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 Post subject: Reccomendations???
PostPosted: Mon Feb 25, 2008 5:19 pm 
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Hi. I am posting to find out what you would reccomend for someone who is on methadone and will be switching to suboxone soon. My wife is detoxing off of methadone. She started at 199mg/day and is currently at 164mg/day and dropping 5mg/week. What would you reccomend for her to decrease to before changing over? Thanks.


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PostPosted: Mon Feb 25, 2008 11:20 pm 
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Thank you for writing. There a couple ways to do things, depending mostly on patient preference. The 'book way' would be to taper the methadone down until she gets to a dose of about 30-40 mg methadone per day-- that dose of methadone is about equivalent in opiate potency to the effect of suboxone. Remember that suboxone has a 'ceiling effect'-- that means that once a person has taken about 4 mg or so, further increases in daily dose will not result in greater opiate effect. Instead, raising the daily subox dose from 4 mg to 8, then 16, then 24 mg does NOT result in significant increase in opiate effect. In fact, at very high doses subox starts to block its own effect at the receptor and induce withdrawal.

Once she is on a daily methadone dose of 30-40 mg, she would stop the methadone for about 24 hours and then, assuming she is in a bit of withdrawal, start suboxone at 8-16 mg or so. When going from methadone to suboxone, I usually want the person to wait more than 24 hours-- more like 4-7 days-- because methadone is highly protein-bound and takes forever to leave the body. But since she would be on a dose that has a potency similar to suboxone, the wait would be less critical.

This is how the book describes things, but there are some problems with this approach. First, it takes a heck of a long time to taper the methadone down that far. And during that long tapering process the person feels lousy, and really wants to use. If the person has chronic pain, they are in pain much of that time as the methadone dose is lowered. Some patients will relapse to street opiates before the taper gets down to 30 mg.

I will tell you how I would probably prefer to handle the situation-- but not right now, because I am still working on the day's charts. I will write later tonight or tomorrow morning.


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PostPosted: Tue Feb 26, 2008 11:16 am 
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suboxdoc wrote:
Thank you for writing. There a couple ways to do things, depending mostly on patient preference. The 'book way' would be to taper the methadone down until she gets to a dose of about 30-40 mg methadone per day-- that dose of methadone is about equivalent in opiate potency to the effect of suboxone. Remember that suboxone has a 'ceiling effect'-- that means that once a person has taken about 4 mg or so, further increases in daily dose will not result in greater opiate effect. Instead, raising the daily subox dose from 4 mg to 8, then 16, then 24 mg does NOT result in significant increase in opiate effect. In fact, at very high doses subox starts to block its own effect at the receptor and induce withdrawal.

Once she is on a daily methadone dose of 30-40 mg, she would stop the methadone for about 24 hours and then, assuming she is in a bit of withdrawal, start suboxone at 8-16 mg or so. When going from methadone to suboxone, I usually want the person to wait more than 24 hours-- more like 4-7 days-- because methadone is highly protein-bound and takes forever to leave the body. But since she would be on a dose that has a potency similar to suboxone, the wait would be less critical.

This is how the book describes things, but there are some problems with this approach. First, it takes a heck of a long time to taper the methadone down that far. And during that long tapering process the person feels lousy, and really wants to use. If the person has chronic pain, they are in pain much of that time as the methadone dose is lowered. Some patients will relapse to street opiates before the taper gets down to 30 mg.

I will tell you how I would probably prefer to handle the situation-- but not right now, because I am still working on the day's charts. I will write later tonight or tomorrow morning.
Thanks Doc what a great way of explaining it. Love getting the new knowledge :)

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PostPosted: Tue Feb 26, 2008 11:30 am 
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Thanks doc. I had been told that she needed to decrease to a dose around 30mg/day. She doesn't have chronic pain, so that will help her I hope. She really wants off of the methadone and has less patience about the detox than I do. I appreciate you answering and will be looking forward to hearing the rest. Thanks again.


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 Post subject: Another way to go
PostPosted: Thu Feb 28, 2008 7:23 pm 
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Sorry for the delay--
Another way for her to go would be to stop the methadone, say taking her last dose on Monday. I would prescribe clonidine, which greatly reduces withdrawal symptoms, and ativan, to help her sleep, and she would put up with the withdrawal for three days. A person's tolerance drops rapidly when they are completely off of the substance, and by Friday she would be good to go-- we would give her suboxone and she would probably feel much better (I say probably, because some people will continue to have milder withdrawal for up to 3 days). By the following Monday (one week after her last dose of methadone) she would be on the suboxone and feeling pretty good.

The last way is to stop the methadone and replace it with a short-acting opiate, and stay on the short acting opiate for a week, while the methadone leaves her body. Then she would stop the opiate 24 hours before starting suboxone. Again, she would probably feel OK once the suboxone is started, but she might have mild withdrawal for up to three days.

I have done these 'fast-track' inductions a number of times, and they work pretty well. Yes, there is some withdrawal with either method. But during a clinic-taper, the person has low-level withdrawal and cravings for WEEKS, and during that time is at high risk for relapse to street drugs.

I do prescribe meds to treat withdrawal fairly liberally-- clonidine for the sweats, aches, and anxiety, provigil for fatigue, ativan for anxiety and to help with sleep, immodium for diarrhea, and compazine or odantreson for nausea. It can't be eliminated completely, but it can be reduced to a great extent.


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 Post subject: Mike's wife
PostPosted: Mon Mar 10, 2008 10:31 am 
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Mike your wife is in my prayers. As someone that was in the medical field myself, I find myself constantly amazed as to the response you get from Doc. He truly seems to have her best interests at heart, something rarely seen in the medical field, I am sorry to say. I so wish this forum had been up for me when I was detoxing. But for what ever reason I crossed over. I wish that for your wife in the most peaceful, healthy way possible. I know you and your wife are listening to his words of wisdom. I don't want anyone to get the wrong idea. I don't know this Doc other than through this forum. But his knowledge has given me an insight that was not there before. Good Luck to your wife, she's going to make it 8)

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 Post subject: Re: Another way to go
PostPosted: Mon Mar 10, 2008 5:51 pm 
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Thanks suboxdoc and Masuka for the replies. Dr., my wife has been tapered to 154/day from 199/day of methadone now. I've made it a point not to tell her about any symptoms because I didn't want to put anything into her head and have her expecting terrible things. However, in the past couple of days, she has had some knee pain and is feeling bad, as in weak. Could she be experiencing withdrawals already? She is tapering 5mg/week and has only within the last week complained of her knees aching, and just today said that she "felt like sh*t." I haven't heard of anyone experiencing any withdrawals at a dose as high as hers, but I'm no doctor.
I've shown her your forum and she says that she wants to taper to a lower dose, as she thinks that will make it easier for her to change over. If you can give me some insight in what to expect for the next couple of months, it would be greatly appreciated. Maybe I've read enough info. online that I'm jumping the gun in even thinking that it could be possible, and if so, please don't hesitate to tell me.


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PostPosted: Sat Mar 15, 2008 7:47 am 
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How are you and your wife doing Mike? I’ve been following your story but haven’t seen anything from you in a week.
Best regards.
Rae


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PostPosted: Sat Mar 15, 2008 8:56 am 
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We are doing well. I had surgery this week so she has been taking care of me. She is sleeping ALOT. She's still decreasing her methadone 5mg/week, and is doing well with that. She is getting impatient though. I can understand that. She really just wants this to be over so she can move on.


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PostPosted: Sat Mar 15, 2008 9:52 am 
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I would also like to encourage anyone who is checking in and reading to go ahead and register, and speak out about how you feel and what questions you have. This forum was started by a real dr. who is very well-versed in suboxone treatment, and is interested in answering your questions. So if you are reading this and have thought about joining, do it. I am so glad that I came here and have learned some things from doing so. Good luck guys.


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