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 Post subject: My Dose
PostPosted: Sat Dec 18, 2010 8:04 pm 
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Hi fellow suboxoners,

I've run into somewhat of a personal issue lately and I need some input from some outside people. I am in week 4 of my suboxone treatment. My doctor started me on 8mg three times per day. I believe he did this due to the sketchy absorbtion of the pills so he likes to prescribe the 8mg pills always to new patients (and even old patients I have found out), plus he wants me dosing three or more times per day to help with my chronic back and knee pain.

After about 5 days on that dosage, my cravings came back and it was somewhat uncomfortable, so he told me to start taking 8mg five times per day. I'm not sure if it was the dosage increase or the fact that the "honeymoon phase" was over, but the energy boost that I initially got had gone away at about the same time. I felt a little lethargic, but it's gotten better lately. I ran out of pills early since I was only prescribed 90 to begin with, so he gave me the additional 12 day supply of 5x8mg, so 60 pills. However, for some reason I just felt like this was overkill and decided to cut back my dose a bit. After being on the 40mg/day for a couple weeks, I cut back to 16mg/day for the past five days now and have not had any ill effects other than a slight decrease in the pain killing effect of the suboxone.

So my question is, should I continue to dose at the 40mg/day that my doctor instructed until I see him in three days? Or should I stick to the ~16mg dosing that I have been doing for the past few days? Also, I have been frustrated to hell getting these pills to dissolve the same way every time I put them in so the frustration just makes me not even want to take them even though I love the medicine very much and I know it's my lifeline. I'm thinking I'll eventually cut back from the 40mg to 24mg at least for a while, and perhaps 16mg is too low because I have had some subsequent cravings due to the dosage decrease from 40mg to 16mg.

Any advice on any of these matters? What I should do about my dose for now, what to do about being so frustrated about actually dosing, etc. I have so many pills that he prescribed I don't want them to go to waste especially because I'm probably switching to the films for next month. I don't know. Any help or comments would be greatly appreciated.



Thanks a lot,
Caleb


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PostPosted: Sat Dec 18, 2010 8:32 pm 
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You may very well get the "prize" or "award" for the highest daily dose of Suboxone I've ever seen. Seriously, 40 mg a day? Just the expense alone... Not to mention you have to be well over twice the ceiling dose. From what you have said it pretty much sounds like you are admitting you're not seeing much difference with the effects of 40 mg over the effects of 16 mg. If that is the case, you are not at all alone. Even pain patients rarely take 40 mg of Suboxone each and every day. Again, just the cost alone would be an issue for many/most - unless you are covered well by insurance. At the retail level, you are taking about $40 of Suboxone a day - a whopping $1,200 a month and, drum roll please, $14,600 of Suboxone a year. Some people don't even have a yearly income that is that high.

Of course, the biggest factor here is, what is all of this Suboxone doing for you? While everyone is different, you would indeed be very unique if you found that 40 mg of Suboxone actually controlled your pain much better than 24mg or perhaps even 16 does.

As for what should you do, well if you only have three days until your appointment, I am not sure it much matters what you do over the next three days. I would certainly discuss all of this with your doctor in three days though. More and more patients and physicians are starting to agree that the least amount of Suboxone that gets the job done is where you should be - whether "getting the job done" involves treating your pain, managing your addiction or both. The current "best practices" maximum dose is 16 mg for addiction. Some still require more than this amount for pain, but rarely 40 mg on a daily basis. Perhaps on a bad pain day or two but not each and every day. I even wonder what the side effects for you are like on 40 mg - especially the constipation.

I hope that helps. Others may well be more helpful for you. The best advice I can give you is have a serious discussion with your doc in three days.


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PostPosted: Sat Dec 18, 2010 8:58 pm 
40mg's a day is serious overkill. My goodness thats, in my opinion way too much. I've heard of people who take it for pain taking 24mg's but thats about as high as i've heard. Well, no i take that back i have heard of people who take 32mg's. When someone says they take 32mg's a day my first thought is, they arent getting the proper absorption. Man thats a lot of money and sub. If you feel ok at 16mg's i would tell your doctor. Maybe tell him that somedays you need 24mg's so he'll give you a few extra for the really bad days. I definitely definitely say that 40mg's is the very highest i've heard of. I think thats probably up their where it will start having somewhat of a reversing effect and actually start to block itself out. Less is more with this medication. I know that sounds crazy but its true. You know it acts as a full agonist at anything below the 4mg ceiling level. The increase could have easily been why you lost the "honeymoon phase" so quickly. If their is such a thing. However i do know what your talking about in the beginning. It did work much better for me in the beginning compared to now but even now, for the most part it gets the job done. I honestly believe its possibly blocking itself out at such a high dose. Anyways, others may know more about this.


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 Post subject: I agree
PostPosted: Sat Dec 18, 2010 9:00 pm 
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Caleb, I posted a resonse earlier but something is up with this computer or the forum....has anyone else had touble logging in or staying logged in while on the forum? It jumps around, i get logged out, I'll be writing a post for forum and a PM will come up....tech issues....

So, I agree with Donh. 40mg is high. Now, I realize I just started Sub but my physician says that 16mg is a pretty good "average" maintenance dose....some need more, some need less...but a ballpark number to shoot for.
I'd gather info and bring it to your dr and discuss it with him but really if you are doing well at 16mg stay there....I don't know about your pain issues and that dosing...others with that issue can help you more. But wow, 40mg? I don't know anyone on that dose. I do have a client on 24 and she has been there a year which I think is too much as well....but i'm not her sub dr! Nor yours....but 40? yikes!


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PostPosted: Sat Dec 18, 2010 9:23 pm 
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Alright, alright. First off, the cost isn't an issue. My insurance covers really well so my co-pay is only $60 regardless of the pill count.

I go to meetings twice a month at my doc's office along with all of the other suboxone patients there and most of them are on 1-3 pills per day. One guy said he was taking 48mg at the start, and a couple others admitted to 40mg at the beginning too, although no instructed. I understand that less is more, but there is no way my cravings would be covered at 4mg, and I wouldn't be able to cut to that dose for very long without hitting some withdrawals I'm thinking. I think my doctor was correct in starting me at 3x8mg, but I don't think there was much difference when I upped to 40mg. I have a shitload of extra pills right now due to me lowering my dosage, but since I've gone down to 16mg, I definitely have had some cravings and been thinking about drugs a lot more. I wouldn't mind a maintenance dose around 16mg-24mg, but 40mg is rather high and dosing five times per day is a little annoying, especially with my dissolving/absorbtion issues. I'll probably stick to 16mg until I see my doctor tuesday, but I'd rather stick to 90 pills per month for my script just in case the 16mg isn't working out after I see him. I'm planning on switching to the films, but I might do 45 films, 45 pills because I'm getting too frustrated with the pills basically. Also, I'm sick of everyone around here almost bragging about how LOW their dose is. I'm not trying to brag about mine being high, it's ridiculous, but I find it hard to imagine people honestly getting by well on 1-4mg per day or less. Although, if that's just for addiction treatment and they're weaning off, it's probably feasible, but for pain and addiction treatment and to suppress my cravings, I've noticed that the 16-24 range has worked for me.


Any response to my issue of dissolving the pills? Every time I dose, I get done feeling like I failed or did it wrong and probably didn't absorb it all. I swallow most of the saliva that builds up, not like it's going to all absorb through my tongue, because it definitely doesn't. The whole pill will eventually dissolve, leaving me with a tasty pool of juice, which I press my tongue down on for an additional 10-20 minutes. I haven't had any withdrawals or major issues so I guess it's working, but it's so hard for me to tell with this medication when I've dosed it correctly since there is no feeling like there has been with previous things I've taken such as other opioids and klonopin.


So, we've decided my route for the dosage issue. I'm going to stick to 16-24mg per day, splitting either to three doses for adequate pain management all day long, and I'll let me doctor know that 4-5 pills is pointless. He, too, mentioned that he was pretty sure there wasn't any noticeable difference between 3 and 5 pills, but he wanted me to try it anyway. I'm sure it was meant to be a temporary thing, but he was out of the office for over a week due to surgery so he just kept me at the same dose since I've not been able to talk to him much. At the beginning of my treatment, I don't want to be super low. 16mg would be fine to me, as long as it adequately treats my pain and cravings. My maintenace is going to last a really long time, so I don't quite mind my dose, as long as the medicine works at its best and doesn't cause any problems.

And as a side note, my constipation has been unbearable since the beginning. I've had very few bowel movements in the 4 week period that this has been...



Anyway thanks for the feedback so far, and any suggestions from any of you guys about SIMPLE ways to dose my pills that will make me feel satisfied rather than a failure, would be greatly appreaciated. Also, if any of you take the films, tell me all about it so I can talk to my doctor and tell me how you do/don't like them compared to the pills and why.



Thanks a lot,
Caleb


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PostPosted: Sat Dec 18, 2010 10:45 pm 
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Hey Caleb,

I think the other members were just surprised by the high dose you were temporarily on, I don't think they were trying to hurt your feelings.

I understand what you and your doctor were trying to accomplish. Neither he nor you knew if the higher dose would bring any additional results so y'all gave it a shot and you decided it wasn't worth it...cool. That's how we learn.

I agree with you, you are only 4 weeks into your suboxone treatment and you simply are not ready for 4mg yet. I don't think anyone was suggesting that, but I could be wrong. Anyway, 16mg - 24mg is where I was at to start. I got to 16mg fairly quickly because I felt fine there, I'm going to say if I were you I would keep my dose on the high side for the first few months until you can learn to deal with your cravings a little better. It took me months to do this. Once the cravings subsided, I stayed on a maintenance dose for years because I knew I wasn't ready to be off suboxone. The cravings will subside as time goes by. Your going to have be patient with that one, man.

As far as getting the pills to dissolve, I'm afraid I can't help, but I know there are plenty of others on this site who have had the same issues. I hope one of them swings by soon and can help you out.

Hang in there man, just because you're on suboxone doesn't mean you're cured. It takes work, buddy...but it's worth it! Very soon you will find out how proud of yourself you are, if you haven't already.

I'm just curious, what is your addiction and pain history, if you don't mind my asking?


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PostPosted: Sun Dec 19, 2010 3:29 am 
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Hey Caleb - Regarding dissovling/absorbing your Suboxone, I noticed that you said that you swallow your saliva while you're dissolving your pills. When I started Sub treatment I was told explicitly NOT to swallow my saliva for at least 20 minutes while the pill was under my tongue.

There is bupe in that saliva you're swallowing - you need to hold it (the saliva) in your mouth, preferably under your tongue, for as long as you can to get the max absorption. I bet this is why you're having cravings and why you've had to increase your dose. Bupe is a very strong drug. Dr. Junig has even written about a patient he had who economized on his Sub by spitting out his saliva, freezing it, and then re-using it. Gross, definitely, but it demonstrates my point.

Early in my Sub treatment, the pills would make me drool like crazy and I often had to sit around for 20 or 30 minutes with a mouth full of nasty orange drool waiting for my meds to soak in. I would hold it in my mouth until I couldn't feel that tingly feeling anymore and then I would either spit it out or swallow. My absorption was great and I quickly stabilized at 14mgs a day.

Next time you dose try this: break the pill in half and put one half on each side under your tongue. Don't swallow or talk or do anything while you wait for the pill to dissolve. If you get a lot of saliva, just do what you can to keep in under your tongue for as long as you can. After 20 minutes (minimum, you could even go longer) you can swish the spit around and make sure the pill is totally dissolved, and then spit or swallow. I bet that this will greatly increase the effect you get from the medication.

The orange pasty stuff that's left when the pill dissolves is just the binders and other shit. Buperenorphine is highly water soluble (I completed my taper by dissolving my pills in water to effectively measure out very tiny doses) so all the medication is going right into your saliva, and if you're swallowing it too soon, it's just being wasted.

I hope you'll try this and let me know how it goes. Good luck.

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PostPosted: Sun Dec 19, 2010 8:12 am 
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I agree with Romeo. I don't think anyone was trying to make you feel bad about your dosage. Like he said, you gave it a try. Hey - your doctor is trying to help you and that's more than some do, from what I hear.

Diary gave you excellent advice on dissolving your pills. I'm not going to add anything to what she advised.

Back to your dose...I think you have a very good plan in mind, to take between 16-24 mg per day. To be honest, 24 mg is very common for us pain patients. Give that a try and hopefully that will help. Keep in mind that for many of us taking sub also for pain, it rarely addresses ALL of our pain. We're generally happy for it to make our pain, for the most part, tolerable each day. What I'm saying is no matter how high you dose, suboxone may never completely erase ALL of your pain.

Please do keep us posted.

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PostPosted: Mon Dec 20, 2010 5:12 am 
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Thanks for all the replies, I really appreciate it.


@Romeo - Thanks for your comment, I've decided that 32mg will be the absolute max for me from now on, and my cravings have definitely subsided since my induction. The cravings were intense and nonstop before suboxone, and after 24 hours it was amazing how much of a difference I noticed in general. The 40mg dose definitely killed my cravings (along with me, and everything else...) but I can certainly get by with less since my thoughts of using and cravings have settled immensely. Also, I have 30 days today! So that proves that suboxone and I are doing something right these days. As far as my addiction history, I'll keep it short: I'm 18 and started abusing hydrodone and cocaine about 10-12 months ago for the first time, ventured through LSD, benzos, and other opioids, specifically methadone. Eventuall after a few months of sparse using, I came into quite a bit of graduation money at the beginning of June and basically went on a summer drug-using spree. I didn't realize it was as bad as it was until I ran out of money and had to face the reality that I "needed" something daily to feel normal. I always chopped up my using patterns a bit though, so I never experienced physical dependency beyond some mild to moderate withdrawals. I live in a super small area and town but my friend's dad would get a methadone prescription for his H addiction each month and he only took about 1/4 of his daily dose, so the extras were sold. I'd buy multiple of the 40mg wafers at a time and started on my first time using it with 10mg, promptly puked several times. Over the next few months of frequently using it and hydrocodone more and more, I was eventually able to handle 40mg at a time (max in one day was 60) without becoming sick, putting me in a great nod. Eventually, methadone ran dry at times and I would have to resort to heroin, but it wasn't that consistent. Sometimes I'd do it several days in a row, then I'd get back into a vicodin binge and not use heroin for weeks. I never shot it up though, I'd take weeks off using in order to lower my tolerance and save some money, not to mention lay low with my parents and not totally screw up my whole life. I had an injury at the end of summer on vacation after I finally went through detox at a local rehab, and got prescribed some 10mg lortabs. Great. I was re-hooked and ended up heading off to college two weeks later with 60 hydrocodone, a lot for me since I was smart about rationing them out to myself usually. After that, I stopped using more than very occasionally, but after a bunch of confusion with meds with my psychiatrist and mental instability (moving from klonopin to adderall to vyvanse, then failing several UAs for him...), I resorted to using methadone quite frequently again, dropped out of school, went to treatment, saw a suboxone doctor a month ago, and now I'm here. :) (sorry...not so short I guess)... In case you want to skip the details above: a year ago I started my path of drug abuse, came into a couple grand a few months later and binged on coke and opiods all summer long, a bit during the fall during my freshman year of college, until finally I decided to go to short treatment, see a suboxone doctor about maintenance, and ultimately start recovery.

As far as pain goes, it's not as detailed. A few years ago I was in a rollover car accident and noticed quite a bit of recurring back pain afterwards, but I figured it was just soreness so I didn't tell anyone. I remember one particular sensitive spot the day after the accident that I still have a lot of trouble with to this day. I never thought there was anything serious wrong since I was still walking and "fine," so I never made much of a fuss over it. I got my driver's license a few months after the accident and started to notice MUCH more through driving around and sitting straight and still how much pain I was really in. For a long year after the accident, I dealt with a moderate scoliosis and some really sharp pains after heavy lifting or sitting for extended periods of time. I finally went to see a chiropractor for a few months and the pain dulled down a bit I guess... But not really. I stopped seeing him and the pain always came back. Eventually I had it X-Rayed but nothing major was found. The chiropractor knew I had plenty of scar tissue built up and some obvious issues, but the x-ray didn't show much so I was left out to dry. I didn't know my options at the time, so I just accepted the results and moved on. I haven't gotten an MRI or anything else done specifically for my back, but being in this much chronic pain, there has got to be some way they can tell. Any ideas?

So I deal with the undiagnosed back pain still. Then, in August of this year I was in a rollover ATV accident while on vacation, and it of course irritated my back some more. So between the two accidents, I have a pretty good deal of back pain, and the opioids I used recreationally were always partially to help relieve my pain. Without the suboxone (or street opiates pre-suboxone), I wake up every morning with an extremely stiff, aching back. And trust me, I have a special mattress to help with my back issues, and it still doesn't help much. The knee pain I mentioned has sprung up since being on suboxone, it's really weird. I have a lot of issues with restless legs now, and a lot of twitching. I used a 0.5mg klonopin (my last one :( ) that cured me for a night, but I'm without help now, and of course there's no way in hell my doctor's going to prescribe me a benzo until I'm off suboxone, he's made that quite clear. The twitching is mainly when I'm sitting still or laying down and fairly still, I have involuntary huge shakes and twitches. But when I'm driving or sitting sometimes, my muscles seem to be restless and I must constantly "exercise" them by tensing them (by tensing I mean a very brief "flex" of sorts, I know, weird) and stretching my neck or legs in awkward ways. It really has gotten quite annoying, but I deal with it. However, due to this muscle tensing, my knee and quadricep on my right leg specifically, become extremely sore and in a decent amount of pain. The suboxone helps with this a bit, but ibuprophen sometimes works better for my leg while suboxone takes care of my spine.

Sorry for the extremely long response Romeo, but there's my rather un-extreme pain and addiction history. I never shot heroin, never became sickly physically dependent, never tried oxycodone in my life, and don't have any x-rays yet to prove my pain, but I swear the mind is a devil and after attending hundreds of NA meetings, trust me, I AM just as much of an addict as everyone else in there. I just didn't have the heart to steal the money needed to feed my habit, which is why I've also never been arrested. Oh well, I hope you find my story interesting, again sorry for its length but let me know if you want to know anything else about me :) just PM or something.

@Diary of a Quitter - Luckily you didn't ask me any questions like Romeo with such a longgg answer haha. Anyway, thank you SO much for you post! This method is really easy for me and I've successfully done it perfectly twice now. After about 20-25 minutes, all that was left was a very small amount of that paste crap on the floor of my mouth, presumably binder and filler, but I mixed it up with my tongue anyway and let it sit under my tongue for another 5-10 minutes just to be safe. I never swallowed the saliva the whole 25-35 minute period, and was able to trap it ALL under my tongue the whole time surprisingly. Every 5-10 minutes I'll shake my head from side to side a bit to help mix the saliva under my tongue aruond and get it all absorbed. It's really much better than the crappy ways I kept trying to do it prior. I'd always end up swallowing a ton of the pill on accident, but obviously with this method, keeping that dissolved liquid under my tongue for 20-35 minutes pretty much HAS to ensure that almost all of the bupe gets absorbed. Even if it doesn't, I feel much more accomplished and confident after dosing this way and I guarantee I'm absorbing much more with this method than my last attempts for the past month, ugh. Again, thanks for taking the time to share your method with me, and I'll update about how it's doing after a bit of time, especially if I get some films!

@hatmaker - Thanks for your post as well. To respond to you and start to conclude and summarize my post here, I will state that I have indeed decided that 40mg is out of the question in the future. I have only taken 10-16mg for all of the past 6 days and I'm doing pretty well. However, due to my pain and the fact that I plan on being on maintenance for quite a while, as well as the slightly noticeable increase in cravings since my dose decrease, I'm likely going to stick with 20-24mg for the time being. I think that 16mg is just a tad low for now, and 32+ is definitely too high, so 20-24mg is a good dose for me I think. Since I have been getting by though with 16mg, I'm tempted to just stick with it. I might for a few more days, but I've noticed an increase in my depression within the past week, which is unusual because I honestly haven't thought about it or noticed it much at all since getting clean and starting suboxone. For the record, I've been on Paxil 30mg for about six months now as well, so it's especially strange when I feel worthless and depressed. Oh well. Regarding the pain, I definitely agree on what you said about how bupe works for our pain. I have certainly noticed that it works a good amount and dulls the pain to a tolerable level, but doesn't cover it all up like our old precious opioid painkillers used it. Although bupe is a really powerful opiate, it never ceases to confuse me since it seems so weak while I'm on it and it has never once made me sick, not to mention I built a full tolerance for it practically after my first dose, it was the only one that I really "felt" anything. I've seen many debates on the web about the painkilling properties of bupe, and it seems like some people (like us) find benefit, while others don't. I have seen videos produced my a few doctors online as well as postings by individuals who all agree that it is a very powerful analgesic. In fact, I stumbled upon a site/thread online the other day where chronic pain patients were discussing their experience with being prescribed suboxone for their chronic pain issues. I was really surprised because these people had some pretty serious injuries and problems and most, if not all, of them claimed that suboxone worked wonderfully for them, even better than dilaudid, claimed one user.

Ugh. I'm truly sorry. My rambling has gotten the best of me tonight. To the point, hatmaker510 I totally agree that the bupe usually helps make the pain tolerable every day, but of course we don't seem to think so since it doesn't make us high like the previous opioids we used. But I'm not complaining, I'm clean, sober, and have daily pain relief better than just OTC drugs. Would you care to expand on your experience with bupe and your pain? I'd be interested in hearing. You can PM me if you'd like. If you skipped the piece above, I've decided to certainly stay at 3 dosings per day, totaling 20-24mg. I'm planning to stay in maintenance for a while, and I plan to taper down a couple milligrams every 2wks-month until I get down to 8-12mg, and I'll stay there through maintenance as long as I'm comfortable. Thanks again for your comments



Thanks again to all who have posted in this thread so far. I'm new to recovery, suboxone, and this site, so I love hearing from you others and getting support! Feel free to share your own experiences about these topics, I'd love to hear. I'll be looking forward to any other replies in this thread as well.



Thanks!
Caleb


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PostPosted: Mon Dec 20, 2010 6:06 am 
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Wow, Caleb, that was truly an epic post :lol:

I'm glad you're having more success with the new dosing method. I truly do think you'll be feeling better & getting better absorption of your meds if you stick with it. You sound like you're motivated to do well & I wish you the best in your recovery.

I also wanted to mention that I got sucked into the world of opiates via chronic pain as well, and while Sub helped with my pain it didn't eliminate it, so I started looking for other ways to try to deal with my pain or fix what was causing it. During my search, I learned about Trigger Point Therapy and it basically changed my life. If any of your pain is muscular, I highly recommend checking it out. The name of the book is The Trigger Point Therapy Workbook, please PM me if you want to know more about it.

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PostPosted: Mon Dec 20, 2010 9:39 am 
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Hey Caleb,

Like many others, I ended up hooked on pain meds due to trying to treat my chronic pain. (I have Fibromyalgia and Interstitial Cystitis.) When I first started on Sub I just knew I was screwed and would end up dealing with this pain forever. I honestly didn't expect sub to address my pain. Then again, I didn't have a typical induction, so I knew absolutely nothing about suboxone when I started treatment. But I was pleased when my pain started to subside. Along with the suboxone I also take Zanaflex, a muscle relaxer. That's just icing on the cake for me. Between the two (and a heating pad), most of my pain is bearable, although I still have some really bad days. Like last week I lost someone very close to me and the stress of it all really pushed my pain over the edge. It felt like neither med did anything for me, but that doesn't happen all that often.

Like I said, I take 8 mg, either 2 or 3 times a day. Some people I know can take 4 mg or less a couple times a day and still get adequate pain relief. So a couple of times I tried to lower my dose,too, but every time I tried, I simply didn't get the same out of 4 mg as I did from 8. So I've finally settled in and accepted that 16-24 mg will be my dose for the long haul.

You just need to find what works for you and stick with it. I remember there was a time when I got a rash of shit from people telling me I didn't need 24 mg, that the dose was way too high, blah blah blah. Those naysayers aren't in your shoes and don't have to live with your pain, so take what they say with a grain of salt and do what you need to do for yourself.

Sorry this is so long....Good luck finding the right dose. We're really glad you joined the forum. I hope you stick around and keep posting.

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PostPosted: Mon Dec 20, 2010 11:03 am 
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Caleb,

Congratulations on 30 days! Way to go.

You sound like you're doing well, have a very good attitude and are ready to tackle your addiciton head on. That's great to hear.

You asked about diagnosing chroninc pain, that's a notoriously hard nut to crack. I'm sorry to say that I don't have any advice for you there, but if I were you I would certainly take a look at the book DOAQ suggested....she's really shmart. :)

Remember, suboxone will give you the opportunity to fix yourself, it won't do it all for you. Be patient and work hard.

Stay in touch,


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Fond Du Lac Psychiatry
Dr. Jeffrey Junig, M.D., Ph.D.

  • Board Certified Psychiatrist
  • Asst Clinical Professor, Medical College of Wisconsin

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