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PostPosted: Mon Feb 22, 2010 9:27 pm 
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I originally tried to email this questin directly to the SuboxDoc but his email account was full and I couldnt send the message so I am posting the question here. Hopefully he will see this and read it and answer but if not I hope someone here can answer the question for me.. So here it is....

I read and watched your video that said that suboxone has a ceiling effect at around a 4mg dose, and that taking any more than this will not increase the effects of the drug as well as the withdrawal symptoms will only stay at or around the symptoms one would get for a 4mg a day dose no matter how many mg's a day they take. This makes sense to me as in my experience i notice no difference when taking a 4 or 8 mg dose.

What has caused me to become confused is a statement you made on a post in which you said that taking less than 8mg a day is not enough to maintain a lack of cravings for opiates and one may as well be taking hydrocodone to suppress withdrawal symptoms.

"...the value of the drug requires adequate dosing to achieve the long half-life and repression of cravings. At doses of less than 8 mg, suboxone becomes more similar to a pure agonist; one might as well be giving small doses of hydrocodone to prevent withdrawal."

I have noticed when only taking 4mg a day around 8 hours after dosing I begin to have strong cravings and end up taking another 4mg which alleviates them. I simply do not understand why this is so if there is a ceiling effect at around 4mg which cannot be surpassed. By my logic it seems to me that if this is truth then increasing your dose above 4mg would have no benefit whatsoever.

If you could explain to me why this is so and how it can have a ceiling effect at 4mg but at the same time have this other effect at doses less than 8mg that would be great.

Thanks, and if you could email me with the answer or at least letting me know where to go or give me a link to the post you make on the blog or whatever so I know how to read it that would be great,


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PostPosted: Mon Feb 22, 2010 11:35 pm 
Hey Wakeup,

I am interested in this also. I have found a dose of 6 mg and 4 mg, alternated every other day, to be fine. I was wondering, can you identify the place where the quote you posted came from? Are you attributing that quote to Suboxdoc? I'm not trying to argue, I'm just confused.

Here's what I know: buprenorphine's analgesic (painkilling) effects only last about six hours, whereas it occupies the mu receptors and therefore blocks other opioid agonists for several days, and can have a half-life of 33 to 72 hours. Also, I didn't know the ceiling-effect was at a specific dose, but if doses above the ceiling-effect are useless, then why do doctors have to titrate up to much higher doses to stop withdrawal symtoms when addicts first begin Suboxone treatment? I do know some people, including some on this forum, use doses of 2 mg's and lower for maintenance, and do just fine. In my opinion, the amount needed to suppress opioid cravings is highly subjective, and is independent of the so-called ceiling-effect. The ceiling-effect only indicates the level at which increasing dosages will no longer increase agonist effects.


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PostPosted: Tue Feb 23, 2010 6:08 pm 
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Hey wakeup great question. The answer my doctor gave me was the fairly low biovailability of Suboxone/Buprenorphine. Even if you take 4mgs orally and you let it dissolve for about 30 minutes without swallowing you're still lucky to get a little under 2mg to actually be absorbed. If buprenophine/suboxone is swallowed the bioavailability basically drops down to 0% of the medication being absorbed. In contrast to buprenorphine alot of our former opiates of abuse: hydrocodone, oxycodone, morphine, etc have fairly decent oral/PO biovailability(the amount of the medication that makes it into your blood stream). This wasn't explained to me at first so when I started Suboxone on 8 mgs with the notion that the value of the medication was that I couldn't abuse it or take more than reccomended. Being a drug addict I unfortunately couldn't stop myself from experimenting with my dosage at first. When I took 2 8mg tabs one day I could almost detect a bit more of an opiate effect. This of course scared me as I started thinking that there wasn't a ceiling effect. However after finding my way to this forumn and watching a few videos of Dr. Junig I'm now able to take 8mgs of buprenorphine and I get good enough absorbtion that taking any more has no effect other than perhaps psychological by not swallowing any of the medication for at least 30 minutes and making sure that I spread it to all surfaces of my mouth. I'd also take an objective look to see if the cravings are real cravings. For me personally I know I'm not having cravings when I'm able to get interested in something else and they're gone after several minutes. When I was actually craving before I started on Suboxone it didn't matter what I did nothing would take my mind off of getting opiates into my system. So there is at least for me a difference between cravings and phantom cravings that go away a few minutes after distracting myself.

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PostPosted: Sat Nov 20, 2010 6:35 am 
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if i am understanding correct you take 4mg and then have to take another 4mg after 8 hours. Your first 4mg might be taking you over the ceiling and after 8 hours your droping below the ceiling so you have to take another 4mg. I watched his video about the ceiling effect and i take 12 mg every morning and i dont have one craving all day. According to what i watched you want to keep above the ceiling to maintain releaf. So you might just want to take the full 8mg at once to maintain. Or you can take a 12mg dose get your blood way above the ceiling and then 4mg daily should maintain for a while.

I have noticed for me personally that after like 2 weeks on suboxone the accute withdrawl symptoms are gone the really bad parts and when i have ran out on a weekend i didnt shoot down to the man on sunday and was able to stay relaxed until monday when the doctor opened.


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PostPosted: Tue Sep 02, 2014 12:06 pm 
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I was going to reply with the same response as Tayanissa; she explained the point exactly. Although it is important to consider the lower bioavailability of buprenorphine when taken sublingually on average, from everything I've researched and discovered, what I can gather from context is that the dose expressed at which the ceiling effect is attained is the dose taken sublingually (since that's how patients are instructed to use it), and not plasma levels of buprenorphine or the dose attained in the blood. From this information, I'd assume that injected, one would reach the ceiling effect of buprenorphine at under 2 mg IV assuming 100% bioavailability and an average of 30% bioavailability sublingually.
That being said, I'm in the same situation as the opening poster where I take 4 mg sublingually in the morning and, although I don't get withdrawals within at least 36 hours after that dose, I DO get cravings, or rather, just the implicit urge to "take something more", even if it isn't a specific drug or a drug of choice in mind, in the evening, about 10-12 hours after the morning dose. In fact it's mostly just the feeling of needing to take a little more buprenorphine. I have a rapid metabolism so it's of no surprise that if I'm taking a dose that is RIGHT AT the ceiling limit (4 mg) in the morning, then 12 hours later my body would have eliminated enough buprenorphine to cause me to dip below that ceiling effect dose, causing the cravings to kick in. I'm undoubtedly getting the proper effect after my first 4 mg dose in the morning because I feel perfectly fine and hardly if ever think about using until the evening. I probably could just take a smaller 2 mg dose in the evening, but dosing twice a day is a bit counterproductive to the point of buprenorphine therapy, in that the habits of feeling your dose wear off and then feeling a need to use again and then finally satisfying that need by dosing again need to be broken. The biggest remaining issue of addiction (at least in my case) once on buprenorphine is that habit of constantly thinking about drugs or using or just being aware that you're giving yourself ANY effect every morning when you take your buprenorphine. The less you can dose, the less you can think about drugs, and the closer you become to living a normal life not driven or motivated by the use or the thought of the use of drugs. This is why dosing once a day is key if possible.
That being said, the solution is as Tayanissa explained, you need to get your blood levels high enough with your daily morning dose so that after a full day of metabolism, you still have a blood level greater than or equal to what you would have after taking 4 mg sublingually and maintain that until your next daily dose. Let's say your metabolism is REALLY good just for demonstrative purposes and your liver eliminates half of the amount of buprenorphine in your system in just 12 hours instead of the average 36 hours... If you dose at the ceiling of 4 mg in the morning, you'll be fine - UNTIL- you being nearing that 12 hour mark where half of the dose is eliminated, leaving the equivalent of only 2 mg sublingually in your blood. Now you're below the ceiling and cravings are possible. If you assume that same demonstrative 12-hour half-life again, but instead you take 8 mg sublingually in the morning, then at the 12 hour mark, you still have the equivalent of 4 mg taken sublingually in your system - still at the ceiling dose. Then your cravings should be managed well into the evening by the time you fall asleep until you can wake to take your next dose.

For this same reason, I need to ask my doctor to increase my dose from 4 to 8 mg, but in the meantime, I've had much success with a certain method of increasing sub-lingual absorption and I recommend you do the same if your doctor is not comfortable raising your dose after explaining this information or if you are still having issues.

1) First, I recommend you follow all of Dr. Junig's instructions on basic sublingual dosing regarding maximizing the concentration of buprenorphine in the smallest amount of saliva as well as increasing the surface area of contact in your entire mouth; not just under you're tongue.
2) Second, and the method I've had the most success with, is using a high concentration or proof of alcohol to prep the blood vessels in your mucosa for better absorption (NOTE: I am not encouraging you to drink alcohol with your buprenorphine!). I recommend using mouthwash as you normally would for 30 seconds, ensuring prolonged contact with all of the areas of your mouth that the buprenorphine will be in contact with such as the gums, and especially the cheeks. Immediately after expelling the mouthwash, go ahead and take your daily dose of buprenorphine.

I have had TREMENDOUS success with this method, and have felt as though I were reaching the ceiling for most of the day with 2 mg once, indicating nearly double the normal sublingual absorption rate. There was a recent study on using various agents including alcohol to increase absorption and the estimated absorption rate was calculated between 60% and 70% which is excellent! Alcohol likely dose this for two reasons: One, it dilates blood vessels, increasing their surface area which increases the contact with buprenorphine and two, it dehydrates the blood vessels to a degree, making them more absorbent as well like really dry skin soaking up lotion quickly! With these two mechanisms to support it, it essentially changes the mouth's absorption efficiency from a thin cotton T-shirt to dense and dry sponge.

I apologize if this was too much information. It's a very important concept though and despite a solid medical understanding of these actions, so many physicians either fail to understand the importance of keeping a person above the ceiling level, or they fail to understand the futility of using doses WAY above the ceiling level (and unnecessarily costing patients a FORTUNE!), such as 24 mg and beyond (honestly I'd say 16mg and beyond; although there may be some specific cases due to the variability of human physiology where 16 mg might be necessary to maintain the ceiling level for a full 24 hours or in someone who's dosing every other day). Fortunately for humanity, Dr. Junig is here to sort everything out!

Best of luck,
Taylor


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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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