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PostPosted: Fri Mar 16, 2012 2:29 am 
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A little while back I started taking St. Johns wort because of issues with SSRI/SNRI anti-depressants. And it was a real revelation in my depression / bipolar treatment. Things were great I was swimming 1-2kms a day, motivated with study and enjoying going out like I used to. I felt on top of things so much that I reduced my Suboxone from 12mg a day to 8mg a day.

When I got to 8mgs, I found I had a problem. I just wouldn't stabilise. I was on 8mg nearly 2 weeks and still I found I was getting withdrawals in the morning and evening, in the hours before my next dose. It was a bit concerning, as I felt if I was having that much trouble settling on 8mg's, how the hell would I ever taper?

So I started searching for answers, and after punching St Johns Wort and Buprenorphine into googz the culprit MIGHT have emerged.

Seems St. Johns wort is a potent CYP3A4 inducer - ie speeds up metabolism of buprenorphine significantly. People were even saying that St Johns wort brought on withdrawals shortly after taking it? While I didn't have it that bad, I've stopped taking it for the time being to see if things will improve.

Will keep you posted.


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PostPosted: Fri Mar 16, 2012 9:28 am 
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TJ - While I don't have the brain chemical understanding that you seem to (based on reading many of your posts), it sounds like you may have hit on something. Do you have the link to share? I'd love to read it and see if I can make any sense of it.

But even more so, I'd love to hear Dr. J's take on this. Maybe we can get his attention? Dr J, are you out there?

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PostPosted: Fri Mar 16, 2012 10:22 pm 
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There has been no direct research into interactions b/w St. John's Wort and buprenorphine, but St. John's Wort is an inducer of the same enzyme that breaks down buprenorphine. There has also been a lot of anecdotal reports of St. John's Wort bringing on withdrawals in people who are on Suboxone.

Here's the lowdown from the drug interaction checker:

Quote:
MONITOR: Coadministration with drugs that are inducers of CYP450 3A4 may decrease the plasma concentrations and efficacy of buprenorphine, which is metabolized in the liver by the isoenzyme. In addition, some of these inducers (anticonvulsants and barbiturates) may have additive central nervous system-depressant effects with buprenorphine.

MANAGEMENT: Pharmacologic response to buprenorphine should be monitored more closely whenever a CYP450 3A4 inducer is added to or withdrawn from therapy, and the buprenorphine dosage adjusted as necessary. Ambulatory patients should be made aware of the possibility of additive effects (e.g., drowsiness, dizziness, lightheadedness, confusion) when taking other CNS-active drugs and counseled to avoid activities requiring mental alertness until they know how these agents affect them.


The PROBLEM in my case is that, so far, dropping the St. John's Wort hasn't made much of an impact. I'll give it another week though.

It is really interesting though that I have unusual issues with metabolism. Some drugs that should cause metabolism issues when mixed don't - and ones that shouldn't DO. Very confusing. Anyway, onward in my quest.


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PostPosted: Fri Mar 16, 2012 11:57 pm 
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This has me wondering if this could have anything to do with why some people who are brand new to suboxone might have trouble stabilizing on it. Maybe they are on something that's interfering with the bupe? Is that possible? Am I understanding how it works correctly? If not, what could/would happen if a person was already on a CYP450 3A4 inducer when they start suboxone? What would that mean to their induction and ability to stabilize on a dose?

I have to wonder how that would affect them. Let me know what you think of this. I'm half-tempted to contact Dr. Junig to ask him to weigh in on this.

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PostPosted: Sat Mar 17, 2012 6:45 pm 
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If a person's on a CYP3A4 inducer before going on Sub, then they SHOULD have issues finding a correct dose. I guess it would depend on how much said drug induced the enzyme as there are different strengths of induction. If someone was on a CYP3A4 inducer then their buprenorphine may wear off faster than it should, or they may need a higher dose than they would normally. And if they immediately stopped taking the inducer, their levels of buprenorphine may increase significantly.

Inhibitors do the opposite. ie if a person on buprenorphine started taking Gingko and drinking grapefruit juice all day - inhibitors of CYP3A4, their levels of buprenorphine may rise.

The other significant thing - esp for people tapering - is that buprenorphine can affect levels of other medications. And when they stop taking their bupe, they may need other meds adjusted.

It's a field of research where new things are being discovered all the time. The "map" of what affects what is getting more and more detailed.


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PostPosted: Sun Mar 18, 2012 10:18 am 
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I guess then the salient questions is what medications are inducers and what are inhibitors? And common foods as well. I have other medical conditions that I take medications for, so I take MANY other medications that could be interacting with my sub. Just a thought that could apply to me or anyone else. That would be something maybe we should know to understand what else could be affecting our sub dose.

At the very least it sure explains why one person's dose can be WAY different from another persons. And why it's so damn important for people to respect another's dose and not give them shit about it.

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PostPosted: Sun Mar 18, 2012 12:51 pm 
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I don't know if you've seen a list or chart like this, but it lists all the CYP3A4 substrates, inhibitors and inducers.

http://www.pharmacytimes.com/publicatio ... 08-09-8687


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PostPosted: Sun Mar 18, 2012 12:59 pm 
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No, Taurus, I had not seen that. And it's truly interesting, so thank you very much for sharing it with us. It's a great piece of accurate and important information for us to add to this forum. This is exactly what we like to offer to our members and readers.

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PostPosted: Sun Mar 18, 2012 1:09 pm 
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It's amazing how many other drugs can have an affect on certain meds. This might help people (myself included) rule out sub as the reason for certain side effects.


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PostPosted: Sun Mar 18, 2012 1:24 pm 
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I just read a post where a person all of a sudden is getting sick on suboxone. Could it be that she added a new medication that changed how sub is being metabolized and she now is getting less suboxone and needs more suddenly? Is that possible? Or am I still not understanding?

I'm normally a really smart person, but there are some subjects I'm just not as good at.

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PostPosted: Sun Mar 18, 2012 2:36 pm 
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That sounds perfectly logical to me hatmaker. A lot of times people will say all kinds of side effects are happening, and then later say, oh yeah, and I'm also taking this med...which could change everything. I think to know all meds up front is key in figuring out what is causing certain side effects. I guess through the process of elimination someone could see what exactly is the cause of the side effects. This could take time though, considering which med is eliminated, what the half life of that med is to make sure it is all out of the system, to see if the side effects are still occurring. And then if so, eliminate the other med and start taking the first med again that was eliminated to see if the side effects are caused by that med. This could take months depending on how many meds a person in on at the time!


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PostPosted: Sun Mar 18, 2012 5:25 pm 
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I did a little more research and I found a few more lists, most of which matched the lists in the link I provided above, but I did find quite a few more inhibitors and inducers on a couple other charts. I wasn't sure why the first link didn't list all of these, so I went and looked at the date of that article, and it was from 2008. So I guess more meds have been discovered since then that should be on this list. Here is what is also listed on some other more recent charts for CYP3A4 in addition to what was listed from the link above. I'm not sure what most of these meds are...I just copied and pasted the missing ones into one list below. It was pretty easy to cross-reference since all the lists/charts I looked at were listed in alphabetical order:

INHIBITORS
amlodipine
boceprevir
cimetidine
ciprofloxacin
danazol
dronedarone
ethinyl estradiol
everolimus
kava
marijuana
methyl-prednisolone
mifepristone
nefazodone
nicardipine
nifedipine
nilotinib
norfloxacin
pomegranate
pazopanib
prednisone
propoxyphene
quinine
ranolazine
synercid
telaprevir
tipranavir
zafirlukast

INDUCERS
amprenavir
aprepitant
ethosuximide
etravirine
garlic supplements
glucocorticoids
glutethimide
ritonavir


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PostPosted: Mon Mar 19, 2012 10:13 am 
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Now that's interesting - marijuana is an inhibitor. Thanks for updating this list, Taurus.

TJ - How do you feel about setting up a sticky topic solely about this topic? I think this is too important to leave it stuck in the middle of a thread - unless....we could just change the topic subject to include "CYP3A4" and then make it a sticky.

This is your baby, TJ, so however you feel it would be set up best is fine with me.

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PostPosted: Thu Jul 05, 2012 10:23 pm 
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In addressing the topics of inhibitors and inducers I read the list of both, and they sound like another language. I do know that if(when I was addicted to H), that if I did a shot of "meth", I would go into opiate withdrawl in like 30 min. Of course as long as I had not fixed for about 3 - 4 hrs. I learned to hate that stuff for that reason. As an addict I tried over and over to find pleasure in "meth", but It always brought an onslaught of pain within an hour. It wasnt like a slow introduction to withdrawl , but like a granade went off. I tried from lots of different sources. Maybe my chemistry, but there is definetly some inducer in MOST of the speed or meth out there. That is the one grateful thing my opiate addiction brought me. I hate meth....


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PostPosted: Fri Jul 06, 2012 3:48 am 
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Another thing about all this stuff is that it's not an exact science in that there's variability from person to person. Things like race, general rate of metabolism, body type, sex etc all play a role, as well as plain old genetic variations. In medication like buprenorphine which is broken down by more than one enzyme, it may be that some people use CYP2D6 more to break it down and CYP3A4 less. I always found SSRI's sped up my metabolism of Sub a LOT ... while many people don't have this effect.

ie I also used speed while on heroin quite a bit and I didn't have that problem. In fact, there were times I used speed to kick heroin, because the stimulant effect of the speed seemed to push me through my withdrawal.

Stimulant drugs though can speed up metabolism of everything.


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PostPosted: Sat Oct 29, 2016 1:20 pm 
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I wanted to bring this old post back up top to help those trying to get off of Buprenorphine.

Hatmaker was successful in stopping 16 mg per day habit down to nothing within about one year of tapering. She attributes the Marijuana to lessening the withdrawal effects she experienced when she got down to a very low dose and then stopped.

As most of you know, I don't advocate using marijuana to get off of Bupe. But science is science and no one should stand in the way of progress, regardless of their own biases. My main reason for being against it is simple. Seeing so many young people not working, seeking housing assistance and getting it, all the while they smoke their dope. Who's left to help run everything if our younger generation is always stoned? But hey, I smoked it and could barely hold a decent job. Only factories and warehouse jobs would hire. When I quit smoking it at 24 years old I ended up in management, my own office with a large wall length window, and a secretary to help with the paperwork. I learned how to first build aircraft and then got the job as an Estimator/Planner for incoming work orders. Meaning, once I got my head out of the cloud of pot, I not only got a better job but a very high profile one at that.

Back to the point. She used marijuana as it fell into the category of an inducer/inhibitor. Which one I don't know. What I do know is that she is off it and doing well. Barely any w/d's at all.

I know the topic is a difficult one to understand. The language is hard to get down. We'll let you decide on how to proceed with it.

Good luck to those stopping Buprenorphine. It is not an easy thing to do. I haven't done it yet. Well, yes I did, but relapsed right back to taking 6-8 Norco's at a time so I went back on it.

Read and learn.......

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PostPosted: Sat Oct 29, 2016 1:23 pm 
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I also used cannabis during my Suboxone taper and experienced little withdrawal. I'm currently over a month with ZERO Suboxone and doing well.
Maybe we are on to something with the cannabis thing:)


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PostPosted: Sat Nov 05, 2016 6:57 pm 
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I'm with ya Rule. Cannabis isn't renowned for moulding ambitious, motivated individuals. The "spaced-out" train of thought that comes with daily smoking doesn't help with concentration. Not to mention the fact you're on a different wavelength to most of the world every waking moment. Marijuana really does breed laziness when it's a daily thing.

That being said, I do believe marijuana is less problematic and has less addictive potential than alcohol. In terms of intermittent use, I think alcohol can cause more dire consequences, especially if you get behind the wheel, or get in a fight.

Given I have a significant libertarian streak, I support legalisation of marijuana. BUT there needs to be serious, un-biased and accurate information out there so people can be aware of the risks. I cringe every time I see someone post some unabashed pro-marijuana article on social media that totally glosses over the risks. At the moment, it seems marijuana can do no wrong, especially on new media (think Vice magazine). It is STILL a drug and as such still has huge potential for harm, ESPECIALLY for those with a family history of psychosis or mental health issues. Some people simply CAN'T do certain drugs, and people with psychotic illnesses should, I believe, refrain from marijuana completely. Survey psychotic patients in any public psychiatric unit, and I guarantee many if not most will have had a significant history of marijuana use.

And then there's lung, tongue and throat cancer. One joint still has 30x the tar of a tobacco cigarette. So one joint a day = one pack a day of smokes. WOW.

All that aside, when it comes time for me to reduce off Sub, I will probably buy a half-oz of weed, a few rollie papers, catapres and nurofen, a heap of frozen and canned food, and hole myself up in a cabin-in-the-woods watching the evil dead trilogy on repeat until I'm recovered enough to do 30 pushups. That's my detox plan!


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PostPosted: Sun Nov 06, 2016 10:38 am 
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Lol! That's definitely a detox environment u should market lol I bet there'd be a waiting list to ur "detox cabin retreat" :)

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PostPosted: Sun Nov 06, 2016 12:07 pm 
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LOLOL OH MY GOONESS!!! That's too funny, cabin retreat. Yes, and I agree, there are too many people, especially the youth, just sitting around doing nothing but smoking dope. I know. I smoked weed like that for years and have fought tooth and nail to get some of the youngans in our family to straighten up and go to work. It seems to rob people of their motivation.


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