, so that you can dose only once per day without having breakthrough withdrawal. Dosing more efficiently allows a person to reduce the amount of medication to get that effect, saving a great deal of money. One last thing-- do NOT rinse your mouth for at least 15 minutes after dosing, as some medication will be attached to the surface of your oral mucosa but not yet absorbed, and you don't want to wash it away.

The veins under the tongue are NOT critical to dosing; my complaint with sublingual dosing is that you end up with a small zone of super-saturated tissue around the tablet, and after that develops, little additional absorption will occur and the rest of the drug passes in the gutter along the sides of the tongue and down your throat. That's wasteful-- heck, what about those starving children in India who have NO Suboxone?

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PostPosted: Sat Sep 26, 2009 2:02 pm 
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Matt I just found that post on maximizing your dose, OMG!! I've been doing it right, somewhat - but I see I can maybe do better! WOW!!!! I'm going to read this and figure this out!!


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PostPosted: Sat Sep 26, 2009 2:09 pm 
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WOW! Is Dr. Junig awesome or what??? I'm not getting the full benefit of the Sub the way I'm taking it now!!!!! I'm all over this!!!!!

You people are awesome, I don't know how to thank you enough........Thank you SO MUCH for finding this and posting it here, I'm having a little trouble making my way around here, have so much inside of my head and hands shaking so bad.....thank you thank you. :)

Good luck to us all, thankfully we have Dr. Junig, what a breath of fresh air why can't they all be like him???


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 Post subject: hi sky, I can relate
PostPosted: Sun Sep 27, 2009 12:40 pm 
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Hi Sky,
Im going through some rough stuff now myself. I just posted under "precip/withdrawal- help." which sounds dramatic, but I feel lousy.
As for you. I found it interesting in what the Dr. had to day about the high dose/extended fentanyl. I used that once, and it was so good that it scared me.
I think, just like everyone said, stay close to folks here, and stick it out. You will feel better. I have been on for a while, and just recently (like this week), because of a lot of changes, I through all into the wind and took oxycontin. I just stopped last night, and took my suboxone again, but prematurely. So, it has put me in this sort of hell.

Just keep in mind. You are not alone in this. I think you are feeling better now, from the previous posts- but I wanted to just give you my support. That is one of the most important ingredients of recovery. It sounds a bit hippocrytical coming from me who has been isolating. But even an online board can be a tremendous source of support. Especially if you feel to lousy to leave home.
Take Care

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PostPosted: Sun Sep 27, 2009 2:23 pm 
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I'm so glad to get your note, please don't isolate yourself. I'm fighting that very bad myself right now, but I honestly think we have to stick together to get through this. Yes it's the Internet, etc. but I am genuine, 100% real - I'm going through the fight of my life literally, and I guess I've even pushed my husband away because I'm sitting here alone right now with only my dogs to listen to me, not good. I feel if I totally isolate myself right now I will surely fail. I felt much better getting the truth, but I still have the fight ahead of me and still feel lousy. I can truly relate to what you're going through, so know that you are not alone, ok? You don't need to get down on yourself or anything, you are doing the best you can and just need to get on the Sub program again and with time (and some support) you'll get back to where you were, trust me. Have I thought about just crawling back into my quiet, warm cave with my prescription pain killers? You bet I have. But I also know that is the way to an early grave, I'm not sure that is how I want to end my life so for now...I will stick to this program. I'm just taking one day at a time, baby steps and holding on for the ride. We have to stick together, if we don't know how to do anything else we can at least lend support to others who are going through this nightmare that only we can understand. I really don't think people who have not been through this can understand, my husband seems clueless. It's like he's thinking go on and get better already, I'm sick of this and I'm not getting enough attention.

Ok, the point of my post is to hopefully let you know you're not alone, I don't want to drag you down further! You are back on track now, you know the Sub works and you'll get there again, don't beat yourself down for a relapse.

Hope to hear back from you, please don't isolate - it's easy to do but not helpful to the situation. We are weak alone but strong together!


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 Post subject: Duragesic to bupe
PostPosted: Mon Nov 30, 2009 1:54 am 
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I have some questions myself about switching from fentanyl to buprenorphine, i have been on fentanyl for about 1 week at a dose of 50 mcg/h and my doctor had givin me 10 patches i currently have 2( iahve been iv,ing a patch/day as well to recieve adequate analgesia) I am a long term addict from heroin and have been on bupe and methadone and quihonestly this fentanyl at this dose is not providing me adequate analgesia and i desperately want to get back on bupe( which provideded me better analgesia and craving supression). So my question is what is the best method to go about getting back on bupe? Please help me I am in terrible pain and have exhausted my 30 day supply of medication in less then a week. Pleasew i am begging for an answer to this one. I cant take the suffering i cant duistinguish whether withdrawl is making my pain problem worse then it really is or its just pain but reguardless the bupe helped more then this stuff i have also been taking 5 lortab 7.5/500/day. I am finding myself needing pain meds every 3-8 hours depending on narcotic used.


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PostPosted: Tue Dec 01, 2009 1:30 pm 
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Hi, I'm afraid I can't be of much help to you...I'm the one who originally posted this question, I was starting Suboxone treatment after using the Fentanyl patch for approx. two years for Fibromylagia pain. You don't mention what kind of pain issues you have, and of course I'm not a doctor but if you read this entire thread you will see the response I got from the doctor....Suboxone doesn't work particularly well for people who have been using Fentanyl patch. My first piece of advice would be to stop the patch, starting that patch was the worst mistake I've ever made in my life, the Fibro pain I have now without any pain meds is nothing compared to the rollercoaster nightmare of using that Fentanyl patch! It took me about three weeks for the bad withdrawal to stop after stopping the patch, and I'm feeling better now than I have in literally years and the strongest thing I take is the occasional Soma and Lyrica, Clonazepam for anxiety and Remeron for sleep and depression issues.

Again, I'm not a doctor but my advice, stop the Fentanyl immediately, it's highly addictive and overall I think it's a horrible pain killer, it's inconsistent and VERY hard to get off of. I would find a doctor trained to dispense Suboxone and let them do their magic, once they know your background they can get you back on the program.

I'm sorry I can't be of more help, but I do wish you the very best. You aren't alone, that is for sure and maybe someone here will have more advice for you.

Hang in there, Suboxone treatment works when taken as prescribed and of course getting into group meetings, etc. Do you have a Suboxone doctor in your area? I think that is the best place to start, but you have to go into the office in mild to moderate withdrawal to be treated.

Hugs to you....you aren't alone and I wish you the very best of luck.


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PostPosted: Tue Dec 01, 2009 7:45 pm 
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Im prescribed subutex but my doctor doesnt have to much knowledge on fentanyl since there arent any guidelines to follow. I need to know when its a go so i dont throw myself into precipitated w/d. That fentanyl was worse then the 80mg of meth and it did nothing for my pain since(the fentanyl) it is acute in type. And btw how did you get off that junk? And pleease help me i feel horrible. I HATE FENTANYL, AND IT SHOULD ONLY BE USED ON PATIENTS WHO ARE DYING.


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