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Metabolizing buprenorphine too quickly

Posted: Tue Aug 02, 2022 9:46 pm
by Metabolized
I have a long backstory, like many I'm sure. I will try to keep it to the pertinent points. Please forgive the length.

I'm 41. In my early twenties I used opioids recreationally. In my mid-twenties I was put on buprenorphine and temazepam (a benzo). By my late twenties I decided I needed to get off these meds. After a long hard fought detox that took two attempts and three months inpatient I was free of opioids and benzos. I spent 6 years or so opioid and benzo free, entirely sober for most of that time, and I attended AA. During this time the only medication I took was gabapentin.

At 35 I relapsed. I used opioids for a couple of years. At 37 I got back on buprenorphine and was prescribed valium. The valium turned on me quickly. I started metabolizing the medication faster than I was supposed to take another dose. This left me in a state of half-withdrawal during the day. These interdose withdrawals were painful and troubling. I tried tapering off of the medication, but because of the interdose withdrawal issues it was too painful.

By age 38 I found a clinic (The Coleman Clinic in Richmond, VA) that offered an accelerated benzo detox program. It takes a week, they put you on lyrica, baclofen, and phenobarb, then flush your system with flumazenil (a benzo antagonist). There's no anesthesia, they don't put you under, its just a constant low dose of the flumazenil that takes a week.

The detox worked, I was off of benzos. I was really amazed at how well it worked. By this time I had become dependent on the gabapentin and the lyrica. I was taking buprenorphine, gabapentin and lyrica daily. Soon I began having the same problems with the gabapentin and lyrica that I had with the valium...interdose withdrawals. I was taking large doses of the meds (300mg of lyrica, 2400mg of gabapentin). It became clear that I was going to have to get off those meds as well. I was able to complete a long slow taper. It took a year, but I got off of the lyrica and the gabapentin. I had problems with baclofen as well.

By age 39 I started having real problems with the buprenorphine side effects. My stomach was always upset, horrible constipation and diarreah. I also felt slightly in withdrawal. I never felt right, I felt much better in my time spent opioid free. I decided I needed to try to get off of the buprenorphine. I started a taper, got from 8mg to 5.5mg. The taper was proving to be very time consuming and painful. The Coleman clinic I mentioned above also offers an accelerated buprenorphine detox. I decided to take advantage of it. This is not the accelerated detox where they put you under, it's a 10 day detox. They provide very small microdoses of naltrexone, starting at .1mg, then slowly increase it day by day. They put most patients on tramadol, clonidine, valium, lyrica and baclofen to deal with the withdrawal pain. Because of my history I could only take the tramadol and clonidine. I made it six days into the detox before giving up. Even with the tramadol I couldn't take the precipitated withdrawal from the naltrexone. I am aware that tramadol itself is a weak opioid, they only give it to your for the first several days, to ease the pain, then ween you off of it. I stayed off of buprenorphine for a few more days, then gave up and started taking it again.

My initial plan was to go back on buprenorphine at a very low dose and pick up the taper from there. At first 1mg/day was enough. After a week though I had to raise the dose to feel okay and get some sleep. I raised it to 1.5mg, then after a week had to raise it again. This happened over and over. I went from 2.5mg, to 3.5mg, to 4.5mg, to 6mg. Every time I would raise the dose by about a milligram I would be okay for about 3-4 weeks, then slowly I would start needing to take more in order to get any sleep and not feel terrible during the day. As it is I take 5mg at night before bed, then wake up about 4 hours later needing to take another 1mg to get back to sleep (I often fall asleep with the 1mg in my mouth which is causing dental problems), for a total of 6mg. Even this isn't really enough. I wake up feeling terrible, I have terrible stomach issues, sweaty, awful anxiety. I don't know what to do.

I am afraid I'm never going to be able to stabilize on the buprenorphine again. I don't know what to do. I think I've caused a kindling effect in my brain with the buprenorphine by trying that detox, and now I don't know if buprenorphine is ever really going to work for me again. The only idea I have left is to try to detox again. But I can't afford it. I really need to go back to work for a little while to make some money. I've been out of work for a while because of the withdrawal symptoms and one other issue.

Has anyone ever heard of this happening with buprenorphine before? This interdose withdrawal issue, not being able to stabilize on a dose? It's not uncommon with gabaergics like benzos, but I can't find anything online about it happening with buprenorphine.

Any ideas or advice would be welcome. I just have no idea what to do, I'm very lost. My doctors don't seem to know what's happening, they just keep saying to raise the dose, but every time I raise the dose it's only a matter of time before the withdrawal symptoms come back and I have to raise it again. I can't go on like this forever, eventually the dose will get too high and I won't be able to raise it anymore. I know I've heard of people being on very high doses of the med, but I've never needed more than 8mg. I'm very afraid that I'll never stabilize.

I apologize again for the length of this message. I'd love to hear any input. Thank you!

Re: Metabolizing buprenorphine too quickly

Posted: Thu Aug 04, 2022 11:42 am
by rule62
Yours is a very troubling story and not one I feel competent to comment on. Being on 1-2 mg's daily myself it is always enough and I never feel withdrawal. The only time I did was when I forgot to dose on a day I took 1mg and by the evening my mood was bad. An hour after dosing I was fine.

Sleep is another issue which I am surprised your doctor hasn't prescribed something else to help you. Trazadone is a common drug used to induce sleep. Taking more buprenorphine seems to be making the problem worse. What I'm hoping for is one of our two doctors to comment on your case being they are both experts on buprenorphine. Unfortunately, this site is slowly getting less and less posts. Not sure how often they check in to view posts. Me being one of the last moderators here I do try to check daily and give a comment as often as possible. But I am only a member who's been on Suboxone since 2010 and most of the knowledge I've gained has been from this site. Can't recall a similar issue like yours being discussed here before so there isn't much more I can say.

Maybe try to find a doctor who knows more about buprenorphine. All the doctors I've come across have limited knowledge about the drug. My own doctor doesn't listen or believe anything I try to tell him about it, but he is good about prescribing so I can't complain.

Sorry I couldn't be of more help.

Re: Metabolizing buprenorphine too quickly

Posted: Fri Aug 05, 2022 2:54 am
by Metabolized
Sorry, I should have mentioned I do take zyprexa for sleep, 5mg. I also continue to take clonidine, .3mg a day, to help with these interdose withdrawals and for sleep. The zyprexa and clonidine do help, but when I wake up in the middle of the night with withdrawal symptoms, nothing really gets me back to sleep except for taking a little more buprenorphine. When I finally actually do get up in the morning I feel pretty awful.

I spoke to my doctor yesterday. He said to raise the dose again, take 8mg at night and 2mg in the morning. I'm going to try it, I just have the feeling that eventually that won't be enough. It may be days, may be weeks. I am going to really try to keep to this schedule, 8mg at night, 2mg in the morning. I'll post here again after a little while and let you guys know how I'm doing.

Until then, any input is welcomed. It is too bad it seems traffic on this board is in decline. I posted on reddit too, but haven't had much in the way of response there either.

Thanks again!

Re: Metabolizing buprenorphine too quickly

Posted: Fri Aug 05, 2022 7:05 pm
by rule62
As you probably already know, buprenorphine has a ceiling effect. It's either 8 or 16mgs. A quick search here will tell you. Once you have hit the ceiling, you're wasting the medication. When you hit the ceiling, it takes around 36 or so hours to wear off. That's why people who stop cold turkey from really high doses won't feel any withdrawal until it finally wears off. There was one member here who went almost a week before the w/d's kicked in. Sorry, got sidetracked there. Still can't figure out how you can have withdrawals from whatever dose you're on. I'd go for the 8-12mgs per day dosing to make sure it doesn't happen. That high of dose should keep you feeling okay. If that's what it takes to live a normal life then what choice do you have? And you obviously have a sleep disorder to deal with. You might want to see an expert about that. Before you ever took any drugs, did you have trouble sleeping or staying asleep? Still no idea what to tell you except to talk to doctors who know more than us.

Re: Metabolizing buprenorphine too quickly

Posted: Sun Aug 14, 2022 1:47 am
by TeeJay
A couple of things could be going on here.

Perhaps because of practicing abstinence based recovery, you're coming from the angle of "less is better" in terms of dose. I understand this as I did it myself for a long time. I've also had issues with rapid metabolism, especially while I'm on certain mood stabilising medications which I swear increase my rate of sublingual bupe metabolism.

Suggest you increase your dose until you no longer feel it wearing off throughout the day. You may need a higher dose than others. Livers do vary.

Another pitfall is comparing what it feels like being on Buprenorphine to being in an abstinence based recovery. I've also done both and I admit that life does often feel better when I'm medication free, mostly because of less side effects. I consider abstinence based recovery to be "high risk high reward". High risk because of significantly increased mortality and relapse risk, higher reward because of less MAT side effects and generally feeling proud of being opioid free. I'm a recovery realist these days which is why I'm okay being on MAT.

Perhaps look into Sublocade because being a depot formulation, and because of bypassing first pass metabolism, I've found there's less issues with rapid metabolism with it. Also many people are finding Sublocade actually helps them come off buprenorphine if they so choose because it slowly reduces in effect over many months when you stop taking it.

Good luck!