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PostPosted: Tue Jan 28, 2014 3:29 pm 
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Hi all. I wanted to briefly relay my recent episode of buprenorphine induction from methadone and see if anyone had a similar experience. Here's the gist:

- Was previously on Suboxone until a relapse in 2011, then placed on methadone later that year
- Started at 200mg methadone (that's 20 tabs/day)
- Gradually decreased dose by 10mg/month
- Doctor recently informed me DEA was restricting her script-prescribing of methadone
- I was down to 25mg at this point and needed to find alternative
- Doctor told me she'd transition me to Subutex
- Doctor gave explicit instructions: after last methadone dose wait at least 24-36 hrs, wait till COWS score of >20
- Prescribed clonazepam and gabapentin as adjunct treatment
- For simplicity, my last methadone dose was day 0
- Day 1 = 24 hrs and completely asymptomatic - no signs of withdrawal
- Day 2 = 48 hrs and still no symptoms
- Day 3 = 72 hrs and still no symptoms
- Day 4 = 96 hrs and still no symptoms
- Day 5 and 6 finally presented with arthralgias (bone pain) of lower extremities
- Day 7 was pretty bad, COWS was ranging from 4-16
- Day 8 was when the restless legs and "kicks" began, and it was BAD - mind you I had no lacrimation, rhinorrhea, fever, chills, sweats, dia, "the works" etc
- Day 9 early morning I took 2mg Subutex (bone pain was too unbearable), waited patiently for any signs of precipitated withdrawal --> amazingly none
- Waited another 45 minutes and took another 2mg Subutex. Immediately all my symptoms including the outrageous arthralgias CEASED.

Main point I'm concerned with is the time it takes for onset of methadone withdrawal symptoms manifesting upon cessation. I'm aware it's a very long acting synthetic opioid that accumulates over time and gets also stored intracellulary, especially in adipose tissue (fat cells). Yet still, 8 days/192 hrs, come on! Has this happened to anyone transitioning from methadone to buprenorphine? And did anyone also have to wait a ridiculously long period of time before withdrawal symptoms from methadone began to appear (8 frickin days)? Lastly, anyone have any experience tapering off from buprenorphine 2mg? Unfortunately I've heard horror stories, but by far the worst withdrawal I've experienced came from methadone (not this particular one I described though). Thanks for hearing me out and in advance for any comments/replies. PEACE.

- some anonymous MD


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PostPosted: Tue Jan 28, 2014 6:05 pm 
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Hello Anonymous MD,

I'm going to break the ice here and attempt a response to your post. Although, I'm not promising any of my information will be anywhere near what you are looking for... :oops:

From what I have seen reported on this site from other members I don't think your experience is all that uncommon. Making the switch from Methadone to Suboxone seems to be incredibly tricky because of the unpredictably LONG half life of the Methadone. I'm not really sure about the 8 day thing, that does seem especially long, but I can't say I was altogether surprised to see it either (if that makes any sense).

I don't have any personal experience with Methadone, but I have seen several members posting here about how difficult it was to make the transition. I remember one member who attempted the switch several times thinking they had put plenty of time (several days I believe) in between the last dose of Methadone an the induction dose of suboxone, only to be thrown into precipitated withdrawals both times.

We do have several members here who I'm sure could give you more precise information about this and I really hope they come along and comment soon for you. Especially our fabulous Dr. J.

The main thing is though, that I'm happy you made it through your switch and are feeling good! This post could be very helpful to someone else out there trying to make this switch. But, I have to be honest, we should probably add a medical dictionary app to this post so that people like me who have no idea what words like lacrimation and rhinorrhea mean can understand what in the HECK you are talking about! :lol:

Welcome to our forum Mr. MD. I hope you stick around and continue to post, we love our MD members who often lend an element of professionalism to the boards.

Q

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PostPosted: Tue Jan 28, 2014 6:45 pm 
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Lol thanks Q. Apologies for the medical jargon. Lacrimation and rhinorrhea = tears and runny nose respectively :)


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PostPosted: Thu Feb 06, 2014 12:56 am 
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Q is quite correct. There have been many instances here of people having terrible trouble going from methadone to suboxone. It may sound ridiculous that you had to wait 8 plus days, but it doesn't seem unusual from the stories I've read.

Most often folks on methadone that are switching do not demonstrate the patience and true adherence to the COWS score that you did. They end up taking sub too early and experiencing PWs. Then they have several days when they mostly feel pretty bad until the methadone is truly gone from their bodies. Unfortunately, there are many heroin users that have trouble with the transition as well because they are so opiate tolerant. But the methadone stories are usually worse.

The good news is that you outlasted the hard part and hopefully the sub is working for you correctly. Welcome to the forum and please feel free to keep posting!

Amy

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PostPosted: Thu Feb 06, 2014 2:42 pm 
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Hello Anonymous MD,

Your story and particular situation switching from methadone to suboxone is actually very common, and does occur quite often. You made the switch perfectly in my opinion!

The length of time it usually takes to get that Cows score up there almost always depends on the amount of methadone used daily, and length of time on this drug. It's difficult because it lingers in the system for so long after you stop as you found out. Lots of people don't use the Cows to determine if they are ready for induction on suboxone. It's easy to tell someone to wait 24 hrs, 36 hrs, 48 hrs, etc. That MAY be ok for some, and they get away with it, but I would want to have further evidence I was ready. The Cows is a real good indicator that symptoms are right for induction. Get to the target score and you are quite safe. Just have to make certain your Cows score is an honest one, and helps if someone else could score each of us rather than do it ourselves. We're sick with symptoms at the time and it's very easy to fudge the score to get the number higher.

200mgs in the beginning is a very high amount. I never got my methadone dose that high, getting to around 140-160mg myself before tapering down and switching to suboxone. I got in a hurry, didn't use the Cows, and tried to switch after stopping the methadone after only about 24 hours. Yep, you guessed it, precipitated withdrawals came calling and I wanted to die I was so sick. Learned my lesson and tried again.

I waited about 5 days, or approximately 120 hours, and my doctor used the Cows. I was good to go at that point. So yes, I find it completely normal for someone to have to wait the length of time you did as everyone is different. Making the switch from methadone to subs is one of the hardest things to do in my opinion. It's usually because most people, being addicts, want things to happen "right now" and rush into it, and don't use the Cows score as Amy mentioned. You did awesome!

As far as tapering, there have been many here, including myself that have tapered successfully. Try not to listen to any horror stories, and I realize that's not always an easy thing to do. If you taper by reducing your dose 10-25% every 3-10 days or so any symptoms should be entirely manageable. Many here have done it that way and been successful.

Sorry this is so long. Read the taper posts when you have time. There are many that will provide info that will be helpful to you. Hope this helps and best wishes!

Karen


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PostPosted: Thu Feb 06, 2014 3:12 pm 
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Brown-It appears that the OP was actually at 25mg methadone (having tapered slowly from 200mg) when he ceased taking it for those few days prior to inducing onto buprenorphine.

I have to assume that the primary issue here is chronic pain as opposed to addiction OR your prescriber didn't realize that methadone could not be prescribed via a DRs office to treat opioid dependence or knew so and was doing 'a favor' for a colleague (I've seen this happen)? I say this because twenty 10mg tablets daily were referenced (clinics use liquid or higher mg disks for addiction) and that his prescriber was having some issues with the DEA related to her prescribing of methadone (physicians can not legally prescribe methadone to treat opioid dependence, this is left to ORT clinic settings and even when prescribed completely legitimately they sometimes have to deal with scrutiny.)

Also, I'm really interested in what insight can you offer as a physician on methadone/buprenorphine? Has this ever come up or effected you professionally? Do you know what the stipulations might be, if any, with regards to a medical professional (specifically, a practicing/licensed MD?) working within various areas within the field of medicine?

EDIT: You did reference a relapse in 2011, so how is it that you were being treated with methadone via office based treatment?

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PostPosted: Thu Feb 06, 2014 3:23 pm 
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TwinCitiesHardcore wrote:
Brown-It appears that the OP was actually at 25mg methadone (having tapered slowly from 200mg) when he ceased taking it for those few days prior to inducing onto buprenorphine.


Brown Eyed Girl wrote:
200mgs in the beginning is a very high amount. I never got my methadone dose that high, getting to around 140-160mg myself
Twin-I realize that of course, and said he was on 200mgs in the "beginning" - as it was his STARTING dose.

I knew that he stopped the methadone at 25mg to make the switch.

Karen


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PostPosted: Thu Feb 06, 2014 4:12 pm 
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Yeah, it's rather strange, unless he meant that he eventually titrated to 200mg because especially with methadone, Dr's like to start low and titrate slow because of the long half-life and inability to truly gauge how a dose/increase will effect someone until 2-3 days later.

So, unless he was switched from like 600mg of oxycodone or some other really high dosage prescribed equivalent opioid, it is fairly odd and frankly reckless.

I'll never forget one of my first patients for a number of reasons but she was prescribed 80mg OxyContin two tablets 4Xdaily (so 640mg of CR oxycodone alone - evidentially she was on the 160mg tabs until they were called off the market, so she had to be switched to two 80mg) plus a couple hundred more mgs of immediate release oxycodone and 120mg Norco for breakthrough pain (all of which she took daily), so this is someone with a HUGE dependence to opioids; she did have severe chronic pain and nerve damage related to many back, neck and body reconstructive surgeries as well as third degree burns related to the meth lab explosion. Anyway, she was switched from the OxyContin/codone and Norco to only methadone, the theory being that it would better control her nerve pain and she would possibly need less and possibly no additional breakthrough medication except occasional additive methadone. She was started day one at 240mg (I remember this amount because it was the same amount I was on as she was relaying the story to me, though I titrated up slowly) staggered dosages of 80mg every 8 hours. Shortly after her third dose nher breathing shallowed and she was turning bluish; luckily her daughter called 911 and her life was saved. It was determined by counting the pills left in the bottle she had gotten that day, she had not taken more than prescribed. So, yeah, methadone can be dangerous if not prescribed by an experienced Dr, and even sometimes by an experienced Dr, sometimes medication is a crapshoot.

Hopefully this MD comes back and gives some more insight as I, for one, am interested.

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PostPosted: Thu Feb 06, 2014 5:00 pm 
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TwinCitiesHardcore wrote:
Yeah, it's rather strange, unless he meant that he eventually titrated to 200mg because especially with methadone, Dr's like to start low and titrate slow because of the long half-life and inability to truly gauge how a dose/increase will effect someone until 2-3 days later.

So, unless he was switched from like 600mg of oxycodone or some other really high dosage prescribed equivalent opioid, it is fairly odd and frankly reckless.
Totally agree with you Twin! My thinking was virtually the same.

TwinCitiesHardcore wrote:
plus a couple hundred more mgs of immediate release oxycodone and 120mg Norco for breakthrough pain
Can't imagine anyone requiring meds for "breakthrough pain" that is taking 640mgs of Oxy a day! But as you mentioned, she did have legitimate injuries. WOW, that's a LOT of drugs per day! I still can't imagine a beginning dose of 240mgs of methadone for anyone! But with a tolerance that high I can understand the thinking of beginning a dose such as that with her.

I hope the MD posts again also. Always nice to have another doctor on board.

Karen


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PostPosted: Thu Feb 06, 2014 5:47 pm 
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For sure, it was the highest legitimate prescribed dosages I had ever come across. She had started/become injured when OxyContin first came out and the 160mg tabs were available, so back then in extreme cases it wasn't unheard of. I wouldn't have believed it had I not had access to medical records.

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