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PostPosted: Wed Nov 08, 2017 10:16 pm 
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I just got back from my appointment and I was told that two previous urine tests were very diluted and showed no suboxone or it's metabolite in my urine. I asked if it had to do with me drinking a lot of water, which I tend to do ever since I replaced too much soda with watser, and they said that would explain the Suboxone not showing up but the metabolites should still be there. I usually take my dose in the early morning and my appointments are always on the last day of the previous script in the late afternoon. I take my dose every day and now they think I have been either hoarding or diverting which is neither. I am just so confused as to why the metabolite didn't show up since they said water intake doesn't affect that part of the medicine there for you must not be taking it. :(

Oh and the same thing happened to me last summer too where they said the metabolite must show up no matter how hydrated you are at the time of the collection.

Edit For more info: I started out at 2mg a day then up to 4mg since starting Suboxone in 2009 and now I'm finally at a dose that seems to be the most beneficial and over the last few years now I've been on 8mg a day. I take them daily and have been, no matter what mg I was prescribed, taking them every day for over seven years and yet some of my UA tests have been coming back with no Suboxone or it's metabolites present in them. One doctor said he didn't think drinking a lot of water would have any impact on the metabolites showing up or not and another doctor said "Maybe don't drink a ton of water before your appointment." It's like is that the reason for my tests lacking both the parent drug AND it's metabolites or not? I drink a lot of water because I'm always thirsty. Ever since I started to lose weight at a faster pace last year or so my need for liquids seems to have increased exponentially. And the last negative test was done after I'd just finished a three day course of a med for a bladder infection.

Now, for the next week I have to come in to the clinic every day for observed UAs, dosing and pill counts. But they are closed on Fridays and through the weekends so it will be Monday, Tuesday, Wednesday and Thursday. On every day but Tuesday I can come in at any time but I work on Tuesday from 8am til 6pm and won't be able to take my dose for the day until that evening after work when I get to the clinic. At least Friday thru Saturday I won't have to wait all day til after work since I will be allowed to take my doses alone. I'm not sure what's going to happen if the drug and especially the metabolites are still not showing up even with the "proof" of me taking them in front of them and counting my meds.

I wonder if I should have posted this as either a reply to my previous post about this when it happened last summer or if I should have created this post in a different section, but since it's been several months since it happened before I thought a new post would be appropriate.

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PostPosted: Thu Nov 09, 2017 9:53 am 
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Hey skyda!

I haven't ever had buprenorphine not show up in my screen but a couple months ago I was told that my urine was diluted. Now let me say this, I'm the most anti water drinker ever (I know I need to be more healthy about this) and I'm a diet Mountain Dew only person. I hadn't overly drank anything that morning I took my screen and I definitely didn't do anything any different than I always do before my screen and it's always been fine almost 6 years, did nothing different. So when I was told my urine was diluted and I was questioned about it......... I was upset!

I started questioning my doctor and he said my creatin (I know I'm misspelling this) was low or something like that..... it's been a couple months ago so I can't remember verbatim. I asked what else could cause that if someone hadn't done anything to purposely dilute their urine. I think he said something about urinary problems or even maybe liver problems, heck I don't remember. All I know is that I didn't dilute my urine and I was kind of offended even though I understand what showed up showed up. I'm VERY sensitive about being questioned about doing something wrong in my recovery and I'm sure that stems from being so worried about ppl not thinking I'm still using. After all these years I still worry my loved ones will doubt me and think I'm sneaking around and lying again. There's just so much disappointment when I think someone else is suspicious or concerned that I'm not telling the truth when I haven't done anything wrong at all and followed every rule to the T.

I'm sorry I got off on my issue skyda, ur post reminded me of what happened with my doctor a couple months ago. I couldn't imagine my doctor telling me that bupe didn't even show up in my screen! I hope someone can give u an answer for why this could have happened because this could be something that some of us may go through at some point. Hopefully Dr. Junig or docm2 will respond.

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PostPosted: Sun Dec 24, 2017 11:09 am 
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jennjenn wrote:
Hey skyda!

I haven't ever had buprenorphine not show up in my screen but a couple months ago I was told that my urine was diluted. Now let me say this, I'm the most anti water drinker ever (I know I need to be more healthy about this) and I'm a diet Mountain Dew only person. I hadn't overly drank anything that morning I took my screen and I definitely didn't do anything any different than I always do before my screen and it's always been fine almost 6 years, did nothing different. So when I was told my urine was diluted and I was questioned about it......... I was upset!

I started questioning my doctor and he said my creatin (I know I'm misspelling this) was low or something like that..... it's been a couple months ago so I can't remember verbatim. I asked what else could cause that if someone hadn't done anything to purposely dilute their urine. I think he said something about urinary problems or even maybe liver problems, heck I don't remember. All I know is that I didn't dilute my urine and I was kind of offended even though I understand what showed up showed up. I'm VERY sensitive about being questioned about doing something wrong in my recovery and I'm sure that stems from being so worried about ppl not thinking I'm still using. After all these years I still worry my loved ones will doubt me and think I'm sneaking around and lying again. There's just so much disappointment when I think someone else is suspicious or concerned that I'm not telling the truth when I haven't done anything wrong at all and followed every rule to the T.

I'm sorry I got off on my issue skyda, ur post reminded me of what happened with my doctor a couple months ago. I couldn't imagine my doctor telling me that bupe didn't even show up in my screen! I hope someone can give u an answer for why this could have happened because this could be something that some of us may go through at some point. Hopefully Dr. Junig or docm2 will respond.


It’s definitely odd. A few months later I overheard another patient going through a similar situation; they were making her dose in front of them and counting her pills because she keeps showing up with no Suboxone in her system even though she said she makes sure to take it every day and even took a little extra to be sure before her appointment but her screens keep coming back as negative. Right now I’m not sure if they’ve figured her situation out or not but I know I’m curious. Oh and she said she wasn’t drinking any more water than she normally does so her urine wasn’t diluted at all!

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PostPosted: Sun Feb 11, 2018 1:37 pm 
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So this just started happening to me. 3 months ago i asked to start being tapered off so i went from 8mg a day to 4 mg but ive been taking a little less then that but yesterday i went to my appt and the dr said that my last three months ive had no subs in my urine which is completely bogus The only thing that i have changed is how much water i have been drinking i read that you shld drink alot of water while your tapering and itll help you so thats what i been doing i havent went one day without subs for the last two years and now he says that i have to come in in a week and if it comes back like that again then im done im freaking out ill straight up lose my mind if he takes it away its rediculous he waits three months to ask me why its not coming back that its in my system im thinking about going to my regular dr to get a blood test i asked for one there but they wldnt do it. Its gotta be my water intake idk what to do im freaking out but im glad to see this happening to other people besides me


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PostPosted: Sun Feb 11, 2018 6:58 pm 
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Hi Jack and welcome here. I've not heard of the drinking water tip but that doesn't mean it isn't the right thing to do. My suggestion is to skip the water intake on the day of your appointment and take your Suboxone roughly 1-2 hours beforehand.

Other than that, I can't say why it's not showing up in the testing. Ask for another test if it happens again.

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PostPosted: Mon Feb 12, 2018 1:00 pm 
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Thanks for reading and responding to that, Rule. I can't get past the no punctuation issue to read it. I swear that I don't worry about grammar and spelling on the forum, except for my own, but I can't read a solid block of text without punctuation. Just give me a couple of periods please! My kingdom for some punctuation! :P

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PostPosted: Tue Feb 13, 2018 5:59 pm 
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That drives me insane too lol! Insane :) more than I already am.

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PostPosted: Thu Feb 15, 2018 5:04 pm 
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This URL has the information in powerpoint form. The information is the basis for what doctors are doing with creatinine information: https://view.officeapps.live.com/op/view.aspx?src=https://www.ok.gov/odmhsas/documents/B%26W%20OK%20Tampering%206-20-14.ppt

In short, the kidneys filter about 50 gallons of blood every 24 hours. Nobody wants to pass that much urine.... so luckily the large majority of that liquid is reabsorbed. The filter is called the glomerulus, and the liquid is the 'filtrate'. Water, some electrolytes, some drugs, and some other molecules are transported out of the filtrate and back into the blood. Larger molecules like amino acids and other proteins do not pass through the filter unless there is kidney disease, so we measure for protein in the urine as a marker for kidney disease.

The filtrate also has things added to it as it passes through the kidney, including potassium and some larger molecules. In the last stage at the kidney, water is pulled out of the urine and back into the blood. That process is controlled by the release of vasopressin by the posterior pituitary. Vasopressin release is blocked by opioids, which is why people on opioids, including buprenorphine, tend to pee more in the middle of the night (normally vasopressin release increases at night to reduce urine production).

After all this, the urine passes to the bladder and you know the rest. But the point is that urine is manufactured, and there are limits to what can happen during that process. The kidneys cannot produce water. The filtrate can only be concentrated so much. So urine that is as dilute as water clearly did not come straight from the bladder; water had to be added to it.

Also when someone wants to measure the amount of a drug, that amount will double if the urine is twice as concentrated. So you need a correction factor to adjust for the concentration effects. Creatinine is most-commonly used for that purpose, especially with THC, so lab tests often provide the 'THC/creatinine ratio'. Personally I believe that it is not all that useful to use urine to determine whether a person took enough buprenorphine, because there are too many variables that affect that ratio beyond buprenorphine dose. For example, a person who metabolized buprenorphine very quickly using a metabolic pathway that produces less norbuprenorphine will have less norbuprenorphine in the urine. Likewise if a person absorbs buprenorphine poorly through poor dosing technique.

But-- creatinine is a useful measure for determining when someone added water to a sample. Adding water can make the urine so dilute that abused drugs don't show up. Studies have shown that it is rare for people to produce urine with a creatinine level below 20. I will see an occasional level of 16 or 17, which only occurs in less than 1% of individuals and only when those people push fluids, and in those cases I am reluctant to throw away the test. But now and then I'll get a sample with a creatinine of 3 or 4-- and those numbers are just not possible in humans.

It sounds like the doc in this case is looking at buprenorphine metabolites. If you are dosing in front of the doctor, and the doc still complains about your levels, then that doctor needs to adjust his/her thinking and reconsider relying so much on the test. Unless maybe the doc thinks you are bringing in fake urine in order to hide something, and THAT'S why the levels are off? It is not that hard for people to find fake urine, and I've seen people hide urine in all sorts of places. I've had female patients who inserted a small bottle filled with urine into their 'female parts', with the bottle covered by a piece of plastic wrap or foil... then even during a witnessed test they could reach down, stick a finger 'up there' and puncture the top with their nail, and voila-- a clean specimen.

Check out the powerpoint at the link above, and you'll get a sense of the concentration issue.


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PostPosted: Fri Feb 16, 2018 12:18 pm 
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Wowwwww. Well that explains how females get away with that! Talk about practicing ur kegal muscles lol. I always wondered how a female could get away with altering her urine screen with someone watching. Our clinic has these plastic things that they place between the toilet seat so that when u sit down to pee (females), it catches the urine and the person in the bathroom watching collects it. We didn't use to be watched but there was an 'incident' where some lady brought in a cup of someone else's urine and literally tried to flush the cup down the toilet! I don't mind being watched but I'd prefer to be alone of course.

I was watching Intervention the other day and a girl was going to her probation appointment. Before she left her house, she put synthetic urine in the microwave to heat it up. It had a temperature strip on the bottle and everything. I'd never saw that before. She stuck the bottle in her boot and went on her way. I had never saw how technical these fakes are.

Thanks for explaining the dilution thing Dr. Junig. I understand it more now.

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PostPosted: Fri Feb 16, 2018 1:37 pm 
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They watch me pee everytime i go in there so i definitly do not use fake urine. My appt is tomorrow and I am freaking out. I quit drinking so much water and I am hoping that it shows up. I have totally taken pics of all these people having problems with these tests. This didnt happen until I asked to be tapered off and I do not like being made out to be a liar!


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PostPosted: Fri Feb 16, 2018 1:46 pm 
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So do you think I meed to ask the Dr to test for that creatinine or whatever it is? I swear to god I take them everyday. I feel like shit when i dont take them. Ive never done anything wrong and Im not a liar. Im honestly a Dr’s most trusted patient. Why wld I ask to be tapered if I wasnt taking them. If I was selling them I sure in the hell wouldnt want the 4mg id be losing money with how mich i pay for the appt and the script. I asked them to taper me off. This punctuation thing is so over rated


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PostPosted: Fri Feb 16, 2018 2:33 pm 
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SubDoc what do you mean by poor dosing technique? I take like a quarter in the morning and a quarter at lunchtime and the rest is in little bitty cut dosing do I need to stop that or what? And if he does kick me off how little of a dose do i need to be at to have little to No withdrawals? I get 4 mg strips but I do not take that much and the Dr knows that I usually take 2 mg and sometimes maybe at the most 3. For this week since I dont know what my future holds i have only been taking 1.5, I had little withdrawal with that so far its only been a week. Im trying to make it last as long as i can just incase I dnt get anymore i still have to go to work. So how low do i potentially need to get down too to be able to come off completely woth little to no withdrawal.


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PostPosted: Sat Feb 17, 2018 12:39 am 
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My thought for the guy is-- can't you just have a heart-to-heart in a calm manner-, talk about the issue, and ask him, sincerely, what you should do? That's what should happen; you shouldn't be placed in an impossible situation(!) The doc doesn't sound like.... like a 'good guy'... but if you were calm and respectful, told him that you will do whatever he needs to prove you're being honest, would he discuss the situation? I hate to hear about situations where patients are actually afraid of their doctor!

I wouldn't get into the creatinine with the doc; that will just make you sound like you're reading up on the internet to challenge him. I would say 'you think because of the lab value that I'm not taking my suboxone. But let's have me take it FOR SURE in front of you. Then tomorrow I'll give you a urine sample. won't that show that there is something about my body that makes the level unusual?'

Or something like that... One thing- there are two issues if I'm following this- first the low levels of norbuprenorphine (so they think you're not taking it all), and second the low level of creatinine. Is that right? Realize the tests address different things. Buprenorphine metabolites are to make sure the person took that medication. Creatinine is used to make sure that the sample is real and didn't have water added to it.

For 'dosing technique' go to my blog post: https://suboxonetalkzone.com/optimizing-buprenorphine-absorption/

Honestly, you will do better if you dose twice per day. All package inserts say to dose ONCE-- but dosing twice makes more sense when tapering. Dosing three times, in my opinion, leads to problems-- especially when tapering. We do NOT want you to start taking amounts based on how you 'feel' at that moment. That only awakens old habits and pathways, and leads to taking more than you intended. Dosing twice is plenty, honest.


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PostPosted: Sat Feb 17, 2018 2:00 am 
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Jackiesapp wrote:
So do you think I meed to ask the Dr to test for that creatinine or whatever it is? I swear to god I take them everyday. I feel like shit when i dont take them. Ive never done anything wrong and Im not a liar. Im honestly a Dr’s most trusted patient. Why wld I ask to be tapered if I wasnt taking them. If I was selling them I sure in the hell wouldnt want the 4mg id be losing money with how mich i pay for the appt and the script. I asked them to taper me off. This punctuation thing is so over rated


But I so appreciate it!!

We all believe you and I'm sorry your doctor is being an obtuse jackwagon! Dr. Junig is giving you as much help as can be given. He started this forum to help opioid addicts and he understands because he has struggled with addiction too.

I sincerely hope that you can talk to your doctor and figure this out. Let us know what happens!

Amy

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PostPosted: Sat Feb 17, 2018 7:07 am 
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Omg that totally makes sense about the dosing! I wondered if how i was doing it was ok so im gonna atop doing that because that is true! Im up for the dr appt so hoping for the best! I am definitly gonna ask him if i can take it in front of him thats a good idea Thank you so much! Ill let you know how it goes


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PostPosted: Sat Feb 17, 2018 11:38 am 
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I had my doctor ask me if I was trying to dilute my urine too Jackie. It was so devastating to hear him say that because I've never done anything wrong or failed any test, ever.

Like u, I have tapered myself (with his permission) and I pay cash so it makes zero sense for him to think I'd benefit in any way of getting my medication for any other reason besides doing right.

He hasn't said anything since so I'm assuming my next test was bk to normal, but I was very upset to think that my doctor actually considered I wasn't being honest. I didn't do one thing different before that test than any other time I've walked in there and taken hundreds by now. Who knows what caused it for me but it wasn't by drinking too much water, that's for sure.

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PostPosted: Sat Feb 17, 2018 11:46 am 
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So Update. Just left the Dr Negative ALL! I do not understand I took a bigger then normal piece this morning and I took more then normal yesterday. I asked him can you watch me take it and come in tomorrow and take another test so i can prove to you that this is not me not taking it. I said I will take it in fromt of you everyday. There has got to be something else going on with my body. He would not let me come in and prove it he said the problem is woth the DEA that they dont care they only care about the labs. He did say he believes me but there ia nothing he can do. So he gave me the rest of the month and said pretty mich im done. Im down to 1 mg now. Does anyone have any suggestions of how to taper the quickest way possible. Mind you i still have to work


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PostPosted: Sat Feb 17, 2018 1:06 pm 
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He would not let me come in and prove it he said the problem is woth the DEA that they dont care they only care about the labs.

He is so full of fecal matter the sclera of his eyes must have turned brown.
How many films do you have left? It would be optimal if you could stretch it out for a couple of months before you make the jump. Will he give you comfort meds at the end (clonidine, gabapentin, trazadone)?


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PostPosted: Sat Feb 17, 2018 3:24 pm 
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Urine drug test results depend on:
1) your dosage, how much you take
2) your dosing interval, how often you take it, or how long it has been since your last dose
3) how dilute or concentrated your urine is
4) the sensitivity of the test being done, how low a concentration can be detected
5) the specificity of the test being done, how often does the test actually read positive when the drug is present
6) variations in individual metabolism - not well documented for buprenorphine, but clearly an issue with some other drugs.

So there are a lot of variables. It is not unreasonable in my opinion, to have a person come in daily for a week for witnessed dosing and daily drug screens. It is also helpful to use a different test. If you are doing an EIA, add gas chromatography/mass spectrometry. If you are doing GC/MS already, send it to another lab. Use another brand EIA cup. Do a saliva or blood screen it you are concerned about fake urine. It's just a test, not the word of God!


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PostPosted: Sat Feb 17, 2018 8:15 pm 
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Jack, please search for another Suboxone doctor. Being pushed into tapering/quitting will most likely not be the best route. Relapse occurs when the patient is not ready to stop.

All that good advice from our resident doctor and he lets you go. Terrible shame but when one door closes another opens. This will probably work out in your favor when you find a sympathetic doctor. Please reconsider tapering unless there is no other choice.

Don't worry about grammar. We've seen it all. It's what you say that matters.

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