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 Post subject: Right dose
PostPosted: Sat Mar 25, 2017 12:47 pm 
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Hi, I am new to the forum, new trecovery, new to Suboxone. I have read a ton of information on this forum and Dr J site, so I feel a little informed. I am trying to find out how you know you are on the right dose of Suboxone? I am currently on 2 mg 2x daily (total of 4mg). How I got to this place, this dose seems like a long story which I will do my best to summarize. I do feel better than I have in years, so I know this drug is helping me and want to continue but wanted some feedback on dosage, among other things. I have chronic pain, bipolar 2 with severe treatment resistant depression, and opiate addiction.

I have chronic neck pain with know known cause that started in my twenties and has only gotten worse through the years (I am now 38). I've tried everything one can think of for pain management- physical therapy, injections, massage, surgery, accupuncture, yoga, nsaids, muscle relaxers, antidepressants, gabapentin, on and on. Opiates helped the most , so whenever I could get them I was taking them, and using every script I took until doctor would cut me off. At one point I had scripts from 3 different docs for tramadol, Vicodin, Percocet, and Tylenol with codeine ( this was before prescription monitoring in my state) and taking them all, one after the other in rotation. My doc was Vicodin. No on ever noticed, until they did. I was cutoff from 2 doctors but the third kept prescribing Vicodin and Tramadol. I would take my script in a week, take another script in a week and then go through withdrawal until time for refill. Eventually this caught up to me and my therapist and psychiatrist insisted on me getting help from an Addiction doc.
I began seeing an addiction psychiatrist, also board certified in pain management. Highly respected in his field and I am finding him to be great now, but we had a rocky start. I asked to be tried on Suboxone- opiates helped my pain and my depression, and since I had been misusing the medication it made sense to me. He said he was concerned about me taking more Suboxone than prescribed so he put me on Butrans, trying to tell me it was like Suboxone, just in patch form. When I found it to do nothing, except address some of my pain, I researched it and realized that the dose was so small. It took me month of begging him and very close to relapse and then he agreed to try Suboxone. Started me out with 1 mg 2x daily. I did exactly what he was concerned about and took the whole script in 2 weeks. I was devastated and afraid of being taken off the medication- and kept wondering how I could be so stupid. With my therapist, my husband and my Dr we came up with a plan. Dr increased dose to 4 mg (2mg 2x daily), my husband is managing the medication while I try to get the addictive habits under control ( I believe I was taking more out of habit - not really abusing it) My husband gives me 2 pills every day. I take it how I am supposed to and never ask him for more. It has worked out great (about 2 weeks). My pain is better managed than everefore, my mood is good and stable and cravings greatly reduced. However, I still do have cravings- usually in the afternoon between doses. I partly want to ask for an increase, but I am not sure if that I'll be seen as (or is) addictive behavior. I know usually people start with higher doses and go down, but with the pain and mood I've done it reverse. Should I just stay the course at 4mg for awhile, or is it important to get cravings down? Also- doesn't it seem a little weird that an addiction psychiatrist would put me on Butrans when I asked for Suboxone? Even in the event that I did take more- wouldn't it be better to take more Suboxone than other opiates? Any feedback is welcome. Thanks

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 Post subject: Re: Right dose
PostPosted: Sat Mar 25, 2017 9:53 pm 
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Hey tragicom,

Welcome welcome here. Glad you've been lurking/reading/learning!! and thanks for stopping in and starting a thread.

Many of us got here - to addiction - thru pain issues w pain pills that as we all know require more and more bc tolerance builds and it takes more and more pills to cover. For some/many, a switch from pain pill dependency to pain pill addiction occurs and it appears that happened to you.

So -- hmmm seems very odd you were started on Butrans when you had a history that looks and acts like addiction. Butrans is approved for pain, not addiction. its illegal to prescribe pain meds to treat addiction. When Butrans is prescribed, its for those in pain w no to low opiate experience, meaning their tolerance is low and Butran's low buprenorphine dose can and does work. But you were an experienced opiate user w a higher tolerance than Butran so Butran was not ever going to work for you, as you now know...

As to cravings, yes, its important to get cravings down and better yet, its important to remove ALL cravings. That's what bup does at the right dose, which enables folks to live good lives. It makes no sense to be on bup and yet not on enough to remove cravings. That's a recipe for most to relapse. You really likely need to be on a higher dose. Suboxone is a very safe drug, given its ceiling effect, especially w opiate experienced, meaning already have a tolerance built up. If you read Dr J's info here and those on bup, seems to take 8mgs -16mgs to cover cravings and the obsession to use. Of course ramp up, don't just double your 4mg dose to 8 mgs. Or maybe 6 mg/day will work. Also, at 4mgs/day you are below the ceiling effect so bup starts acting like a full agonist, where it wears off faster and you feel Wds.

http://suboxonetalkzone.com/ceilings/

I know you said your addiction Dr is highly regarded -- but in what way?? Your Dr puts you on the wrong med Butrans to avoid putting you on the higher dose suboxone that has a ceiling effect so if you took too much there is no harm, no more help, but no harm. And then agrees to put you on suboxone but not at a decent dose to cover cravings???
-- Sigh--
I'd have run fast thru my pills too...

One last comment - you mentioned 2mg pills so I assume those are generic bup/nalox tabs? I had to look up and learn that they come in not only 8 mg but also 2mg tabs. Best!! P

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 Post subject: Re: Right dose
PostPosted: Sun Mar 26, 2017 6:21 am 
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Hey tragicom and welcome!

Pelican said everything I was going to say :)

Imo I think ur dose isn't high enough. I started on 16mg, I know everyone's tolerance is different but if ur still having cravings then u probably should be taking 8mg or 6mg would be a good dose too.... like pelican said. Plus ur only taking 2mg at a time, of course ur cravings aren't being taken care of. It sounds to me like u have been put through a lot.... switching this and trying this first, that would be exhausting and stressful, for no reason imo.

I totally understand being hesitant about asking ur doctor for a little higher dose. We (addicts) get really worried that our doctor will think we're trying to just ask for more to get a buzz or something. I have to admit, I still hate to ask my doctor for certain things because I don't want him to think I'm anything but perfect lol. That's crazy I know but it's true. In the beginning he wanted to start me off at 12mg and I was so scared to ask for 16 instead. But I did and it turned out ok. So don't be afraid, just be honest, after all he did to u in the beginning by switching u to this that and the other, think of it like that.

It sounds like ur not getting enough relief from cravings to have good peace of mind, worrying about ur dose not lasting long enough. Peace of mind is everything to me, and u deserve it too :)

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 Post subject: Re: Right dose
PostPosted: Sun Mar 26, 2017 10:32 am 
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Hi, I typed a whole reply and then it disappeared, so hopefully I'm not repeating myself. Thank you so much Pelican and Jenn. You both confirmed what I was thinking. Jenn, it is very true that I feel like it is very hard to trust what I'm thinking because in active addiction our minds often trick us into getting what we want at any cost. I also worry that my doctor will think I'm trying to be addictive when I'm really trying for the opposite. I also have social anxiety which makes it almost painful to advocate for myself sometimes. I have an appointment on Wednesday and will ask him for an increase, although I am nervous about it.

In retrospect I think my Dr did me a huge disservice by putting me on Butrans. Not only was it not helpful I think it made things much worse. I was receiving microdoses of an opioid agonist, and consequently wanting more, more, more with no way to satisfy those cravings. And cravings got 100x worse. I honestly thought I was going crazy at the time but it makes sense now. I was hours away from getting Vicodin when my therapist talked me down and assured me that we would work with my Doctor to find something that worked. She is not very knowledgeable about Suboxone- she doe not specialize in addiction- but we have worked together for 10 years and she knows me well.

Pelican- I don't know what makes someone a "highly regarded" Dr- that is just what my old psychiatrist told me. And when he finally agreed to Suboxone he seems knowledgeable about buprenorphine- but why the hell he would put me on Butrans and give me problems about getting on Suboxone is beyond me and still bothers me. I suffered a great deal for the few weeks I was on Butrans and life has turned around on Suboxone. He was very understanding when I used up my script up quickly and acknowledged I probably needed more- thus increasing the dose slightly. Why he was so reluctant to give me Suboxone makes no sense to me.

Oh, Pelican- I am taking 2 mg/.5mg generic Bup/nal tablets.

Thanks again!

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 Post subject: Re: Right dose
PostPosted: Sun Mar 26, 2017 11:04 am 
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Yes Pelican already nailed it, and all I can do is reinforce what he/she wrote (sorry Pelican- I don't know your gender!)

Over the years, the process I used to start buprenorphine products has changed. I used to start low and increase, but I noticed a problem. People on too low of a dose run out early, and lose confidence in the medication. Then, when I would increase, it was difficult to get that confidence back and get them on track again.

So now I do what most doctors do, which is start buprenorphine at a dose of 16 mg-- not the first day, but I have them there within a week, unless they have a very low tolerance (although then I probably wouldn't even put them on buprenorphine in the first place). As mentioned already, the ceiling on buprenorphine prevents overdose, even in opioid-naive patients in most cases unless a second respiratory depressant is added. In someone tolerant to significant opioids, there is very, very, very little risk with buprenorphine, and that risk is the same with 4 mg or 40 mg of buprenorphine. If anything, risks are greater with small doses, as that allows cravings to remain, and reduces the block of illicit opioids.

I disagree with the use of Butrans for the reasons Pelican mentioned. It IS illegal to use for addiction. I don't know if many attorneys, DAs, board members, or even physicians KNOW it is illegal-- but it is!

I think 8/10 buprenorphine prescribers would say your dose should be higher, probably 16 mg per day to start, and then MAYBE lower it at some point in the future-- after 6-12 months-- when you are doing well. If you ask just the doctors who have significant experience with buprenorphine, I think 10/10 would say your dose should be higher. How do you know it should be higher? Because you do not have confidence that it is working. I wouldn't use that reason to increase beyond the average dose, but I would definitely use that reason to go to 16 mg. From the sounds of things, I don't think your doctor will understand my point, so don't use that reason with your doctor. But to explain, addiction has a psychological element; a very LARGE psychological element. We all know that; we all know that we have relapsed, even when we are not having physical withdrawal symptoms. So part of buprenorphine treatment comes from the combination of the patients motivation to stop opioids, and the belief that buprenorphine will allow those efforts to be successful. Buprenorphine's actions are far, far beyond psychological, but the psychological element helps with some issues.

Don't say 'all my friends take 16 mg', and don't say 'but other docs give 16 mg'. When people say that, I want to say 'then go to those doctors!' Instead, say (if it is true) that you are getting withdrawal symptoms near the end of the dosing interval. That is the classic symptom of 'underdosing'; the effect doesn't last the full 24 hours (with once per day dosing) because the blood level drops below the ceiling level, and then withdrawal kicks in. If you dose twice per day (which can help provide a steadier blood level) the symptoms would start at 10-11 hours. Does that make sense?

Good luck!


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 Post subject: Re: Right dose
PostPosted: Sun Mar 26, 2017 5:17 pm 
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Thanks Dr J! That really does make sense. And thanks for the advice on how to relay the information to my doctor. I struggle with that, so perspective from the Dr's point of view is helpful. I will let you know how it goes.

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 Post subject: Re: Right dose
PostPosted: Wed Mar 29, 2017 3:30 pm 
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Hi all. Just wanted to give an update. Doctor increased dose to 8mg, so hopefully that will help. I had been taking generic bup/nal tablets but the pharmacy gave me brand name Suboxone films. I'm a creature of habit and I liked the tablet. Took one half of film and felt burning all over my mouth. It also seemed like it took forever to kick in. Is the burning a common symptom and if so does it get better, or do you get used to it? Hoping I don't have a sensitivity to an inactive ingredient. The effectiveness must be in my head, right? I've heard the other way around- film seeming to work better than generic, but not the other way around. Let me know if you have feedback.

Also- I'm going to start a new thread on this- my doctor is really pushing for probuphine once I am stabilized on a dose for a few months. Thinking about how I feel about this . . .


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 Post subject: Re: Right dose
PostPosted: Wed Mar 29, 2017 8:16 pm 
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Tragicom wrote:
Hi all. Just wanted to give an update. Doctor increased dose to 8mg, so hopefully that will help. I had been taking generic bup/nal tablets but the pharmacy gave me brand name Suboxone films. I'm a creature of habit and I liked the tablet. Took one half of film and felt burning all over my mouth. It also seemed like it took forever to kick in. Is the burning a common symptom and if so does it get better, or do you get used to it? Hoping I don't have a sensitivity to an inactive ingredient. The effectiveness must be in my head, right? I've heard the other way around- film seeming to work better than generic, but not the other way around. Let me know if you have feedback.

Also- I'm going to start a new thread on this- my doctor is really pushing for probuphine once I am stabilized on a dose for a few months. Thinking about how I feel about this . . .

the films taste really gross. i've never had any burning. now that i'm on a smaller dose (.8 mg x 2) it doesn't bother me as much. would your husband let you cut them into 1/3s? to take 3 times a day? my therapist was concerned that at fist i was taking small pieces all day long because it was similar to my addition behavior, so i limit myself 2 2x a day. the 4mg would be a low dose to someone already experienced with opiates. the clinic i go to starts everyone on 16mg then adjusts it from there.

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