But Discontinuation Syndrome ??? Studies

Buprenorphine Post
Posts: 267

Postby peterorrin » Tue Dec 20, 2016 2:54 am

Re: duration of Bup withdrawal varies from fast to never...average to zero is several months by mutual agreement. One of my patients is a parochial school teacher with a young family. He has been on suboxone 1 mgm for a year. He does not go to more than 2 self help meetings/month. Another patient is on bup 20mgm who states he wants to remain on it for 'security' and pain relief...all signs indicate he is in 'full recovery'. I have been prescribing bup for 14 years, and more pts are off MAT than remain on it. I think some who remain on low/high doses seem to enjoy the structure of meeting with the doctor and/coming to group (many arrive 20-30 minutes early and socialize in my parking lot; timing of the group meeting make it possible for them to attend a follow up self-help group--alone or in pairs. This is helpful for newcomers.


Posts: 32

Postby mattkeene » Tue Dec 20, 2016 2:54 am

I'm not sure that the Zubsolv 0.7 mg will really meet your needs. Recall that 0.7 mg Zubsolv is approximately 1 mg of Suboxone (purportedly due to better bioavailability). Zubsolv tablet are so fragile, that I can't see how one could cut them into quarters without most of the medication turning to dust

Posts: 1404

Postby drpasser » Tue Dec 20, 2016 2:54 am

Most recently, Zubsolv is now offered in an ultra low dose, which I think is great. I think it's 0.7 mgs of buprenorphine. I plan to use it when needed for pts having trouble taking less than 0.5 mgs/day, i.e. a quarter of a 2 mg size.

Posts: 66

Postby jhartdo » Tue Dec 20, 2016 2:54 am

The difficulty in going from 2 mg to zero, is not a matter of milligrams but a matter of receptor numbers. At 2 mg, buprenorphine still has command of a large number of receptors. Compared to 16 mg, the percentage is small but when compared to 0 mg, it is significant. I think of the normal brain as having a full supply of dopamine. At 1 or 2 mg the drug is making up for that deficit of dopamine. The buprenorphine discontinuation syndrome is simply the brain saying "where's my dopamine".This is similar to the smoker lighting up the next cigarette or the addict reaching for the next pill. It is chemistry. The advice given in this column is very good. At low dosages go small and slow in reduction.

Posts: 1404

Postby drpasser » Tue Dec 20, 2016 2:54 am

Generally, withdrawing from buprenorphine is exactly like withdrawing from other opiates. It's opiates in general folks are withdrawing from. Because of bupe's longer 1/2 life, it can be a bit more gradual. But it is the same as other opiates, for which people are dependent. If a pt is used to taking 20 Lortabs/day and they are tolerant to that and then, they are switched to bupe and stabilized; then one or two weeks later they stop the bupe-they will say the bupe wdrl is just as bad as hydrocodone wdrl. But it's opiates in general causing wdrl, bupe is merely substitution tx.

B/C bupe is a mixed agonist-antagonist and has a ceiling effect; it is easier to become stable on a set dose and then taper off than the full agonists. So, the key is to slowly taper off the bupe while allowing the opiate receptors to reach a new, lower equilibrium; much like occurred in reverse when the person developed their tolerance. As such, one can see how it is much easier stopping bupe from a stable dose of one mg/day compared c 16 mgs/day.

It can take a long time. Some pts are never able to come off the bupe. In my experience, those are pts c comorbid probs c pain, depression and anxiety. The other factors which seem to influence the length of treatment include the pt's daily dose of opiates, the potency of the opiate, the route (IV > PO), the length of time c the problem and family Hx.

Many consider Opiate Use D/O to be a chronic disease. Outpatient based opiate replacement therapy with buprenorphine is Harm Reduction.


Posts: 32

Postby mattkeene » Tue Dec 20, 2016 2:54 am

My norm is to gradually taper far lower than the 2 mg dose every few days. I have far greater success having patients cut the 2 mg tabs or films into 1/4s or even 1/8s as a means to gradually reduce. The one interesting observation that I have found (though my n is still quite small), is that patients seem to have less post acute withdrawal when tapering Bunavail. Scientifically I can't explain that...but I have "seen it" several times.

Posts: 183

Postby MChaplin » Tue Dec 20, 2016 2:54 am

two observations- getting down to a daily dose of 2mg does not seem to be difficult for most motivated patients- but coming off that last 2mg can take months and lots of patience- I recommend 2mg every other day then every third day then every fourth etc Also- once off, tolerance is LOW and small amount of full agonist can be deadly

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Postby kcairns » Tue Dec 20, 2016 2:54 am

doubt will find, all individual, and what matter as will be what will be

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