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PostPosted: Mon Nov 16, 2015 6:50 pm 
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I have been on Suboxone (sublingual strips) for six weeks now. Today is the day that I have began my taper off of Suboxone under the care of my physician regarding this portion of my healthcare. I landed at this forum from viewing some of your videos on youtube. Specifically referencing the videos titled "How Suboxone Works Parts I and II". I believe I understand the fundamentals of how Suboxone works except for the following part: the 4mg ceiling effect. I get that you say that anything over 4 mg is pretty much a tolerance issue, However, what if 4 mg. is all you have ever been on?(the you being me) Please endure the following explanation as I feel like if I tell you my specifics, I will benefit by getting the understanding/information that I am looking for in return. So here's the deal: I used/abused heroin for exactly 24 months. I won't get into the reasons for waiting until I was 43 years old to start the use in the first place in this post, but I became physically dependent none the less, and sought to terminate the habit six weeks ago. While actively using black tar heroin, my tolerance never developed in a way in which I have witnessed in many (every)of my peers.(fellow heroin users) I used the same miniscule amount 24 months into it as I did the first week I started. (which happened to be .10 to .20 grams per day depending of the quality of the with the higher amount used when quality was low) So going into the ATC at the VA, I felt like the Dr. really had no good method to use to know how much Suboxone to prescribe. The drug addict in me felt like I needed to exaggerate the amt. I used to compensate for any variable in which I would end up in withdrawal.(I assume most addicts do too)But I didn't. The Dr. prescribed an 8 mg strip 1x per day. I immediately said that I thought that was too much, and I requested to start out at 4 mg. The negotiation resulted in me being prescribed 6 mg daily, with the first 2 mg being observed at the clinic, and me taking 4 mg (2x 2 mg strips) home each day. I accidentally discovered that 4 mg per day was my "ideal dose" by forgetting to take 2 mg of the 4 mg. several times during the first week of being on the Suboxone. (no withdrawal symptoms) So I was able to put one 2 mg strip away into the "rainy day" stash for the first 4 weeks. Then on the 5th week for whatever reason they (Dr./Pharmacist/Therapist,etc) suddenly had me take all 6 mg at once under observation. I have since learned that that is the way the medicine was meant to be taken in the first place. While taking 4 mg daily, I never experienced any withdrawals, or euphoria. This last week I have felt kind of "high" while on 6 mg taken all at once.(observed) Fast forward to today,(first day of 21 day taper under Dr. supervision) I took 5 mg.
I don't know if I am correctly interpreting the information in the video, but does it mean that until my taper goes down to 3 mg per day, I won't have any withdrawal symptoms. But at that point I will start to experience withdrawals from the Suboxone? And in your opinion, is a 21 day taper from 6 mg to 0 mg a realistic way to succeed in terminating my use of opioids/opiates over the long term? I do welcome and thank in advance for any advice offered from the forum on this matter. I appreciate the collective experience a forum such as this can offer. I'm just too lazy and busy to put the effort into finding the answers to my ignorance via the world wide web.


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PostPosted: Mon Nov 16, 2015 11:42 pm 
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I'll take a shot, as much as I hate to contribute to someone's laziness.... (!)

There is not much of a connection between a person's heroin tolerance and the 'correct' dose of Suboxone. There is a cap on the opioid effect produced by buprenorphine. So if a patient comes in taking a tenth of a gram of heroin per day, and starts buprenorphine, the buprenorphine creates about the same effect as that tenth of a gram of heroin. But if a patient comes in who is taking 5 grams of heroin per day, the buprenorphine will provide an effect equal to a tenth of a gram of heroin-- whether the person takes 4 mg or 32 mg of buprenorphine. The person taking 5 grams of heroin per day will probably experience withdrawal after taking buprenorphine, as the buprenorphine will instantly 'pull' the tolerance down to the lower level. The person on a tenth of a gram of heroin per day may feel neutral on buprenorphine, or may even get a small buzz from the drug-- whether the dose is 4 or 32 mg of buprenorphine.

Some docs will give more buprenorphine to 'high tolerance' patients, even though that doesn't make much sense from a science standpoint. The main reason to take higher doses of buprenorphine would be either because of higher metabolism of the drug, or because of a desire to get a greater blocking effect from the drug. It is much harder to out-compete 32 mg of buprenorphine than 4 mg of buprenorphine, using heroin.

To answer your questions-- yes, the withdrawal will mostly start below about 4 mg of buprenorphine per day... and no, trying to taper in 21 days is not reasonable. The ceiling effect of buprenorphine is about equal to the tolerance caused by 40 mg of methadone per day... and people typically taper off that much methadone over a period of 3-6 months. Unfortunately, we don't have the lower doses of buprenorphine needed to facilitate a soft taper-- which is why some people use Butrans. The highest Butrans patch is about equal to 0.5 mg of bupe per day... and the lowest is about equal to 0.1 mg per day. A true, linear taper of buprenorphine would be best-designed by taking dose ranges between 2 mg per day and zero, where you drop by about 10% every week or two-- from 2 mg to 1.8, then 1.6, then 1.45, then 1.3, etc. Hopefully some company will come up with a taper pack, one of these days.


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PostPosted: Fri Nov 20, 2015 7:10 am 
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Hey Doc...Thank You!!! That was precisely the info I was looking for! Now here's where my mind fuck begins. 4 days ago (monday) my dose was reduced to 5 mg/day. Today (thursday) I received a call from my Dr. and he said that after consulting with "the team" (which is done on wednesdays) Everyone decided I would start my taper this next Monday. Mind you that last Monday BEFORE the order was put in to reduce my dose, I sat down with the VERY SAME Dr. to discuss my wish to taper. So I don't know WTF is goin' on. I am very grateful I found this forum. Now that I have read a few more posts, and considering what was said in your reply to my post, I really have some thinking to do. Nobody enjoys withdrawing from opiates. For some reason (ignorance) i had it in my head that I could do this gradually in a comfortable way. I had read a few studies on the subject of tapering off suboxone on the SAMHSA's website and one of the experiments explored the difference of a 30 day taper compared to a 7 day taper. And in the end it appeared that there was no significant difference between the outcomes of either one. Anyway, can you recommend somewhere else I can look to get more familiar with different schedules and recommendations for tapering? Now that I'm thinking of it, there doesn't appear to be a mathematically feasible way to do a 21 day taper comfortably if the problem isn't going to start until I drop below 4 mg. (which by the way was all I was on until last week) As usual, I was running into this thing with blinders on, and by the sound of it, once again, the distance between "my way" and reality is too great of a gap as it is at the moment. I think I am going to ask for more time to familiarize myself with the process tomorrow. Once again, Thank You for providing such a valuable resource.


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PostPosted: Fri Nov 20, 2015 2:28 pm 
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Those two studies are entirely insufficient! We have had folks who take months to slowly taper and it makes a huge difference! Not all people can taper over such a long period of time, but yes, you should have that option. A good sub doctor would work with you and let you take the lead on tapering. But there are plenty of doctors who think that they should direct everything. Very lame.

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Dr. Jeffrey Junig, M.D., Ph.D.

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