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PostPosted: Tue Jun 25, 2013 6:34 pm 
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Hello,

I picked up my first prescription for Suboxone 8mg/2mg (films prescribed 3x daily) - have been taking 180mg Oxycodone (short-acting, NOT long-acting Oxycontin - I know, same drug, just addressing that it is immediate v. extended release). I have been doing quite a bit of research and reading online over the past week since he prescribed it, which is enough in itself to scare the bejeezus out of you. He knew that I would be picking it up today and starting tomorrow, and I have an appointment next week. My doctor is a pain management physician and prescribes this to many others, and one would think he knows what he's doing. However, he didn't say anything at all (and at the time I didn't know to ask) about "precipitated withdrawals" if not waiting until already in withdrawal to begin the Suboxone. So I called his office to ask about it. First I spoke with one of his nurses and then him, and BOTH told me that I did not need to worry about that and to simply take the Suboxone when it would be time for my next Oxycodone dose in (which I told them has been every four hours).

I also asked the pharmacist about it, and he said he's never had a doctor tell him anything about needing to wait to be in withdrawal before taking it or of anyone going into precipitated withdrawals when starting. He said he's never had patients report anything like that either. The medication instruction sheet that came with the prescription also says absolutely nothing about needing to wait for withdrawal before beginning the Suboxone or anything about precipitated withdrawal.

So do I need to wait until I am in mild to moderate withdrawal before taking the first dose of Suboxone like everything I'm reading online says to do, or do I need to not worry about that and simply take it as the doctor and nurses said?


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PostPosted: Tue Jun 25, 2013 7:09 pm 
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How do you take your 180mgs? At once or broken up throughout the day? I would absolutely wait before taking suboxone. Oxy is shorter acting so you shouldn't have to wait as long as a heroin or methadone user, but you should wait to be on the safe side. PWs are no fun.. I'd say at least 12 hours from your last oxy dose.. longer if you can make it.

Also, I'm not a doctor but 24mg a day of suboxone is overkill.. If you end up with headaches and/or nausea, it's the dose.

Good luck, let us know if you have more questions. Someone will surely chime in.


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PostPosted: Tue Jun 25, 2013 7:27 pm 
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I was taking 120mg a day of oxycodone, spaced out at 8 times a day. My doctor also gave me a script to take at home and told me to wait 24 hours before taking it. Actually he gave it to my husband, and made him swear not to give it to me early. I lasted 22 and a half hours and at that point I was pretty close to severe withdrawal. My doctor said to take one 8mg film and then take another 12 hours later. Since I was in such a high state of withdrawal the sub worked really well. Took about 15-20 minutes and I felt a thousand percent better. 24 hours may be overkill, but it's better than the alternative. Good luck. I hope the sub works as well for you as it has for me :-)


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PostPosted: Tue Jun 25, 2013 7:31 pm 
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I think the easiest way to induce is to take the last dose of your drug of choice in the evening then go to sleep, and when you wake up the next day wait until the afternoon to induce on sub. Just found thats the easiest way to wait it out, cuz sry to say but i have been from opiates to subs to opiates back to subs more times than i would like to admit. good luck let us know how it goes


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PostPosted: Tue Jun 25, 2013 8:11 pm 
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Thanks so much for the replies. I have been taking the 180mg daily Oxycodone in 30mg increments 3-4 hours apart.

BeautifulDisaster, I was wondering if that would be easiest. Logically it sounds like it - just go to sleep and wake up in the morning, then go as long as possible. When I wake up in the morning, if the pain isn't horrible and I am able to differentiate the withdrawals from that (not to mention many aspects of withdrawal that are uniquely withdrawal and not pain-related), I can really feel the physical withdrawals at that time. Take the first Oxycodone dose and of course those go away in 15-20 minutes.

I don't understand why the nurses, doctor, pharmacist - none of them have ever told anyone to wait until physical withdraws to begin or of precipitated withdraws if taking too soon or even had it reported back by other patients who they've simply started the same way. It was like being in a "twilight zone" talking to them after reading all this online. One would imagine it HAS to be part of the training doctors have to have to be able to prescribe it. Very odd.


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PostPosted: Tue Jun 25, 2013 9:29 pm 
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Hi SnapShawt,

Welcome to the forum!!

The active ingredient in Suboxone is Buprenorphine. I'm providing you with a link to NAABT (the National Alliance of Advocates for Buprenorphine Treatment.....aka, Suboxone treatment). The link is the COWS (Clinical Opiate Wd Scale). NAABT provides the COWS so you can score yourself and how bad your wd's are BEFORE you start Suboxone. At the bottom of the sheet is description of Precipitated Wd. When you start taking your Suboxone isn't so much about how long you wait, it's more about how bad your wd's are.

http://www.naabt.org/documents/cows_ind ... _sheet.pdf

Why your doctor didn't tell you to wait to start your Suboxone is beyond me.

If you have any more questions, please feel free to ask.

BTW, I agree with tinydancer in that 24mg of Suboxone is a large dose. If I were you, I would start with 8mg and wait an hour. You may find that 8mg is plenty for you.

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PostPosted: Tue Jun 25, 2013 10:16 pm 
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hey just wanted to say good luck and Romeo gave you some great advice, espically with the COWS (scoresheet), if you are completly honest with yourself you will know when the time is right to take the first strip.. I also agree with the whole dose thing, take what you feel is right. I came from a 200 dollar a day minimum heroin habit and i found that my first day on suboxone 4mg twice the first day was plenty of enough to pick me up out w/d and rid most of the cravings. i know plenty of people who felt they needed more, and everyone is different so its understandable if you take whats been perscribed to you

Youre in a good spot for friendly support here.. be sure to keep updates.. anyways good luck on your new journey

btw Precipitated w/d is real as hell.. ive been through it twice, i honestly could compare it to when i was hospitalized when my kidney shutdown on me.. so like i said, make sure you are completly honest with yourself on that scoresheet to gauge your w/d and you will know when the time is right to dose,

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PostPosted: Tue Jun 25, 2013 10:37 pm 
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You sound like you may be taking suboxone for pain rather than addiction or only addiction. Is that right? If that is true, did your doctor tell you to split your dose into 4 parts to be taken every 6 hours? Suboxone has an analgesic effect, but it only lasts 4 to 6 hours. If you have pain, the sub will be much more effective if you dose a few times a day.

If you are taking sub strictly for addiction, it's best if you only dose once per day. I agree that 24 mg is a lot of suboxone and I would think that 16 mg would be enough at most. Obviously I'm not a doctor, however.

Amy

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PostPosted: Tue Jun 25, 2013 11:37 pm 
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I really appreciate these replies folks, very much.

Romeo, I will absolutely make use of the COWS sheet and be completely honest doing it based on how I FEEL instead of how much time it has been. That makes more sense anyway. Obviously if there were some magic number for how many hours/days to wait, well then no one would need to ask the question. So I'll just keep score on that sheet. What I read on that says that it is advisable not to take the Suboxone until at least 5-6 on that scale, but preferable a 10. So if I wait until I'm at least at an honest 10 or higher, that should be okay right? I just know me - I've attempted to just toss the pain medication a couple of times and BOY OH BOY was that a bad BAD idea! Once it starts to get above a 10 on that scale I'm not sure how much longer I could wait, because I do also have pain to contend with - the reason I started this crap years ago to begin with. So while keeping score on that, I'll also have to mentally differentiate between what is pain and what is withdraw, which can be a bit tricky but not too difficult as my pain is very specific and I'm obviously very familiar with it. In any case, I will absolutely be honest and wait until at least a 10 and higher if I can stand it.

Rob, I'll definitely be honest with it. I've read some horror stories about the precipitated withdrawal bit and do NOT want to go there. BUT - yes I'll be honest and will wait - but just in case, I've also read on those stories that the precipitated withdraws, if they do happen, do not last for days like regular withdraws do but instead dissipate usually in an hour or so - just tends to be the absolutely most hellish hour a person could experience. Is that correct or does that also seem to vary?

Amy, well, it's a long story that I need to get into the introduction when I type that. The HOPE is that yes this will also help with the pain. However, my choices have been removed and I HAVE to go on this. My pain management doctor suddenly was gone, and good luck finding another to take over. The second it comes out of your mouth that you have been taking pain medicine for a long time and are now of necessity at a high dose, the conversation is over. I swear to you that people in legitimate chronic PAIN can come to a point where they would get more help by just claiming to be an addict. I did not do that, but I'll tell you I wasn't far from it. In any event, the fact is that regardless of that, I AM opioid dependent having been on them and at such a high dose for a very long time. That is simply a physical consequence of it, but then withdrawals are obviously a consequence of abrupt cessation. I cannot deal with BOTH the pain AND withdrawals, so I am simply left to at least be able to address one in the absence of being able to have the other treated. In truth, if I have to choose between those two monsters (pretty horrible pain versus withdrawals), I'll take the pain. Sounds stupid, right? I know. But that's the way it is. I just can't take the withdrawals.

I'm crossing my fingers and hoping with everything in me that this Suboxone really works like practically everyone I've seen on it claim that it does.

I have actually also been a bit concerned about the high dosage that you all mention at 24mg daily. Oh, Amy, he simply prescribed three 8mg films three times a day for the 24mg daily total. Obviously never having taken it, I can only go by what I read online. I don't know if the high dose is necessary given the high dosage of Oxycodone (180mg daily) that I was on or not. I'm definitely going to take the first 8mg strip. Actually I'm inclined to simply take what he prescribed instead of getting into just taking two or cutting them down or whatever. I'm already nervous.

He also said, and I quote, "You'll be on this for years." I don't know if he was referring to the fact that we're hoping for the off-label pain-relieving effect if it happens or if he was referring to the opioid dependency. Everything I've read seems to indicate Suboxone as an extremely short option to eliminate withdrawals for addicts to provide the chance to focus on recovery. I could be completely wrong here, but that's my impression. Mind you, IF it also does relieve the pain, then I'm in no hurry to jump off because that would be great. What does concern me though are the conflicting things I read about hopefully if you come to a point that you can begin to taper of the Suboxone as well. I've read that if it's done right then it's much easier than full opioids, but if done incorrectly then it's worse. I've also read that no matter what it's the worst of all them no matter how you do it and not to stay on it for long. But if I don't have a choice and have to stay on it, I'm just stuck with that I guess.


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PostPosted: Wed Jun 26, 2013 8:05 am 
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Hi Snap,

Welcome! I find your story very interesting. I too wonder how your doctor has been successful with not telling his patients to be in WD before starting the suboxone. I'm wondering if this is something that alot of doctors who prescribe it for off-label pain relief are doing things. I just read an article in another section on the forum about a doctor who is using suboxone in his pain management clinic. In the article it covers one particular patient who started suboxone treatment while still using a coctail of other opiate pain relievers. I wondered then how in the heck that could be done successfully. It just goes against everything I have ever heard about suboxone. I would definitely use the COWS scale Romeo posted for you and make your transition smoothly.

As for the 24mg dose...that is very high. I know that you were on a high dose of oxycodone, but I think you are going to be surprized at how strong Suboxone is. Keep in mind what Tiny Dancer said, if you get nausea and a headache you know you have had too much. It's always better to start small and work your way up if you need it.

Good luck with your induction!

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PostPosted: Wed Jun 26, 2013 12:04 pm 
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Thanks Q!

I read the same as you - that you CANNOT take both full agonist opioids and Suboxone because the former won't work and the latter will cause horrible precipitated withdrawals. In fact, that is the only thing the doctor said in regard to the two. He said that if I were to take another narcotic while taking the Suboxone, I would get, quote, "Dog sick." He didn't say a word about being in withdrawals before starting the Suboxone even after I called and asked.

Practically everyone I talk to also says the 24mg is very high. Before researching and reading, the day he prescribed it I thought the opposite because my mind wants to compare milligram to milligram. So I thought wait, 8mg versus the usual 30mg, isn't that a terribly low dose? 24mg Suboxone daily compared to 180mg Oxycodone daily? Now I understand - I hope anyway - that you cannot compare them like that, and apparently and even lower dosage of Suboxone might well be plenty to eliminate the physical withdrawals.

I have to say, after starting this and stabilizing, I'm actually inclined to see if I can find another doctor who will take over. I'm just really concerned about what seems to be this doctor's lack of a full grasp on this medication.

The only real problem beside all of this is financially. I do not have health insurance. The Oxycodone and doctor visits were costing $300 a month. That's obviously expensive, but I was able to do it. This is a different creature entirely. The cheapest I can find the medication here is $700 per month, and the doctor visit is $80, so this will be a total of about $800 a month. I don't know what I'm going to do. It would be cheaper if I could purchase private health insurance that will pay for the medication. I'm looking into that. However, I don't know. I know they won't cover the health issues that are pre-existing, but then now so also is the Suboxone. So it's probably not going to happen. This doctor has his "free" slots - where the patient receives it for free for one year at least - filled already.


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PostPosted: Wed Jun 26, 2013 1:13 pm 
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If you are already stabilized on suboxone, you can take a full agonist opiate. You will not get sick because the sub has already attached to your receptors and will block the full agonist from binding. Because of that, you won't get much relief, if any at all, from a full agonist. It is also dangerous to take full agonist opioids while on suboxone. Since you can't feel the effects, it's easy to over do it and think you need more.

On the flip side, if you induce on suboxone while a FAO is still attached to your receptors, the sub will knock the FA off almost immediately and brutally. This is PWs. It literally feels like you're dying for at least a few hours and then a lingering crappy feeling up to a few days (like getting over a full blown stomach flu.) It can take a while for the suboxone to start working after PWs.

As for Oxy mg to Sub mg, it doesn't compare like that. Suboxone stops working after a certain point. This is called the "ceiling". I can't remember where the ceiling level is, it's changed a couple times, but it's not that much. I think around 12mgs.. I could be wrong.. I am sure someone will correct me shortly if I am. Anway, when you get up to 16-24mg.. you don't get more of a good feeling, because you're past the ceiling. Most people get the opposite result and suffer from negative effects at that high of a dose. BUT.. everyone is different. I'm sure you'll find the dose that works for you.

Hope that explains some things..


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PostPosted: Wed Jun 26, 2013 2:50 pm 
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tinydancer, it certainly helps. I'm getting a wealth of information here!

The PWs are the highest of my concerns starting this. I'm going to be using that COWS sheet Romeo linked me too. It suggests waiting until at least a 5-6 to begin the Suboxone, preferably a 10 or more. So no matter what, I'm sticking with it till I hit at least a 10 on that thing. But the way my mind works, I'm STILL horribly worried that even if I wait until then, I'll be unlucky as all heck and STILL get PWs and then be in a boatload of trouble. I just can't handle the pain I have to deal with and those kinds of withdrawals on TOP of that! All I can do is hope I guess.

I have to also say that I'm really considering something. I've never been on this and may be speaking to the wind and wrong on this, but everyone is telling me the 24mg is really just serious overkill. So I'm thinking I'll dose the initial 8mg strip. Then wait and see how things go until I need the next one, no matter what at least taking the other 8mg later in the day just to be on the safe side for a total of 16mg. If that holds things fine, then forget the third for 24mg daily. Or maybe even cutting the second strip in half for 4mg on the second dose. I just don't know really .... I hate to get into doing that because truly all I would be doing is taking a shot in the dark based on what I'm reading online and hoping. I don't know if I should try keeping it low or just take it as prescribed for now. I'm also reading that even if you are on a really high dose, if you are ever at a point that you can taper and don't need the medicine anymore, pretty much everyone at any dose has a pretty seamless time tapering down to what I'm continually seeing as what I'm calling the "2mg wall." That's where most that I read about start having tapering issues, but then I see two sides to it. Some claim they wouldn't have such a hard time if they would take it as slowly as is recommended instead of just trying to hasten it and jump off altogether, and others say no matter what it's gonna be horrible. But I really can't concern myself with that right now. That's not an immediate concern. Right now I'm just concerned with inducing and stabilizing, hoping it takes care of the the physical withdrawals and then seeing where I'm left with the pain.

When and if it comes time to completely taper off (this would be good because that would mean the pain has been dealt with surgically or otherwise), then I'll concern myself with that.

Oh (edit), say I do decide to try to keep it as low as I can - say I take 8mg and then cut one in half later for 4mg alter but then start feeling withdrawals. Would going ahead with the other 4mg half if that starts be bepneficial, or are you just stuck to deal with withdrawals until it's time for the next dose?


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PostPosted: Wed Jun 26, 2013 4:58 pm 
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You can break your dose up into as many pieces as you want. My first 2 days I only did 1 and a half, and then I moved onto two whole strips. I am on sub for addiction and pain. 120mg of oxy was barely getting rid of my back pain. Since I started sub, my back hardly hurts anymore. Sub works pretty good for pain, but the effects only last about six hours. So I split my dose into either 3 or 4, depending on how my back feels. 16mg made me so tired I could barely function. Always nodding out. I cut back to 8mg a day when I was off work for two weeks and felt so much better. Actually had some energy. Unfortunately when I went back to work I raised my dose back up to 12mg. I feel more tired than I did on 8, but not near as bad as I did on 16. Also the higher dose you take, the more you raise your tolerance. Sub is crazy strong! I think you should do like you said, take the 8 for the first dose, then try 4 for the second dose. If that doesn't feel like enough you can always take more. When do you plan to start? Today or tomorrow?

P.S. I was scared to death the first time I took the sub. I had all these questions like you, unfortunately I hadn't found this site yet. I was so scared I made my husband stick the sub under my tongue (that's how the tweezers got started). I'm also pretty sure I spit out about half my dose. It was very orange. But it still worked great. Probably because I was pretty bad in withdrawal. So even if you mess up a bit like I did, I think you'll still be fine. Good luck! Keep us posted! :-)


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PostPosted: Wed Jun 26, 2013 5:37 pm 
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Hey Snap,

You're getting some fantastic replies to your questions, the only things I wanted to add was is the $800 you're figuring for Suboxone based on 24mg per day? If so, you can probably cut that number by 2/3 because I'm guessing you'll be fine on 8mg per day. You may end up at 12mg, but that still cuts that $800 in half.

If you're that concerned about PW, you could also start your Suboxone dose at 2mg or less. 2mg is usually not enough to precipitate wd fully. If you feel fine 45 minutes after taking 2mg, you can take more.

Also, if I were you, I would be in moderate wd before I start Suboxone, that's a score of 13 (minimum) on the COWS. I believe I was at 19 before I induced. One more thing, if you reach a score of 13 twenty minutes after your last dose of Oxy, you're scoring yourself wrong!! :wink:

It's actually best to have someone else score you, we addicts in wd tend to score ourselves a bit high, know what I mean? It "usually" takes more than 12 hours to hit moderate wd.

When do you plan on starting Suboxone?

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PostPosted: Wed Jun 26, 2013 6:48 pm 
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These replies are so great, I just can't really begin to tell you how appreciative I am.

Kitty, I think I'm going to do that and just see how it feels. I'll take the first whole 8mg strip and go from there. Romeo makes a good point to start with 2mg and see if PWs hit, but I really think I'm just scaring myself here. If I'm truly honest on the COWS, I'll know when it's time. Actually, even without the COWS (though I'm still using it) I still believe I would know when it's "time." We all know that feeling of coming out of our skin, temperature variances, bowel issues. I've been through WDs a couple of times, and the one thing I've never done is vomit. I've always been the kind of person that it takes something serious for me to puke. I just hardly ever do it. Actually, at over 40 years old, I can count on ONE HAND the number of times I've ever vomited in my life. WDs just don't do that to me. Anyway, boy do I get everything else though. Although even the temperature thing is by feeling only - I only sweat a little if at all even when I was in severe WDs. Strange, I know, but there it is. All that aside, we all know what stage of WD we are in if we're honest with ourselves I think. My most telling indicator has always been my legs. RLS just doesn't do it justice. Legs tingling/a little jumpy = mild WDs. Legs driving me nuts, crawlies beginning, pretty rough = moderate WDs. Legs have developed a life of their own, all previous issues very heightened, they're wanting to come off and go off by themselves and I'm coming out of my skin = severe WDs. All other symptoms follow the same pattern along with them.

When I'm somewhere between 10 and 15 on the COWS is when I'll induce. From all of your advice and everything else I've been reading, I really should be fine to take it then.

I will be inducing this weekend. I've made arrangements to stay with my sister and will not have to worry about anything at all except dealing with this. If it goes like I've read from many others, the WD period prior to induction will suck but the first dose of Suboxone will hopefully do wonders. I have set aside the whole weekend, this is the plan:

Friday night, last dose of Oxycodone. Saturday morning, wake up already in mild to moderate WDs (I'm always in that spot when I wake up, and of course the Oxycodone takes it away in 15-30 minutes). Continue as long as I can hold out, minimum of 10 on COWS and hopefully more. Romeo, I showed my sister the COWS worksheet and she will be scoring me as well as my myself so that we have both my own score based on how I'm feeling and her score based on what I tell her and what she sees. "Twixt the two we should have it covered. Scoring that high only 20 minutes after Oxycodone (and I know you were joking, but we all know that game too that we play with ourselves) it would be purely psychological.

If this goes as I'm hoping it goes, not having any experience with Suboxone so not really knowing, I'm hoping that I'll feel much better after the first Saturday dose and Sunday be doing even better and getting to work on stabilizing the dose. On that, I'm assuming that of an 8mg strip, two halves are obviously 4mg each and half of a 4mg is 2mg. I'm just not sure how to go about it. Say I take the 8mg and feel fine. Say 6-7 hours later I still feel fine, but then maybe at 8 hours I feel WDs starting up. Let me compare it to Oxycodone, a 20mg pill cut into quarters for 5mg each. If I take 10mg, that won't do anything and WDs will start. 45 minutes later, another 5mg and an hour later another 5mg don't take care of that at all. But from what I understand, for some reason Suboxone doesn't work the same way and the smaller doses DO help. If I did the Oxy that way, I would just stay in those WDs until I took a 20mg pill. My mind is thinking that Suboxone is the same way then, that when I feel the WDs I will need to take another full 8mg strip. Very confusing to me or some reason.

Like Kitty said she was, I'm am truly scared that I'll be in moderate to severe WDs, the Suboxone won't do anything for it, and I'll up the creek. It does feel better knowing that the worries about screwing up taking it just right are really misplaced and just that - worries. I'm just so scared the Suboxone isn't going to at least take care of physical WDs for some reason. But from what I've read, that's not something to be concerned about.


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PostPosted: Thu Jun 27, 2013 3:14 am 
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Snap,

I understand all your worries, they are pretty common when you are starting something so unfamiliar to you. And as an addict, you feel as if you are putting the most important thing in your life in danger. Giving it up to something unknown. Rest assured, the suboxone WILL WORK. You WILL feel fine after you dose. I'm 100% certain that the suboxone will take away all of your physical WD.

As for the dosing questions you had, you heard right. The suboxone doesn't work like oxycodone. Taking a small dose, then re-dosing if you're not feeling quite better will be fine. I know what you mean about taking small doses of SAO's after a larger dose, it doesn't work...but it does with suboxone. You are going to be surprized at how well the subs work for you. And, I'm pretty sure that you won't be needing to re-dose after 8 hours, but if you feel you need to it's okay. Just be careful not to take too much right away. Alot of people report nausea the first few days of treatment and it's usually due to taking too high of a dose.

You will see when you finally start it. There's really no way to explain how well it works, you just have to experience it. Relax, you're driving yourself nutzo! No worries!

Q


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PostPosted: Thu Jun 27, 2013 3:53 am 
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Thanks so much, Your reply and those of others have just been wonderfully reassuring, which is what I need right now. I don't know if I'm an addict or not (see my introduction), but in any case you're so right, it's like losing a best friend. I say that in my case because it kept me largely pain free, but I'm exploring that it may have been a closer friend than I thought or wanted.

It's just crazy how the mind thinks that the ONLY thing that will take care of WDs are, well, drug that you're no longer giving your body (in my case Oxycodone). Now you're told about this medication that supposdedly DOES take care of them, MAY provide pain relief as well - and you're wondering why on Earth hasn't another doctor mentioned it to me by now?


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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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