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 Post subject: Is My Dose Too Low?
PostPosted: Mon May 10, 2010 9:53 am 
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I started suboxone about 18 months ago at 16mg. I was taking 8mg in the morning and 8mg at night. I came off a horrendous Oxycontin habit and I have a long, long history of opiate abuse, dating back 30+ years, including a TON of IV Heroin use when I was a young man (I'm 46 now)

I tapered my dose from 16mg down to 1mg over a period of about 14 months, but when I got down to the 1mg, I was not doing so well and even started having thoughts of using again. :evil:

By the way, I have been in and out of recovery dozens of times, I am basically the relapse king. I'm so sick of the merry-go-round and nothing has ever worked for me (meetings, counseling, in-patient programs, out-patient programs, etc) until I got on suboxone, this is the longest I've gone without drugs in 30+ years.

So anyway, when I was at the 1mg and struggling, I kind of panicked and I took more subs to get myself stable and called my doctor. He told me to come in right away. ( he's VERY cool) So I went in and told him that at 1mg I was depressed, anxious, and having pretty much constant thoughts of using. He increased my dose back up to 4mg, and I felt pretty good at 4mg for the next few weeks, and I even went back for my next appointment and we talked and he prescribed me 4mg again, which I've been taking this month, but I have noticed that I am still having *some* thoughts of using, not every day, but at least a few times per week.

This NEVER happened when I was at higher doses. And I mean never.

Now, my doctor and I have both decided that given my long history of drug abuse and relapse, my age, and the fact that I have HepC, I am an excellent candidate for long-term maintenance on suboxone, and I've come to terms with the fact that I will likely be on this drug for the long haul......

But if I'm going to be taking it long term, I want to be on a dose that lets me focus on working with my therapist on the issues that contributed to me becoming a drug addict in the first place, I don't think dealing with intermittent cravings for opiates is helpful at this stage, and honestly, it's scaring the shit out of me that thoughts like this are crossing my mind. I'm in therapy and I attend a weekly substance abuse group-therapy meeting.....and I feel like I was doing SO much better back during the period when I was above this current dose. I NEVER, EVER had any thought of using AT ALL when I was on 6mg or 8mg, but that is not the case now.

After all this time, I don't want to move backwards, but I refuse to jeopardize my recovery just so I can be on a low dose of suboxone. What's the point?

So, anyway, I am looking for some input from YOU. Based on what I've told you here, do you think it would be in my best interests to mention all of this to my doctor? This is not an attempt to get "high" I don't abuse my suboxone, I have always taken in exactly as prescribed and will continue to do so, but I am afraid that I may need a slightly higher dose to keep the noise in my head quiet.

What do you folks think?


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PostPosted: Mon May 10, 2010 7:27 pm 
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Hey there,

I can tell you that once you get down under 2 mg your mood can be very up and down and your brain is no longer saturated meaning parts of your brain/receptors are wide open. They will heal and you'll get better but you have to be patient.. I'd say don't taper any further until you start feeling better. Give it time. I have been where you are. I'm down to .1 mg a day now and am taking days off here and there. I don't feel 100% awesome all the time but I'm feeling good. But there were definately times I thought i'd tapered too fast. Just wait...your brain will adjust.


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PostPosted: Tue May 11, 2010 8:20 am 
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hawker1 wrote:
Hey there,

I can tell you that once you get down under 2 mg your mood can be very up and down and your brain is no longer saturated meaning parts of your brain/receptors are wide open. They will heal and you'll get better but you have to be patient.. I'd say don't taper any further until you start feeling better. Give it time. I have been where you are. I'm down to .1 mg a day now and am taking days off here and there. I don't feel 100% awesome all the time but I'm feeling good. But there were definately times I thought i'd tapered too fast. Just wait...your brain will adjust.


Hello and thanks for the reply. The problem is I am not tapering. I am staying on suboxone indefinitely. And my thought is, if I am going to be on it indefinitely, should I be at a higher dose, a dose that will prevent receptors from being "wide open?"

I do not want to go through life having thoughts of using every day, but that is what is happening to me lately. Pretty much on a daily basis, I think of using. From the time I started suboxone, until I tapered down to about 6 or 8mg, I NEVER, EVER had any thoughts of using AT ALL.

My original intent was to taper and jump, but I have since changed my mind, with the advise and counsel of both my substance abuse therapist and my suboxone prescriber. So, given that I will likely remain on maintenance for quite some time, and given that I am currently experiencing pretty significant desire to use drugs, I am considering talking to my suboxone prescriber about increasing my does a bit, maybe up to 6mg instead of 4mg.


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PostPosted: Tue May 11, 2010 9:27 am 
You know, I don't see how it would hurt for you to try going back up to 6mg/day, with your doctor's blessing of course. I do think it's possible to not be completely "saturated" at 4mg/day. I know that's when I started running into some issue with increased cravings.
I guess it is all about your personal goals. If you've decided to remain on bupe and have no plans to come off it or reduce your dose, then why not be sure you're 'at the ceiling' dose-wise? That's probably your best insurance at avoiding the cravings. And you know at higher doses before, you had no cravings at all.
I can't say the same thing. I don't know that I ever got completely craving-free, even at higher doses. Maybe the first couple of weeks on Sub, I didn't have cravings, but since then, I've had to deal with some. They are fleeting and mostly pretty mild, but not obliterated. My goals are different though, and all of us have varying drug histories. I wanted to reduce my dose gradually and eventually come off bupe. So for me, learning to deal with cravings (other than bupe) is an essential part of the plan. To me, one of the beautiful things about bupe is that if you taper slowly enough, you don't have to get slammed with unmanageable cravings.....You start having some, you slow your taper down and learn to cope with them, they subside, and try another dose reduction. If, like you, junkie, I get to a place where I feel real unsteady and overwhelmed by cravings, I'd do what you've done and say, "screw it....I'm staying on Sub."
So yeah, to me, you've got a couple of options.....up your dose or work on your cravings from other angles. You may have to do both....probably will. Just remember that cravings pass. As long as you don't act upon them, they can't hurt you. They're just 'thoughts,' 'feelings,' 'memories,' whatever you want to call them. When cravings hit me, I have to force myself not to dwell on them, instead think about what addiction stole from me. And go occupy myself with something else....anything else....to distract me from the cravings. I'm sure you've heard all this before, so I'll stop.
Talk to your doctor and do whatever is necessary to avoid relapse. Let us know what you do and how it works.


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PostPosted: Tue May 11, 2010 9:45 am 
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Hi There, setmefree,

Thanks for the reply. I know that cravings are just thoughts, believe me....the problem for me is my relapse history. I have literally lost count of how many times I've relapsed in my life, since I first started honestly trying to stay off drugs, which was in the 80's.

I'd get clean for a few weeks, or a month, or two months, or even 4 or 5 months and then relapse. Over and over and over again and again and again. I still have a LOT of work to do on myself, which is why I am in private therapy twice each month and group therapy 4 times each month. I am very committed to my recovery. But it's kind of difficult with all of this chatter going on in my head to focus on good stuff....I find that I am spending my days just kind of "holding on" and I would really like to have some time to get past that "holding on" thing and dig a bit deeper into myself.

I hope that makes sense.

I remember being on 6mg - which was about the time of my last liver biopsy - and the drug thoughts and cravings were completely NON-existent. I would really like to get back to that place for a while.....

Luckily, I have not done anything stupid, and I am absolutely convinced that my current dose is what has prevented that. But I guess my thinking is along the lines of this: If I'm going to stay on bupe indefinitely, I might as well be on a dose that is going to allow me to get the most out of my therapy, and right now I just don't feel like that's the case when I am just spending all of my time battling these cravings.

It's weird, because when I was tapering, this never happened....I tapered all the way down to 1mg and only THEN, when I had been on 1mg for about 2 weeks, did I start feeling crappy and having cravings. Then, for a short while, when I went back up to 4mg, I was doing quite good, but I seem to have kind of leveled off a bit there and actually have felt lately like the 4mg is not having the same effect it did when I first went back up to that dose. I'm guessing I've got some tolerance issues here, perhaps. I've always had an extremely high tolerance for opiates of any kind, so that's probably related to this issue I'm having now.

Well, anyway, my suboxone prescriber is a very cool and understanding doctor who has been more than willing to work with me, so when I have my appointment tomorrow I am going to tell him how I am feeling and see what he thinks.


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PostPosted: Tue May 11, 2010 10:25 am 
yes..I totally understand where you're coming from. It sounds like you have really come a long way! You should pat yourself on the back, for sure, for working so hard on your recovery this time around! It is difficult to say the least. To me, what you're going through just emphasizes the fact that bupe alone is not the cure for addiction. We have to use the medication to help, but when it all comes down, the issues that led to our drug abuse and relapses, are still there needing to be dealt with. And you are doing that in every way possible. I agree with you....if bumping your dose back up a bit will squelch these cravings and that obsession to use that we all struggle with....then why not do it? Because white-knuckling our way through every day will only last so long, right? I hope a dose increase will assist while you continue working on things. There's a good chance, at least in my opinion, that it will. No harm in trying it. I'll be curious to know what your doctor thinks and whether it works. Be sure to let us know. Hang in there in the meantime and keep doing what you're doing as it seems you're doing an excellent job!


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PostPosted: Tue May 11, 2010 10:40 am 
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Thank you for your kind words and encouragement, setmefree, I really appreciate it! :D

I will be sure to update this thread tomorrow after my appointment.

The other thing I have to talk to him about, at the same time, is the fact that I am going on vacation in June and will be in Breckenridge Colorado during the time that I would normally have my June appointment with him, so we are going to have to find a way to get me enough of a supply of suboxone that I don't run out while on vacation.

He helped me conquer this problem last year by prescribing me 8mg, even though I was only supposed to be taking 6mg. He said, kind of with a wink, "we'll keep this little dosage manipulation between you and I" but I know he did it because he trusts in the fact that I am actively working on my recovery and trying to get better.


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PostPosted: Tue May 11, 2010 10:43 am 
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My opinion is that you should definately raise your dose. The point of taking buprenorphine is eliminating the obsession for opiates-- not to just stave off withdrawal on a day by day basis. The focus on treating addiction should be eliminating the obsession, and in that way buprenorphine 'treats' addiction very effecttively-- but only if taken at a sufficient dose.

I understand and respect the idea of taking the lowest effective dose necessary. I think the considerations would be even more important if we knew of toxicity from buprenorphine, but the cost issue is enough reason. But make sure that you are getting all that you are supposed to get from the medication.

As for psychotherapy to find the things that led to addiction, if you are like most people you will find that to be mostly an academic exercise without as much usefulness as the general public tends to believe. Understanding our make-ups, triggers, character defects, etc can help us find our way through life, but such understanding unfortunately has little benefit to maintaining sobriety.


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PostPosted: Tue May 11, 2010 11:11 am 
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Oh, wow, a response from Dr. J. :shock: :shock: :shock:

Thank you so much for chiming in, Dr. J. That is extremely helpful. I am going to print out this thread and bring it to my doctor tomorrow.

As for your comments about triggers, I mostly agree with that, however, I'm going to share something about myself here that I think it germane to this discussion:

I was criminally abused by my father as a child. Not sexually abused by him (my cousin took care of that :roll: ) but physically, and very violently (to the point of broken bones) abused. My father would beat me to the point where I could not even scream any more because the pain was beyond anything I had ever felt then or since then...and I've been shot - in the shin - with a .45 caliber bullet - and I'd rather get shot ten more times than to ever take another beating like the beatings I took at the hands of my father.

I've never been able to come to terms with those beatings. They are a source of incredibly intense anger and a burning, vivid hatred for my father.....I believe that my treatment as a child, and my feelings surrounding that treatment were what pushed me to into drug abuse at an early age, and are a part of why I have continued to anesthetize myself in adult life - I have spent my entire life avoiding dealing with this.

Addicts are professional "avoiders"

So, anyway, the point is, I really, really want to try to come to terms with this stuff through continued therapy, but I'm finding it extremely difficult to focus on anything right now because of the fact that I am just kind of "getting through" every day. So, yes, I am going to discuss this with my doctor tomorrow and I am confident that he will do what should be done. He's very compassionate and understanding, and I really like the guy a lot.

Thanks again for your input, Dr. J.


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PostPosted: Tue May 11, 2010 1:28 pm 
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Junkie: I think you should use the sum total of the information in this thread and have a talk with your Sub doc. I would tell him exactly what you have told us about how you are feeling. Certainly add in that the closest thing that we have to a physician Sub expert suggests that your dose be increased as well. I think I've said before that if there is ever a case that would appear to call out for life-long Sub treatment, it very well may be yours. While the cost sucks, it would appear that the benefits of continual Sub treatment far outweigh the risks in your case.

Putting all of this together, it seems rather clear that the best thing you can do is have your doctor increase your dose to perhaps 6mg or even 8mg a day and put you back to where you were and keep you there. It sounds like you have a good doc and he is willing to listen to and work with you. Put your little "presentation" together and deliver it to him at your next appointment. That's what I'd do.


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PostPosted: Tue May 11, 2010 1:58 pm 
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That's good advice, donh, and that's exactly what I'm going to do.


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PostPosted: Tue May 11, 2010 3:57 pm 
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Hey sorry...for some reason I read it as you were trying to taper off eventually. I think you got your answers from Dr. J buty if I was in your shoes and was going to stay on I'd take enought to feel comfortable and not have cravings.


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PostPosted: Wed May 12, 2010 2:13 pm 
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No problem at all, hawker1

I'm off to my appointment shortly and will let you all know what the doc had to say when I get back.

Thanks again for everyone's thoughts!


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PostPosted: Wed May 12, 2010 4:03 pm 
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Just got back from the doctor's office. As I have already mentioned, this guy is great. I told him everything, gave him a copy of this thread printed out, but he didn't even really want to read it all, he just took my word for it and we're raising my dose to 8mg. He even dated my prescription in such a way that I can pick it up this Friday, which means I can start on the higher dose TOMORROW :D

He said, "you know, YOU are the one who pushed the taper plan, not me. I would have advised staying on a higher dose for a LOT longer than you seemed to want to."

And he's right. It was me who was pushing for the lower dose, not him....

He reiterated his opinion (which I agree with) that I should just plan on staying on this medication for the long haul.

So, all's well that ends well, as they say :D


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PostPosted: Wed May 12, 2010 4:46 pm 
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Hey junkie,

I am happy to hear that you have such a good doctor that actually listens to you. It's good to hear after all the doc nightmares I have heard recently.

Good it all turned out, as I just learned in another thread you wrote in today, you have people that depend on you (your mother for one). You have come a long way, and it's good to hear that you know what dose you do best at and don't have a problem staying there.

All good!

Ginger


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PostPosted: Wed May 12, 2010 7:22 pm 
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Hi Ginger:

Thanks for the reply! I consider it the crowning achievement of my life to have given my mother a comfortable retirement. And while I am certainly in recovery for myself, it definitely does not hurt to have additional outside motivating factors, like my support for my mom and the awesome friendship and love that I share with my wonderful wife...we'll be married 10 years this December, and it all went by in the blink of an eye.

Anyway, I'm definitely happy that I have such a good doctor. What's interesting about this guy is he is urging me to speak to my Primary Care Physician to see if he'll prescribe suboxone for my HepC pain, which I do have a little abdominal pain from it....so he's actually encouraging me to move on from his suboxone clinic, which tells me he's not just "in it for the money" and he even told me that if my primary won't prescribe it for pain, that if I want to switch primaries and make HIM my primary, he's be open to that. I am definitely fortunate to have such a good doctor who seems to genuinely care about his patients.

He even asked me today if I can give him a quote on a new web site 8)


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PostPosted: Sun May 16, 2010 7:42 am 
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So, just to close the loop on this thread, I have now increased my dose back up to 8mg. I expressed some concern to my doctor about jumping directly back up from 4mg to 8mg (I recall when I was on 16mg per day that when I first started out on it, there was some euphoria for about a week, and I DO NOT want that from this medication) so he told me to increase from 4mg to 6mg for a couple of days, then go up to 8mg after that. And that worked pretty well. First 8mg dose produced some very mild side effects, but I've now dose with 8mg twice and the only thing I notice now is the urges and obsession to use are completely GONE and I am sleeping like a log again :D


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PostPosted: Sun May 16, 2010 8:15 am 
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Junkie, I am SO GLAD you're feeling better! That's terrific news, really. You must be so relieved that the cravings are gone. Such a load off your mind, isn't it? You're a great support to others and I'm glad to see you getting support from us, too.

Take care!

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PostPosted: Mon May 17, 2010 9:52 am 
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Thanks, Hatmaker. I learned a LONG time ago (we're talking 1981 or so) in the halls of the 12 step programs, that you can't keep what you have if you don't give it away. I try to live every day of my life in a way that produces a POSITIVE impact on the people around me, especially if/when I encounter another addict or alcoholic who is suffering.

This web site has quickly become a key part of my sobriety, and I am extremely grateful to Dr. J and everyone here for all of the support that I've received since signing up.


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PostPosted: Fri Aug 13, 2010 4:58 pm 
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So, I decided to bump this thread because my dose is going to be changing again, but I think I'm getting some mixed messages from this doctor.

Now, on the one hand, he didn't seem to have a problem taking me back up to 8mg, after I almost relapsed at 1mg, tried to stabilize at 4mg, but was still feeling some cravings, so went back up to 8mg, where I've been for a couple of months now.

The problem with the 8mg dose is the side effects, the main one being the pretty much total lack of libido.

So I talked it over with my wife and decided that I'd try to lower my dose again to 6mg.

I had my appointment yesterday with my sub doctor. He had asked me to ask my primary care physician if he'd be willing to prescribe the suboxone for me as a pain reliever in the context of my HepC. My primary said he would not do this. I wasn't really surprised by that.

But what I was surprised by was my sub doctor sort of pushing me to lower my dose to 6mg, before I ever brought it up. Now, granted, I was going to suggest this anyway, but the last HE knew, I was AT RISK when I was taking 4mg, and felt like I should be at a higher dose, and even Dr. Junig chimed in on this thread and suggested that being at a dose that is just keeping withdrawal at bay is not really the best way to use Suboxone, so it kind of surprised me that my sub doctor wants me to lower my dose again to 6mg. He seemed to agree the last time we spoke that I should probably just stay on suboxone for the long haul, so I'm a little confused by the mixed message from him and I told him that in our appointment. He said he wanted me to try to take 6mg instead of 8mg and I said "Is there any specific reason why you would want me to lower my dose" and his answer, quite frankly, seemed a little....odd. He said something along the lines of "well, we had you all the way down to 1mg, then back up to 4mg, then up to 8mg, so you've been bouncing around a bit and I'd like to have you at 6mg, taking a single 2mg tablet three times per day"

Now, first of all, even though I don't really like to go against what my doctor tells me, I take my suboxone once a day, in the morning and that's that.

But the reason I feel like I'm getting mixed signals from this guy is that on the one hand, he's telling me that he agrees I should probably be on it long term or indefinitely, and he's also changed my prescriptions so that I can now get one refill before I go back and see him, so I only have to see him every other month now, but I have to wonder why the push to get me down to 6mg without ME suggesting that I am ready to lower my dose (which I AM ready to do that)

Sorry, I know this was a bit of a rambling post, but do you know what I mean here? He agreed to up my dose to 8mg, wrote it that way for two months, no questions asked, but now that he's putting me on an every-other-month schedule he wants me to go down to 6mg........because my dose has "jumped around" a bit?

I don't get the point. What does my dose jumping around a bit have to do with him suggesting I lower it?

He's not being a prick about it. And, in fact, the way he asked me to do it was very nice. Right now, he thinks I'm taking 4mg in the morning and 4mg at night. I just take it all in the morning and get it over with. So, he said, something like, "I want you to try to switch when you have about two weeks to go before your next appointment with me. Start taking it three times a day, one tablet at a time, so that will be 6mg instead of 8mg"

Anyone have any ideas why HE would suggest this?

Again, I was going to do this anyway, but it just kind of made my antenna go up a bit, like, he's telling me one thing (oh, yeah, you should stay on this long term) when maybe he doesn't REALLY feel that way....or something.....


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