Buprenorphine Caused Opiate Withdrawal in Clinical Trial, Part II
I can’t stop thinking about it. The other day we talked about a guy on buprenorphine who saved up his pills and tried to return to maintenance after a heroin relapse by taking 11 8-milligram pills only to find himself smack in the middle of a nasty opiate withdrawal.
If he took Suboxone—a combination of buprenorphine and naloxone—without waiting for withdrawal symptoms to kick in first, then that makes sense. When you’re already strung out on prescription painkillers or heroin and are ready to detox, the doctor will most likely start you on Subutex first or wait for withdrawal to start before switching you over to Suboxone with the express purpose of helping you avoid an onslaught of withdrawal symptoms. According to the Associated Press article, this man continued to take buprenorphine after the first handful of pills and yet the symptoms still did not subside.
What The Experts Have to Say
In the article, they have this comment:
“When buprenorphine is taken soon after opiates with less opiate-receptor affinity, such as heroin and methadone, it displaces them from the receptors. Since buprenorphine is only a partial agonist, this causes a drop in the level of overall opiate activity and is experienced as opiate withdrawal. While we are aware of only three other reported cases of buprenorphine-precipitated withdrawal after heroin use, it is common in methadone patients transferring to buprenorphine therapy, particularly with higher doses of methadone (> 40 mg), a short time between the last methadone dose and the first buprenorphine dose and when higher initial buprenorphine doses are used. Withdrawal symptoms typically commence within 1–3 hours of the first buprenorphine dose and can last for several days.”
What This Case Shows About Buprenorphine
First, it shows that you can take 88 milligrams of the drug and not die. The highest dose prescribed is 32 milligrams, so that’s almost three times as much, and there was no respiratory depression to speak of. Considering that’s the problem with opiate overdose, that’s good news for those on buprenorphine who can’t be rescued from respiratory depression by naloxone. So here’s more evidence on the ceiling effect of buprenorphine, that you don’t “feel it” per se even when you increase your dose. I’ve heard people say that it doesn’t feel like they’re taking anything at all, no matter what dose they’re at.
This case also shows that repeated doses of buprenorphine doesn’t help matters any, since his withdrawal symptoms didn’t subside with multiple doses. Maybe his dose of heroin was too high. And his initial dose of buprenorphine was definitely too high. But this, too, is an interesting fact to ponder.
Okay…. Discuss!
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June 25th, 2008 at 2:45 am
I have a theory about this situation, based on my own experience with Suboxone.
I think that at high doses, Suboxone just makes you feel sick in a way that mimics withdrawals. I noticed this when I was first on Suboxone and my doctor was adjusting my dosage. I was in a research study, and it was difficult for him to know exactly how much (if any) buprenorphine I was getting from the implant in my arm. A couple of times, after I had supplemented the implant with oral Suboxone, I got sick (chills, sweats, yawning, leg aches, runny nose) and when my dose was lowered I felt better.
Of course, I have no idea why buprenorphine works this way - but I have heard tell of others who have had a similar experience. It’s such an interesting drug, isn’t it?
October 7th, 2008 at 6:29 pm
precipitated withdrawal occurs when one takes Sub without being in at least moderate to full w/d. Higher affinity means it knocks off whatever is bound to the receptor. It being a partial agonist however makes it more difficult to replace what’s been bounced off. Precipitated withdrawal is VERY difficult to reverse without throwing someone back on what they were trying to get off and at a much higher dose,(risking resp.depress./death). This is not part of the “protocol” so the addict is left to suck it up and wait it out. this is a nasty experience and will turn someone who probably needs it totally off to Sub as a recovery tool. The symptoms of Sub at too high a dose is not actually w/d, it is a condition called hyperalgesia….too much analgesia…same with too much tylenol or IBU. With Suboxone, it’s hard for us pill poppers to believe that actually, less is more.
November 11th, 2008 at 10:17 am
I totally agree with valerie, it is hard for opiate users to think less it more, but after a detox center where they PUMPED me full of subutex, i ended up relapsing and a month or two later i acquired 12mg of suboxone and was able to detox myself, and felt 20 times better then at the clinic. Thats 12mg bupe compared to the detox center where i got 4mg the first night, 16mg the first day, 12mg second day, and 4mg the third, then they gave me another 4mg to take home!!!!!
WAAAAAAY to much if i woulda known i woulda cheeked like 75% of those meds and either tossed em or saved em in case of a problem later on!
But yeah, i take the smallest doses of subutex and it works great!!