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PostPosted: Fri May 04, 2018 5:56 pm 
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Hey Guys,

I just wanted to see if any of you or the doc that runs this forum know anything about this... I have been on Buprenorphine for a couple of months now and I think that I am a rapid metabolizer (if there is such a thing) I started on 12 mg then 16, 20 and 24 mgs. The biggest issue that I have is that the medicine does not last very long at all, I am only kept out of withdrawal for at most nine hours (I have to split my dose because of this) Any advice? Should I just taper off and try vivitrol? Methadone is not an option for me.

Thanks,


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PostPosted: Sat May 05, 2018 12:38 pm 
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Hey trenttalbott, welcome!



So first thing I wanna ask is how are you taking your buprenorphine? & For how long do you hold it under your tongue? This all makes a huge difference. The longer that you have it under your tongue, the better chance you have of absorbing the buprenorphine. I usually keep mind in for about 45 mins, sometimes even longer. Also, when you put the tab/strip under your tongue, try to "paint" it all over the part under your tongue. This will definitely help!



Also let me add that buprenorphine is meant to be taken forba longer period of time. At least one year. If you were to taper off the medicine soon, your chances of relapse are at an all time high. I hope that you choose to stay on bupe for a while, it really does work! I've been on Suboxone for over a year now & I've never felt better!
Hopefully some of the others will come by and chime in.

Ash

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PostPosted: Sat May 05, 2018 11:35 pm 
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Trent, yes, we have several members who also stated a very high metabolism similar to you so you're not alone. I would name names but if they see this post they'll respond.

Having to go up that high in dose seems a bit strange but maybe one of our doctors will answer you with a more professional answer. I'm just another addict like you who happens to be a moderator.

Hope you can get to a good stable dose and stay there.

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PostPosted: Sat May 05, 2018 11:48 pm 
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Many people new to buprenorphine have problems taking medication appropriately because of 'conditioned' withdrawal.

When starting methadone, patients feel a bit of opioid effect during the 6 hours after dosing (nothing major, but a slight warmness or sleepiness). Patients who use higher dose of methadone sometimes feel some minor opioid effect that has been described to me as a 'warm blanket'. But on buprenorphine, there is none of that. The opioid effects of buprenorphine are completely flat, with no rise and fall.

In your case, you may be correct that it is wearing off, or it may be that your mind is essentially playing tricks on you, making you THINK it is wearing off. To tell the difference, you need blood tests of buprenorphine levels. Without that, I would not conclude you're a rapid metabolizer unless we could find something objective to measure.

In my job at a methadone program, people come in every day and tell me that they went into 'severe withdrawal' at 8 PM. I will be seeing them at 8 AM, 12 hours later, and they will have tiny pupils, no sweating, and no problem sitting calmly and talking with me. I'll point out, 'you couldn't have had severe withdrawal 12 hours ago, because here it is twice as long after dosing, and you're not showing any sign of withdrawal now.'

My point isn't to say you're wrong; I'm just trying to give you good advice. Have you had levels drawn showing that it disappears from your blood?


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PostPosted: Sun May 06, 2018 1:06 am 
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Hey Guys,

Thank you so much for the replies! I know everyone has busy schedules and I appreciate the help. To answer your question subox doc I have not had blood levels drawn but all of my urine samples show that my levels are very low for the amount of suboxone I am taking. (they think I am diverting my doses :( I am talking to the doctor on Monday about a blood test. I know that I am in withdrawal because when I wake up in the morning my pupils are abnormally large. I wish that this was just psuedo withdrawal like it usually is. This whole thing has been very frustrating, I might have to go to the doctors office everyday for observed dosing because they do not believe I am taking my medicine. Does grapefruit juice help slow down the break down of Buprenorphine? My uderstanding is that it inhibits some of the enzymes that break it down. Has anyone ever tried this?


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PostPosted: Sun May 06, 2018 1:10 am 
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and I forgot to add I take the medication under my tongue and I have tried painting it all over my tongue and the sides of my cheeks to aid in absorption. Also I usually have the buprenorphine in my mouth of at least 20 minutes.


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PostPosted: Sun May 06, 2018 8:50 am 
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This is not in the guidelines, but given in the hope that you don't return to using and end up dying. You said you are on 24 mg a day, that you feel you are in withdrawal after 9 hours. Have you tried splitting your dose? If you take it every 8 mgs 8 hours that will blunt the withdrawal at 9 hours and you would consistently be above the ceiling (probably way above at that dose).
Some may comment that this is encouraging addict like behavior but losing a patient is worse in my opinion.
What other recovery activities are you involved in? AA, NA, SMART, individual counseling?
Just an aside, I participated in a webinar last week.
The speaker used the acronym MAT - Medication Assisted Therapy.
She has modified it to recognize the preeminence that medication now has; MAT - Medication for Addiction Treatment.


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PostPosted: Sun May 06, 2018 6:09 pm 
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Hi docm2- I struggle with using the term 'MAT' because people have used it (and still do in some settings) as 'methadone assisted treatment'. I agree with you that it now is supposed to stand for 'medication assisted treatment', meaning buprenorphine or methadone. But then you have the Vivitrol people trying to make sure naltrexone use is 'MAT'....

Where are the dictionary police when you need them?

Trent, if you look up cyp3A4 on wikipedia you'll see a list of inducers and inhibitors. Grapefruit juice inhibits that enzyme, which converts buprenorphine to norbuprenorphine. But the degree of inhibition really varies between individuals, and there are other pathways to metabolize buprenorphine, so it may or may not make a difference for you.

I do not routinely check buprenorphine levels in patients so I don't know how costly or reliable they are. I DO check methadone blood levels on a daily basis, so I am familiar with the concepts... for example urine drug levels are of no value unless something is used to correct for concentration effects. Usually creatinine levels are used for that purpose. The actual results often vary from what is expected because of all sorts of individual variables, such that urine drug levels should almost be seen as an oxymoron. Blood levels are going to give you a lot of information.

I'll keep reading comments....


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PostPosted: Mon May 07, 2018 3:01 pm 
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Hey Doc,

Thanks for the info! I tried talking to the doctor about a blood test but he says they do not do blood tests for Buprenorphine at that facility. He said that my levels were so far off that I am either kicked out or going to have to do observed dosing every single day. I did make a big mistake and start playing around with my dose (taking more than I was prescribed) this whole process has been really embarrassing and I dont know if I really want to do MAT anymore :( What are the options if a 24 milligram dose does not hold someone? Should I come off and get my tolerance down and then come back on? I tried the using grapefuit juice but it did not make the effects of the Bupe last longer. Also another question for the doc.. does norbuprenorphine cross the BBB? From what I can tell it is a full agonist that does NOT cross the BBB and causes constipation. I know this sounds stupid but I am thinking of trying to inject my dose IM or try taking it rectally so I get more out of the dose I am on. I just wish this would work for me like it works for everyone else......


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PostPosted: Wed May 09, 2018 1:00 pm 
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Hey Trenttalbott,


Whatever you do, do NOT inject your buprenorphine. This will throw you right into PAWS, you will feel so horrible. Why don't you try splitting up your doses all throughout the day/night like Docm2 said? I'm on 8 mgs everyday & I now break up my dose, I find it to be most effective. Whatever you do, do NOT inject your buprenorphine. The naloxone (antagonist) will override the buprenorphine (partial agonist) & will throw you into withdrawal. I'm sure Suboxdoc & Docm2 will be chiming in soon. Why don't you try holding it under your tongue longer? Like more than 20 mins? I hope this helps somehow!


Ash

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PostPosted: Wed May 09, 2018 5:22 pm 
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Quote:
What are the options if a 24 milligram dose does not hold someone?


Methadone or abstinence based recovery (comfort meds for acute withdrawal and support during PAWS.

Quote:
I know this sounds stupid but I am thinking of trying to inject my dose IM or try taking it rectally so I get more out of the dose I am on


Doesn't sound stupid, desperate? Type 'plugging' in the search box. You can increase absorption via rectal mucosa. Sorry Razor for resurrecting the topic. Please don't inject, complications abound, related to sterile technique and the fillers or other substances in the films or tabs.
I agree about the previous post regarding urine drug levels. I only check to see that it is present, the # is meaningless and a waste of money in my view.

Ashlee - I love your posts. To clarify PAWS is post acute withdrawal syndrome - the mental stuff when the acute withdrawals are mostly completed. You were referring to PW - precipitated withdrawal, what happens when buprenorphine is taken too soon after full agonist use.


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PostPosted: Thu May 10, 2018 1:48 pm 
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Sorry about that, Docm2!

I appreciate the clarification! Also, I really appreciate your input on everything, you've helped alot of folks here, you've also helped me :)


Trenttalbott,

I hope you're doing alot better! I lack education in the science of buprenorphine, but I try to help as best as I can. Hope you're feeling well.


Ash

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