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DETOXING FROM METHADONE WITH SUBOXONE: A STEP-BY-STEP GUIDE
What is Suboxone?
Buprenorphine is a semi-synthetic partial opiate agonist that's been around for quite a while, although it was only recently approved for 'opiate dependency treatment' in 2002 in the United States.
It's sold in two main forms: Suboxone, which is a mixture of 4 parts buprenorphine to 2 parts Naloxone, and Subutex, which is pure buprenorphine. The most common form of these medications are sub-lingual (under the tongue) tablets, while newer patented films have recently become available, along with much controversy, because many people believe that these films contribute to drug abuse and illicit 'diversion' of buprenorphine.
I don't have the space to give the complete history of buprenorphine. There's tons of information on the internet, and I've included a few links below. For now, I want to focus on using this medication as a tool to transition from long-term methadone use, with the ultimate goal of complete methadone withdrawal.
When You Should Use Buprenorphine
While I don't usually recommend Suboxone (buprenorphine) for most types of opiate detoxes, there's two instances where it's a very useful tool: for a quick detox from short half-life opiates like oxycodone, hydrocodone, or heroin (not more than 12 days), and to transition from methadone, for a 'softer-landing.'
Suboxone ('Sub'), if used correctly, can be a 'stepping-stone' between detoxing from methadone and being completely opiate free. You must be careful though, because Sub is an addicting opiate with a very long-half life, and it has a nasty withdrawal of it's own, although it's not as bad as methadone.
The Two Keys to Transitioning From Methadone
There's two keys to correctly doing a methadone-buprenorphine transition: proper methadone tapering and a proper buprenorphine 'induction'. There's a lot of misinformation about this, and even many doctor's are misinformed when it comes to this scenario.
You must taper to at least 15 mg/day of methadone or BELOW if you want any chance of a smooth transition to Sub. This is because unlike traditional opiates, buprenorphine can actually cause a severe withdrawal if there's high levels of full-agonist opiates in your body. So make sure to taper to 15 mg/ day or below. Some people say you can taper to 20 mg/day of methadone and still be okay.... but I'd stick to 15 mg or below just to be on the safe side.
You can read more about how to taper from methadone in THIS HUB.
Then you have to wait at least 36 hours after your last methadone dose before you begin a buprenorphine induction. The longer, the better. Some people even wait 48 or more hours after their last methadone dose. The main point is that you must at least be in the beginning stages of opiate withdrawal before you take Suboxone or Subutex for the first time. If not, you can precipitate an acute withdrawal. Since the half-life metabolism of methadone is so variable among the population (due to variations in certain enzyme conversion systems), it's hard to give the exact time to wait after your last dose. Just make sure that you're in the beginning stages of a methadone withdrawal.
Like I mentioned before, the second key to a successful transition is a proper Suboxone 'induction'. The Suboxone induction usually lasts about 4 days, and it's the phase where you transition from methadone to buprenorphine. The doctor will attempt to adjust and gauge your Suboxone dose during this time. Unfortunately, many doctors are still misinformed about Suboxone and have a tendency to 'over-prescribe' as a result.
Unlike regular opiates, the key rules to keep in mind with Suboxone are "less is more" and "go slowly" at first. Your optimal dose is the lowest possible amount of medication that can 'block' withdrawal symptoms. If you take too much, too fast during a buprenorphine induction, you'll risk precipitating a nasty methadone withdrawal.
While I can't dispense medical advice, I personally found that any more than 6 mg/day of Suboxone could cause a bad methadone withdrawal during the transition. If you doctor is prescribing high doses (8-32 mg/day) during the first few days of induction, you'll probably run into trouble.
Don't think that you'll feel better by taking more. Chances are that you'll still have a rocky transition no matter what you do. Most people switching from methadone to buprenorphine will experience some discomfort for the first 3 days (and especially NIGHTS) of the transition. While it won't be as bad as a straight-up cold-turkey methadone withdrawal, it's still somewhat intense.
Even if you follow the 'start low, go slow' rule, you may feel some discomfort about 1 hour after you take your first few Subxone doses. This may be due to a slight 'precipitated' opiate withdrawal caused by the buprenorphine. However, this discomfort will usually subside after a few hours.
My doctor prescribed 16 mg on the second day of induction and it was way too much. Within 10 minutes after taking this dose, I practically collapsed on the street and had the worst panic attack of my life. Luckily, I was able to find a taxi (after what seemed like an eternity), and make my way home to bed.
So I immediately lowered my dose to 4 mg/day and it took me about 1 week to stabilize and 'feel like myself,' despite the terrible headaches.
The Mechanics of Tapering
You'll want to stick with Suboxone for a while and then you'll need to taper down after a designated time.
Unfortunately, a bupenorphine taper isn't so easy because of the long-half life and deceptive nature of this drug. Many people won't even feel a dose reduction until 48-72 hours later, so it can be difficult to gauge a taper schedule.
How long you stay on Suboxone depends on a lot of things: the amount of time you were taking methadone and your daily dose level, your schedule and finances, and your personal tolerance for discomfort.
If you have the time and money, try to taper for at least 45-60 days or more.
One example of a good taper schedule is to taper by .5 mg (use a pill splitter) every 5-7 days. The problem starts when you get to below 1 mg/day of Suboxone, because many people will start to feel a lot of discomfort at this point.
When you get down to about .5 mg/day, you may want to dose every-other-day at this point for a few weeks until you're ready to stop. Some people even dose with .25 mgs at this point, which is just a tiny 'crumb' of buprenorphine.
After you stop, you probably wont feel any withdrawal symptoms for 3 days. The withdrawal from buprenorphine is somewhat difficult and long, but not as bad as methadone.
If you're going cold turkey after a precise and well-executed Suboxone taper, you'll probably experience about 14-16 days of a semi-acute and drawn-out opiate withdrawal, complete with insomnia and nighttime restlessness and cravings.
The second phase of a Suboxone withdrawal lasts about 15 more days, and it's less intense. The cravings, insomnia and fatigue will gradually subside. By the 30th day, most people will be feeling a lot better, although some people may experience varying Post Acute Withdrawal Syndrome (PAWS) symptoms.
PAWS is a big topic that I hope to discuss in future hubs. There's a lot of good information out there, but I like to focus on some less-known and highly-effective treatments for PAWS. You can read a little bit more about how you can treat PAWS in THIS HUB.
Personally, I was on low-dose Suboxone for about a year (about 2 mg/day or less), and I didn't really like it. It gave me a lot of headaches, caused depression and fatigue if I missed a dose, made me feel 'speedy,' caused some cognitive impairment ('brain fog'), and generally made me feel 'sleezy.' For these reasons and more, I tried a cold-turkey detox from Suboxone against my doctor's orders, and it didn't work at first.
I finally achieved success when I researched and perfected my own personal detox method, ignored all the doctors and so-called 'experts', and quit by myself.
How To Get Off The Ladder of Addiction Once and For All
So we've learned that there's really only a few basic steps to using buprenorphine to transition from methadone. While the steps themselves are simple, actually executing them is more difficult.
The things to keep in mind are to comfortably taper to 15 mg/day or below of methadone, THEN do a proper Suboxone induction and THEN do a proper Suboxone taper.
Keep all these things in mind, and you'll have a much better chance of success.
Wishing you the best on your recovery.
Basic Info on How To Taper From Buprenorphine
This video has some quick and basic info on why a Suboxone taper is different from other opiates and some useful tips on how to proceed.
Helpful Info About Buprenorphine
SAMHSA works to improve the quality and availability of substance abuse prevention, alcohol and drug addiction treatment, and mental health services. Includes links to support groups, information resources, events and articles.