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Is Suboxone / buprenorphine an opioid?
Yes 100%  100%  [ 2 ]
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PostPosted: Tue Apr 25, 2017 8:04 pm 
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Just curious what people believe on this topic, given some people group it as an opioid, and other's don't. Language is important.


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PostPosted: Tue Apr 25, 2017 9:12 pm 
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Someone please correct me if I'm wrong, but since Suboxone/Buprenorphine is a synthetic partial opioid receptor agonist it is considered an opioid. The only difference in language for opioid agonists are drugs derived from opium (Papaver Somniferum, or other opium producing poppies) and are called opiates.


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PostPosted: Tue Apr 25, 2017 9:26 pm 
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Yeah that's what I thought. Sometimes people consider it it to be separate to other narcotic drugs like methadone, codeine, oxycodone, morphine and heroin because it's only a partial agonist. But it's still a strong opioid and very difficult to come off in my opinion. Much stronger than codeine, hydrocodone.

IMO the drug that's most similar to buprenorphine in terms of subjective effect is methadone. Methadone is also very difficult to taper off, and requires a lot of motivation to do so successfully.


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PostPosted: Tue Apr 25, 2017 9:59 pm 
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I don't have any experience with methadone but I agree buprenorphine is unique amongst opioids. It really does deserve its own classification since it is a self limiting (ceiling effect) partial agonist.

I think the language aspect of your question relates to how people accept suboxone and methadone in society, right? Maybe addiction maintenance/taper meds will get their own classification sometime soon as more and more of America's upper and middle class fall victim to the opioid epidemic and the stigma aimed at addicts softens to a more sympathetic, if not empathetic, understanding. Wishful thinking! Imagine someone running for office and their use of suboxone gets leaked to the press... I think the acceptance milestone is still a decade away, unfortunately, but people like us on this forum, Dr. Junig and Dr. docm will hasten it.

Edit: As far as the strength and difficulty of coming off of suboxone and methadone vs other opioids, I think the only real difference is the half life of the drugs. Anything that binds to those receptors and builds a tolerance is going to cause addiction and withdrawal upon cessation eventually, it doesn't matter their chemical make up. The brain's regulation of endorphins due to the addiction is still always going to be the cause of the negative symptoms no matter the drug. To what degree that happens will vary, of course. Even if buprenorphine is harder to quit than every other opioid agonist (a very subjective statement) at least we can function normally while we're on it! Haha


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PostPosted: Tue Apr 25, 2017 10:41 pm 
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I mostly agree. Yes, buprenorphine is 'potent', but that potency is limited. It has strong opioid effects in microgram amounts, which is one view of potency. But the potency of buprenorphine is limited to a certain maximum effect, and in that regard it is not potent at all. No matter how many milligrams, grams, or pounds of buprenorphine you use, it is not more potent than one 80 mg tablet of Oxycontin, or 5, 10 mg tablets of methadone.

Likewise, it is not typically possible to overdose on buprenorphine alone, even in a person who has never used opioids. But it is very easy to overdose from only oxycodone, or only fentanyl. So from the danger standpoint, buprenorphine is not potent at all.

As for how hard it is to stop, I've written this before-- but the brain has no idea what drug you are coming off. The brain only knows that your opioid receptors have a high tolerance, and that high tolerance must be corrected. The difficulty stopping is a function of only two things-- the degree of tolerance and the quickness of correction. Buprenorphine cannot shift tolerance higher than the effect of 40 mg of methadone, so that limits the severity of withdrawal. Almost every heroin addict I've met over the past 2 years-- about 300 people, coming in as new patients in a methadone program-- have tolerances MUCH higher than 40 mg of methadone. The average, in my best guess, is about 4 times higher, judged by the very small effect that 40 mg of methadone has on them.

This point comes up so often, and the reality is very simple. The problem is the change in mu receptors-- nothing else.

Buprenorphine has features that make it easier to 'come off'. We always use long-acting agents to taper, off anything. People coming off Xanax are changed to clonazepam, for example. It is not really possible to taper off something that has a blood level that goes up and down throughout the day. You need something that creates a stable blood level, and then you can slowly decrease that blood level. With oxycodone, the blood level goes from very high to zero in 4 hours; with heroin in 8 hours. You can taper using a patch, and doctors often go from one fentanyl patch to another to lower tolerance and dose.

Methadone is unusual in how much it varies from person to person. Patients in methadone programs often get pulled in to jail on warrants, and are forced to detox 'cold turkey'. I see that happen at least a couple times per week. Some people-- about half, many more than I would have expected-- say 'it wasn't all that bad' when I see them a month later when they are released, and return to treatment. And others, of course, say it was horrible. But clearly the withdrawal from methadone is less severe than from heroin, and that's probably from the longer halflife caused by methadone binding to proteins in the body.

As for the length of withdrawal, it takes 6-12 weeks to feel close to normal, no matter the opioid. People always remember it differently, and that's not surprising given how memory works. Think back about how long you had pain after your last surgery, or how long you had a bad cough after you had the flu. Unless the memory is pegged to something (like days off work), nobody remembers those types of things. We all have impressions, which are formed by what we've said or what we've read from others.... but human memory is not good at remembering 'how long' something happened. That's probably why women go through pregnancy over and over-- they wouldn't do it more than once if they remembered the entire experience better!


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PostPosted: Wed Apr 26, 2017 12:45 am 
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Thanks for putting it so eloquently, Dr. Junig. I should have added that, empirically, buprenorphine's withdrawal phase should always be a lesser evil than short acting agonists and methadone due to the reasons you've listed.


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PostPosted: Wed Apr 26, 2017 8:20 am 
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suboxdoc wrote:
That's probably why women go through pregnancy over and over-- they wouldn't do it more than once if they remembered the entire experience better!



I think if it weren't for what causes pregnancy...

Conceiving a child covers any bad memories of childbirth...

What's the old saying...."if it feels good, do it"...

I tell my wife all the time that she "got herself pregnant"...

Knowing full damn well if she hadn't gotten a tubal ligation, she would likely either already have had a baby by now, or would be pregnant with #5 on the way...because it just feels that damn good.
She's had baby fever for quite a while...but can't get pregnant. I think we're lucky in that respect.

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October 8, 2013

RIP little brother. Gone, but not forgotten.


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PostPosted: Wed Apr 26, 2017 7:26 pm 
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Back when people told jokes, I remember a story from a doctor in Kentucky.... he was talking with his patient after she delivered her 12th child. She said 'doc, I can't do this anymore. I'm exhausted, and we can't afford any more. I can't afford to go on the pill, and my husband doesn't want me to anyway.'

He thought for a minute, and said 'I tell you what--every night when you go to bed, stick both your feet into a 10-gallon jug, and don't take them out until morning, no matter what happens.'

She came back a couple months later pregnant again. He said 'what happened? Didn't you do what I told you?' she said 'yes, doc-- I did it just like you said. I just don't understand it.'

He said 'you used the jug, like I said? And put your feet in it?'

She said 'yes, exactly. I mean, I didn't have a ten gallon jug, but I used two five galllon ones.'

That type of thing could actually be said in 1980... now it is probably out of line for a dozen reasons!


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PostPosted: Thu Apr 27, 2017 9:45 pm 
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LOL

Reminded me of the opening scene of Idiocracy for some reason.


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PostPosted: Fri Apr 28, 2017 11:05 pm 
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Hahaha! I hate to bump this for no reason, but that cracked me up.


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Fond Du Lac Psychiatry
Dr. Jeffrey Junig, M.D., Ph.D.

  • Board Certified Psychiatrist
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