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PostPosted: Sat Mar 10, 2012 10:19 am 
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Hi Cherish -

At very low doses - under the ~ 4 mg ceiling - suboxone ACTS more like a full agonist (regular pain pill) and one can FEEL it when they take it. If you plan on taking suboxone for addiction treatment, it's best not to take it at low doses. It's meant to be taken in "high doses" to treat addiction. It only works as it's supposed to at those high doses - blocks cravings, stops withdrawals, blocks other opiates. Otherwise, at those very low doses, it's not much different that taking regular pain pills - USUALLY.

May I ask why you say you want to start and stay on a low dose? Especially if you don't yet understand how the medication works yet?

Suboxone is very strong and it's normal to feel sort of "high-ISH" the first day or two when starting it. It WILL pass. Going on suboxone 3+ years ago, for me, was the VERY BEST thing I ever did for myself. EVER!!! My life was OUT OF CONTROL....the only place I saw it ending was death or the streets for me. Now I'm secure in my marriage and home. We're planning our retirement and our first vacation in over 10 years. I couldn't be happier. I attribute that in part to suboxone and the rest to all the work I've put into my addiction remission MYSELF and with MY THERAPIST and my support system.

I hope this helps answer some of your questions and maybe gives you some things to think about. Ask as many more questions about sub as you have and we will do our best to answer them for you. :)

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PostPosted: Sat Mar 10, 2012 10:28 am 
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Because I figured at a low dose, I might possibly come off it easier (when its time)I thought maybe the wds would be less intense? I'm still learning about it. I go in for my first appt with the Sub doctor this morning. I just have a lot of anxiety about Suboxone. I'm SO afraid it wont help my GAD. I'm excited toget started, just sooo nervous! Its so good to see it helped you...I'm trying to stay away from the "horror stories" I'll definitely take what my doctor prescribes. I'm just a bundle of nerves....Thank you :)

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PostPosted: Sat Mar 10, 2012 10:39 am 
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It's SO normal to be afraid. Try to stay away from the horror stories. The people who do really well on suboxone are out living their lives and are not sitting in front of a computer bitching and screaming about their lives. Keep that in mind.

If one is on a higher dose of suboxone, the only thing it will mean when tapering off is that it will take a bit longer to do so. But remember what Dr. Junig theorizes: that the people on suboxone the longest have the best chance for success when they go off: they've had lots of "practice" time on suboxone to live "drug-free" so when they go on without suboxone, they are better prepared to live successfully even without the suboxone.

I look at it this way: You broke your leg badly and suboxone is like a full cast. You NEED it to get ready to properly walk again. Sometimes a "crutch" is needed for a while until you are fully ready to walk without one. And there is nothing wrong with that. The people who chose not to use a crutch won't be walking very normally, now will they? But those who chose to go to PT and use that cast and re-learn to walk again will be back to normal once all that "broken leg" treatment is over. And you'll be far better off than the person who chose to just walk around on their broken leg and not get the appropriate treatment for it. It's an analogy that I think explains it pretty well.

Do come back and let us know how your sub doc appt goes. I'll be thinking about you. :)

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PostPosted: Sat Mar 10, 2012 7:33 pm 
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Hat - I coulda probably said it in much fewer words. All I meant to say was, IMO, there's more evidence that the Sub ceiling for analgesia / opioid effect is in the 8-16mg range, than right on 4mg. In the last video I saw of Dr. J (a response to subie's question about 32mg dosing), he said that the ceiling was 8-12mg's.

He also said most of his patients on prescribed 2-4mg a day, which I found interesting.

I'm also interested in the idea that buprenorphine under 4mg acts as an agonist. I'm assuming it means that bupe loses its antagonist / blocking effect at doses under 4mg? Because surely if I took under 4mg tomorrow, I wouldn't feel any kinda agonist buzz. If anything I'd feel withdrawal?

Cherish - you will be FINE. I don't know of anyone ever who has gone on Sub and not felt gratitude for feeling functional again. And everyone I know, myself included, felt that the transition from addiction to Sub treatment was a huge step-forward in their recovery. And for the vast majority of people, induction is really smooth. It's mostly a passive process - take the pill, feel better then go about your day. After that there may be some minor tweaking with dose, but that's it. It's really remarkable that we can feel so healthy and functional from Sub within days of stopping our drug-of-choice.

With your dose, just find the one that's right for you, whether it's 2mg or 20mg. It's more important to have enough Sub to hold your cravings than to concern yourself with tapering at this early stage. Under-dosing comes with an increased chance of relapse, and staying clean off Oxy is the real priority at this stage. IMO only after you're stabilised on Sub and been clean off Oxy for 12 months would I consider tapering.

At the same time, IMO there are downfalls to taking more Sub than you need as well. So if you find yourself feeling a significant opioid buzz off the Sub, I'd contact your doc before you become tolerant and see if you can get your dose reduced a bit.

Take care, and you'll be fine!


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PostPosted: Sun Mar 11, 2012 12:52 am 
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Here's the link to my post about ceiling level: http://suboxforum.com/viewtopic.php?p=40495

I'm reproducing the post here but you can refer back to the original thread for further clarification:

It seems the "ceiling level" or "ceiling effect" thing became a point of contention. Ironic understands the term "ceiling level" to mean "the dose at which the agonist effects of bperenorphine reach a maximum and do not continue to increase linearly with increasing doses of the drug" which is stated by SAMHSA to be between 16 and 32 mgs of bupe taken sublingually per day.

Breezy Ann and others understand the "ceiling level" to be the minimum dose of bupe at which a person's opiate receptors would be completely engaged, thus preventing cravings and withdrawal symptoms. They also understand this dose to be the dose at which the opiate-agonist effects of buprenorphine level off. Per Dr Junig, this dose is around 4mgs per day. Also per Dr. Junig, the benefit of taking a dose higher than 4mgs per day, despite the fact that this is where he indicates the ceiling effect is reached, is that the higher dose guarantees a stable blood level of buprenorphine at a level sufficient to prevent the patient from feeling withdrawals or the ups and downs that may be felt at lower-level dosing. This stability is held to be an important factor in a patient's ability to break the response-reward cycle that is the hallmark of addiction.

So it appears that we have a conundrum! Someone here must be wrong. Is it SAMSHA or Dr. Junig? 16-32mgs or 4mgs?

What is the TRUTH?

I'm going to attempt to make the case that BOTH understandings are true. Hang on, I'm about to get all pedantic.

First, let's get clear on what we're actually talking about. I'm sure that we've all seen some variation on this chart:

Image


This chart illustrates the "ceiling effect" of buprenorphine. The ceiling effect is the point at which increased doseage no longer creates an increase in "opiate effect."

What do they mean by opiate effect? Is it a measure of feeling of euphoria, withdrawals, or analgesic effect? Can they actually look at our brains or do a blood test to see what percentage of our opiate receptors are occupied? No.

They are measuring increased respiratory depression as indicated by Pco2 (partial pressure of carbon dioxide) levels. When Pco2 levels no longer increase with increased doseage, you have encountered the ceiling effect. Respiratory depression is how they measure "opiate effect," which makes sense because it can be objectively measured and it relates to the safety of the medication. But it doesn't really tell us much about the subjective experience of the patient and it doesn't directly describe things like how many receptors are occupied, level of cravings or withdrawal symptoms, etc. For example, this measure does not tell us that at 4mgs, 95% of your opiate receptors are engaged while at 16mgs 98.7% are engaged. All it tells us is how repiratory depression correlates with buprenorphine dose.

Samsha, NIDA and the rest of the Feds have determined that the dose where this ceiling effect occurs is between 16mg and 32mgs sublingually. Dr. Junig says 4mgs. How can they both be right?

Look at the line on the chart that represents Buprenorphine. You'll notice that it begins to rise in a linear (straight) way. Then, right around the part of the line that is directly beneath the red arrowhead, the line begins to curve. This is the point on the curve where it begins to transition from a steeper slope to a shallower slope.

This point on the line is known as "the knee in the curve." It is also known as "the point of diminishing returns." This is the point where the level of opiate effect begins to decrease exponentially with each subsequent increase in doseage.

The "knee in the curve," "point of diminishing returns" is also known as "the sweet spot." This point indicates the point where you are getting the MOST opiate effect for the LEAST dose of buperenorphine.

Because the graph doesn't supply any raw data, I can't say what this "sweet spot" dose is. But looking at the chart, we can reasonably state that the "sweet spot" dose is lower than the 16-32mg dose indicated by that pointing arrow as where the "ceiling effect" occurs.

Dr Junig has made known his opinion that the "ceiling level" for bupe is around 4mgs sublingually. I think it is entirely possible that what he has found is that the 4mg dose is right in that "sweet spot" indicated by the bend in the line of the graph. It is below the dose found to be the point where Pco2 levels no longer continue to rise, but it is not far enough below that level to really matter as far as the lived experience of the patient is concerned.

Looking at this chart it's possible to see that the actual difference in opiate effect (as measured by respiratory depression) between a dose of 4-8mgs and a dose of 16-32mgs is pretty negligible. It's a pretty flat line. But we don't go around as Sub patients taking measure of our respiratory depression and resultant Pco2 levels to determine what dose is best for us. We subjectively measure how we feel physically, mentally and emotionally. How are our withdrawals? Our cravings? Our mood?

I think that what Dr. Junig is getting at with his 4mg ceiling is that 4mgs is the dose at which he finds most patients begin to see those diminishing returns with incresed doseage. More than 4mgs may get you slightly more "opiate effect" as measured by Pco2, but it really doesn't get you more "opiate effect" as measured by patient experience with regard to cravings and withdrawals. To Dr. Junig, 4mgs is the dose where the line on the graph flattens out enough that the differences between 4mgs and a higher dose begin to matter significantly less.

(The one caveat that he places on his 4mg ceiling estimate is that Sub patients will want to take a high enough daily dose that they do not dip below the blood level concentration required to maintain that 4mgs, thus eliminating withdrawals and ups and downs. For him, this is where the higher doses come into play.)

To Samsha, NIDA and all, the ceiling effect is the point where Pco2 no longer increases with dose. Period.

I argue that Dr. Junig and the Feds are BOTH right - because the actual difference between the "opiate effect" of 4mgs and the "opiate effect" of 16-32mgs is insignificant enough that it becomes basically meaningless.
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For what it's worth - I think that a lot of the people who are abusing Sub in place of heroin are actually injecting it and probably in combination with benzos, which reportedly is a much more euphoric, heroin-like high than you'd experience taking it sublingually as a maintainence medication.

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PostPosted: Sun Mar 11, 2012 2:05 am 
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Thanks DoaQ ...

But in the last video I saw by Dr. J, he said the ceiling in "opioid effect" for buprenorphine is 8-12mg, not 4mg. It seems his opinion of the ceiling level has moved closer to the SAMHSA definition recently?

I always took that graph to just be highlighting the concept of the ceiling effect for the layperson. As you said, it doesn't give any data as to where the ceiling effect really lies. If it was a representation of real clinical data from a study it would have some kind of scale on it.

Most research indicates the ceiling for respiratory depression lies at about 4mg. Recent studies into buprenorphine for analgesia has shown the ceiling effect for analgesia is a lot higher than that - ie 7mg at least. Since Grumenthal have moved into the buprenorphine market, they've injected a bit of money into disproving the "4mg analgesia ceiling" myth. Because the myth would severely limit their market, esp in palliative care.

According to what I've read / heard so far, the present research indicates that buprenorphine has a ceiling on respiratory depression at around 4mg. One study said that the ceiling for subjective opioid effect was 8-16mg. SAMHSA have said that the ceiling for buprenorphine is between 8-16mg. Dr. J recently said that the ceiling for opioid effect was 8-12mg, though many times in the past he has said the ceiling is at 4mg. Grumenthal study said analgesia keeps increasing linearly up to 7mg.

So where does the truth lie?

And what truth do we choose to tell members on the forum?


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PostPosted: Sun Mar 11, 2012 10:48 am 
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I say we never speak of this ceiling effect thing again, it's too damn confusing!! :lol:

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PostPosted: Sun Mar 11, 2012 11:25 am 
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THANK YOU! I've been trying to explain that in a few different threads in the MOST pathetic way possible!

Would you reproduce your post and make it a sticky thread? Maybe under dosing? What do you think, Diary?

This comes up SO often I think a sticky would be great.

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PostPosted: Tue Mar 13, 2012 4:18 am 
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But it doesn't answer the question. Should we keep telling people on the forum that the ceiling is at 4mg?

Here is the link to the video where Dr. J says the ceiling is actually at 8-12mg.

http://vyou.com/jeffreyjunigmdphd/1112763/Been-on-sub-for-1-month-32mg-for-a-400mg-oxy-habit-Should-I-have-any-trouble-getting-down-to-16-or-8-mg-Thanks


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PostPosted: Wed Oct 19, 2016 10:18 pm 
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I was reading this post in order to try to get a handle on the ceiling effect issue of buprenorphine. I was recently prescribed buprenorphine by my pain doctor to help me get off of a hydrocodone daily dose of 60to70 milligrams. I thought I could go without it because my pain condition has improved and wanted to get off it as soon as possible. He prescribed me what I thought to be an exorbitantly High initial dose. I was prescribed 8 milligrams buprenorphine every 12 hours for two days and then half a tablet or 4 milligrams twice a day for two days. Then 2 2 milligram tablets 2 days and 1 2 milligram tablet per day for 4 days and then he said I would be off with no withdrawals. I thought this was a very high dose for my level of narcotic use. I tried only using one milligram after going through a 37 hour time With no hydrocodone and took my first dose at only one milligram. It relieve my restless legs and other withdrawal symptoms very well and I actually felt a bit high from it. Second day I only took .75 milligrams didn't feel any opiate withdrawals end of third day I only took about a half a milligram. The reason I tried to go this route as I suffer from very high anxiety and depression and try tapering down on the hydrocodone exasperated my anxiety extremely. Actually in addition to help me with my pain problem to hydrocodone help and put your mind to sleep with my anxiety. It seems like the buprenorphine cut the opiate withdrawals at Bay but my anxiety skyrocketed. I also read that at low doses buprenorphine acts more like a full Agonist and you can actually build up tolerance to it. I assume you could also build up a tolerance to it taking it in a large dose. But I've read conflicting opinions on the ceiling dose not actually increasing the tolerance to opioids. After 3 days my anxiety got so bad I had a panic attack and had to go to the hospital. I was also concerned cuz I also take clonazepam and was worried about respiratory issues with the buprenorphine. Upon communicating with the pain doctors nurse with my problems the doctor basically said if I had taken the dose he recommended that I would not have had any respiratory issues between the clonazepam and buprenorphine. At that dosage I would have been way above the ceiling level from what I've read based upon my opiate usage. That's why I only took a small amount. He now says I need to take it at the larger dosage that he said initially otherwise he won't treat me with it. I have my doubts about taking this much of it still and want to know anybody's opinion on this from this forum. Based upon my high anxiety level and being able to cut down successfully on the hydrocodone by itself I was considering actually going into detox instead. This whole ceiling level thing still confuses me. And I still think this doctor has not prescribed to correctly. I read that induction Center as they give you couple milligrams to see how you do and stabilize you at the dose that you feel comfortable at. I was also doubtful that only being on it for 8 days that I would not go through withdrawals from it also. Would taking it this large of a dose for the short. Of time raise my tolerance level and would it be hard coming off of 2 milligrams today I would think so. Maybe I'm wrong but from a lot of the reading I've done. His method would have ended up having me worse off than I was to begin with. Any input advice would would be appreciated. I was also wary about taking a small dose one milligram or what I was taking slightly less that would be acting as a full Agonist and just give me a high tolerance because it's a strong drug. Taking a small dose for a short time was another way another doctor suggested that I take it. Thanks


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Dr. Jeffrey Junig, M.D., Ph.D.

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