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PostPosted: Sat Jul 23, 2016 5:19 am 
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I'll keep it as short as possible, and hope that suboxdoc or other informed members can help; it is possible that I will answer the question by asking, but confirmation would be much appreciated.
I have been on Suboxone for 3 and 1/2 years, starting out at 8mg, dropping to 4mg, then 2mg followed by a failed and uninformed attempt to quit. I learned that lesson the hard way. Not doing it again.
I am a member of the sub-for-life group, and accept that a lifelong maintenance is required for sobriety.
When I dropped from 4 to 2, I was exercising daily, and quite robustly healthy, but one thing that I noticed was a morning slump until I took my dose,followed by a minor high when I took my medication. This was partly to blame for me thinking that I could jump off at that point. This may prove relevant...
When I was restarted on Suboxone I went back onto 4mg daily. After 18 months sobriety, my psychiatrist was happy with my stability, and we agreed that lifelong maintenance was a requirement.
But her view is that the aim should be to get to 1 or maybe even 1/2 mg daily maintenance dosage. My experience has been that it is very hard to go below 4mg, because I will feel lousy first thing in the morning, take the meds and feel fine most of the day. If drop to 2mg then I feel very definite physical, not mental, discomfort by evening, followed by poor sleep until my morning dose.
Having read many threads on this forum, it seems that there is possibly a minimum dose to maintain an even blood plasma level. And that it may exist about the 4mg level. Would this be accurate? If so, is it unrealistic to expect to be able to achieve a daily maintenance dose (I.e. no highs or lows, no cravings) of 0.5mg? I am prepared to go through a period of readjustment, even if uncomfortable, if dropping from 4 to 0.5 is attainable, but not to suffer daily ups and downs in perpetuity just to stay on the minimum dosage. That would seem to be to invite disaster at some stage.
So, please, what is the correct answer? To maintain on 4mg (as stated, I did drop from 4 to 2 successfully, but with definite highs and lows) and be satisfactorily stable, or to aim to drop to the lowest possible dose (if attainable) over the next year, and will I be able to maintain at 0.5mg with no deficit in quality of life, and importantly, the same low risk of relapse. Currently I am 3 1/2 years "sober" with zero temptation, much better quality of life and significant gratitude for a medication that has undoubtedly worked wonders.
Thank you for reading, any replies much appreciated.
Grant S.


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PostPosted: Sat Jul 23, 2016 10:45 am 
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Hi Intense,

You've got it right. Many bup docs don't understand bup, and looks likes yours does not. If you haven't yet, read this recent post from someone getting down to .5 mg and what happens. Especially read Raudy's posts. topic12767.html which shows that getting down to .5mg will act like a short acting opiate where you'll feel the need to redose and redose. Maybe this is what happened w your prior attempt to stop? That's why those tapering off often jump at these low doses.

Also, if you haven't yet done so, at top of the page, go to the Talkzone link. There on the top menu, select SuboxSearch and search both fields for ceiling effect. Lots of good links come up! Your personal story well describes bup's ceiling effect. Here is an example of info I obtained from that search: SuboxSearch.http://suboxonetalkzone.com/suboxones-c ... -recovery/
Wishing you my best, P

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Did well on Suboxone. Stopped May 2011.
Stopping went well -- its the staying stopped -- where the real work begins.
Coming here 'keeps recovery green'.


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PostPosted: Sat Jul 23, 2016 11:13 am 
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I'll just correct one thing. You said it may take 'a minimum dose to maintain an even blood plasma level'. An 'even blood plasma level' isn't quite the issue. Blood levels of buprenorphine go up and down throughout the day in stable patients.

What you meant to say is that it takes a minimum dose to prevent the blood level from dropping below a critical point. And as long as blood levels stay above that critical point, the patient will experience an even level of opioid effect at the brain.

As Pelican pointed out, buprenorphine acts like an agonist-- like oxycodone or morphine or heroin-- in low doses. What makes buprenorphine 'special' is that if the blood level is high enough, the opioid effect remains completely constant.

I can't get in your doc's head to know the thought process-- but I disagree with the approach you describe. If you are keeping a patient on a dose of buprenorphine below 4 mg, you may as well just give the person oxycodone every 4 hours. People don't feel stable at those low doses, for good reason--- the medication just isn't at a high-enough dose, to benefit from the ceiling effect of the drug.

In case anyone is still struggling with the ceiling effect issue, go to youtube and search for 'subdoc's (my) videos-- I have one video where I have a small hand-made graph to try to explain it. Another way to think about it.... let's say that we want to get the maximum amount of opioid stimulation at the receptor produced by buprenorphine-- an amount equal to '100'. If we look at the dose of oxycodone to get to that '100' level, it would look something like this: 5 mg = 20, 10 mg = 40, 20 mg = 80, and 40 mg = 160, and 80 mg = 320.

If we used buprenorphine, it would look like this: 0.1 mg = 5, 0.2 mg = 10, 0.4 mg = 20, 0.8 mg = 40, 1.6 mg = 80, 3 mg = 100, 8 mg = 100, 12 mg = 100, and 24 mg = 100.


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PostPosted: Sat Jul 23, 2016 12:06 pm 
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Intensecure,
I have a few people at 4 mg a day (almost all taking a split dose).
Only two below 4 and they are in active taper mode, not long term maintenance.
I try not to have 'an agenda' when meeting with patients, will do what they need as long as it is safe and within my comfort level.
If you are happy, productive and secure on 4 mg a day that is where you should stay.


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PostPosted: Sun Jul 24, 2016 5:07 am 
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Firstly, thank you for taking the time to reply to my questions. P - thanks for the confirmation and the links. Suboxdoc, thanks for correcting my maladroitly phrased "blood plasma levels", I watched several videos and learned even more. Docsm2, thanks for your very plain and helpful answer.
It seems from your answers that my experiences were guiding me correctly, and that my psychiatrist was being optimistic in her ideals for long term maintenance. Without being judgemental I can only assume that her knowledge is incomplete with respect to the ceiling effect, and that she assumed a linear dosage pattern.
She has the pressure of trying to aim for the lowest possible dosage for economic reasons; Suboxone is hellish expensive in the developing nation in which I live. No insurance cover, no subsided medication, no generics, medication costs would be 40% of the average monthly blue collar wage based on 8mg, which places crippling choices on those on low incomes. She also wishes to minimize side effect damage; I do suffer low testosterone from only 3 1/2 years use (+x years on other medications) so her motives are good, but her experience limited.
I am so very glad to have this resource available, otherwise I might have tried, and probably failed, to make further dosage reductions. I can refer her back to this, and I know that she will be receptive to being corrected without feeling that I am trying to prolong higher doses unnecessarily.
Thanks for confirming that 4mg is an OK dose to maintain my much improved quality of life. I can get on with things now without worrying about changing doses.
Highly appreciated. :)


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PostPosted: Sun Jul 24, 2016 4:37 pm 
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Not sure where you live, but in the US we have access to cheaper options than Suboxone. Plain bupe costs about 25% as much, and generic bupe/naloxone costs about half as much as Suboxone film.

Good luck!


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PostPosted: Sun Jul 24, 2016 8:37 pm 
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Thanks Doc.
I am an ex-pat Brit living in Malaysia. Malaysia is a wonderful country but still a developing nation in some ways, frankly I was very surprised to be able to get treatment here. I'm just grateful that Suboxone is available, maybe one day generics will be available too.
Every time I visit my psychiatrist, she tells me we will be changing to the films, every time I go to the pharmacy they give me good old RB Suboxone tablets. Things kinda work like that..it takes longer here... ;)
Cheers!


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PostPosted: Mon Jul 25, 2016 2:24 pm 
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Grant,

I can't say what is good for you, what I can say is what helps me stay stable and not crave any other opiates.

Like you, my first induction was a large amount. (24 mg's) This was back in '10 when the doctors knew very little about the drug and just did what the manufacturer told them. They got mad when I reduced my dose w/o telling them first. But I dropped down to 16 mg's within the first week and stayed there for a few months. Throughout the year I was here learning about Suboxone. I tapered, like you, to 1 mg after maybe 14 months of use. Then I got really sick. (oral cancer) Got off the bupe, (big mistake) took Lortabs which did nothing for the pain, eventually took way more than I should have and went back onto 6 mg's of Suboxone (the film) and have been there ever since.

If you only have the tablets where you are then I'd say take one 8 mg pill per day. When and if the films are available, those can be controlled much easier by cutting them. I take the 2 mg films. One in the AM and 2 in the PM. That seems to work for me and sometimes I take only 4 mg's total if I don't feel good.

So what I'm saying is that it's a personal thing. Don't let the doctor push you down in dosage if you're not ready. Many Sub lifers take one 8 mg dose per day and that is a sufficient enough dose to keep you stable and happy. Only you know what dose works for you. We can't tell you for sure. All we can do is share our own personal stories with you.

The whole purpose is not to end up back on pain pills/or whatever you were taking.

Good Luck!

rule

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PostPosted: Tue Jul 25, 2017 2:28 pm 
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Just wanted to add my 2 cents in case it helps anyone else reading this forum.

I found 1mg at 9AM and 1mg at 5PM to be the perfect maintenance amount for me.

And this is after a lot of trial and error. The twice a day dose is a must and has been since I dropped below 4mg. At one point I attempted 0.5mg twice daily but it was really torture and was my "guilt" forcing my hand to go so low.

I've had bipolar, generalized anxiety disorder(panic, agoraphobia, etc) since 18 years old (now 36) and self medicated with opiates for much of that time. Its the stigma of opiates that causes the "guilt" as I gladly stuff all sorts of "acceptable" drugs down my throat without second guessing myself. But more and more studies are showing the benefits of buprenorphine maintenance in regards to opiate addiction, pain and mental illness so I am trying to not be so hard on myself anymore and just accept that this works.

Sorry for going on a tangent at the end there. I know a lot of people are in the same position reading these posts so I want them to know that for a lot of us a maintenance dose for life should be looked at like any other medicine. If it makes you a healthy, responsible, well functioning person in society then use it and dont be too hard on yourself. *Note-I also take Lamictal 25mg and 0.5mg Xanax Xr
-Steffen


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