On the issue of “treatment failures” with Suboxone…
Yes, they do happen, and are not uncommon.
Usually, the treatment fails the patient because of one of two issues:
1. The medication is not strong enough to effectively block cravings for some people with a history of heavy opiate use. Buprenorphine dosing includes a “ceiling effect” at which point increasing doses have no additional effect. If this happens, the patient should consider switching to methadone –which permits a larger range of dosing options.
2. The medication is provided without adequate supports to a person who is not stable enough in their recovery to successfully hold their own medication. In other words, the patient’s recovery is not stable enough for the patient to take the medication as prescribed and/or withstand the temptation to sell the medication (to pay rent, buy food, or buy other opiates).
In my experience with hundreds of people who have tried medication-assisted treatment, only a small percentage needed the stronger dosing options available with methadone.
What is much more common, is that the person needed additional supports early in treatment before they were able to successfully stabilize in treatment.
For this reason, we added a buprenorphine support program to the range of services we offer at the program for opiate-dependent people I supervise at my workplace.
The support program provides counseling, case management, medication management (pill counts etc.) and drug testing –all provided in a non-punitive, supportive context.
These are the kinds of services you might want to try to have in place, or add if the person seems to be struggling (of course also making sure they are not being under dosed). The closest thing to a standard dose is 16mg/day.
If the person does well, but has a relapse (especially early on), consider taking a wait and see approach. If the relapse continues and the person is unable to self-limit the relapse, the person should consider seeking residential treatment at a facility that will allow the person to continue to take their Suboxone while in residential treatment.
This period of residential treatment (where the medication will be held and administered), is often very effective in stabilizing recovery. In fact, a good way to begin Suboxone treatment is to be inducted (started) while in residential treatment.
This post is based on a comment I wrote at the parent blog A Mom’s Serious Blunder. Read the original post I was responding to here.
{ 7 comments… read them below or add one }
As always, very informative and helpful.
Great Site! I agree. I’m a recovering Heroin/Cocaine addict and I’ve been on Suboxone for almost two years now. I’m almost tapered off of it. I feel like a million bucks! I would try to steer people away from methadone as it is more addictive and painful to get off of but i guess you have a point about a small percentage of addicts that can’t use the Suboxone.
Thanks Mike! Glad to hear you are doing so well in your recovery.
Methadone withdrawal symptoms do tend to be more severe than buprenorphine withdrawal symptoms. But the solution is to taper off of methadone slowly so that the withdrawal is gradual. Both medications have worked miracles for thousands of people, and we are lucky to have them. Tom
hi,
i am 21 years old and i have been on methadone for about 3 years after injecting OxyContin, Hydromorphone, Morphine Etc.
I went upto about 85 MG but had to start splitting my dose, half when i woke up and half around 4pm, because it was wearing off very quickly. my doctor didnt believe me it was wearing off so fast, i have had two different methadone doctors and they said it was impossible.
i have since begun to taper, one 1mg every two weeks, with frequent pauses. it has been about 1 yr, and i am now at 62mg. I am starting to really feel withdrawl symptoms, constant sweating, sensitivity to cold, watering eyes, and EXTREME leg pain ( i have had to leave my university classes a few times beacause of it).
my questions are 1) is it weird how fast my methadone is wearing off, a methadone therapist i once spoke too said some people have a lack of or over abundance of an enzyme in their body that increases methadone metabolization, but my doctor didnt seem to know what i was talking about/care to test it.
2) my doctor doesnt think the leg pains are related to the methadone, even though i only started getting them when i first felt withdrawl from opiates after my first oxycontin binge, and i get them when my methadone starts to wear off (which is now 2-3 hours after i take my dose). are leg pains common?
3) if i am feeling so crappy at 62mg what am i going to do when i get to 10mg, i feel like i will be incapacitated and not be able to go to school. am i right?
4)my doctor suggested switching to suboxone, but she said i can only do it when i am down to 30mg and have stopped taking my methdone for 3 days so i dont go into withdrawls. is that true and should i switch?
thanks for your great site and sorry for the long post.
-Alex
Hi Alex,
Thanks for reading and commenting. To answer your questions as best I can:
1. I know hundreds of people on methadone and the need for split dosing is not that uncommon. I wouldn’t call it weird at all.
I’m not a medical doctor. But there is an answer to your medical question by a great doctor here:
http://www.methadonetoday.org/doctips.htm#Serum
2. Muscle aches are a symptom of withdrawal. Since you say you experience the leg pains when your methadone is wearing off and you are also getting other symptoms of withdrawal, it seems reasonable to conclude that the leg pains are related to your withdrawal. It doesn’t sound like your doctor has offered a better explanation. And I must say it sounds like your doctor is in denial (a little recovery humor there) about the fact that your current dose and dosing schedule is not adequately treating you. Well, if you aren’t going into withdrawal then what’s causing these symptoms, huh doc?
3. Your body will eventually adjust to a lower methadone dose or no dose at all to the extent that you won’t be in acute physical withdrawal. But some withdrawal symptoms last a long time, and more importantly you won’t be getting the treatment benefits of methadone. My concern would be that what will interfere with school at that point is not symptoms of acute withdrawal but unmanageable cravings or relapse. So my question to you is why are you tapering in the first place? Your goal is not to be on the lowest possible methadone dose, but to be on the most effective dose (check out that link, I think you will find the information helpful). Of course, if you do switch to Suboxone, this should prevent withdrawal symptoms if you are at an effective dose (keeping in mind that for some people it is hard to reach an effective dose with Suboxone for the reason mentioned in this post). I get the impression that this taper is doctor imposed more than something you want to do yourself. Has your doctor provided a reason as to why she thinks it’s a good idea for you to taper off of methadone –or why she thinks Suboxone would be a better fit for you?
4. It is true that to switch from methadone to Suboxone you will need to taper down to 30mg and wait a few days after your last methadone dose before you start Suboxone. Your doctor could switch you from methadone to a shorter acting opiate like morphine before transitioning you to Suboxone, and then you would only need to wait 24 hours instead of 3 days. I don’t have enough information to have an opinion about whether you should switch to Suboxone. I would ask your doctor for her reasoning and see if it makes sense to you. Let me know what she says and I’ll try to help you think it through.
Also, it doesn’t sound like you go to a methadone clinic, so is part of what this doctor is treating you for pain?
Hang in there…it’s worth figuring this out and getting it right.
Tom
Good to see a telant at work. I can’t match that.
Suboxone treatment is nothing more than drug replacement. The brain remains in the diseased state until the drug is removed. Addicts do not make changes out of comfort. Suboxone, methadone, heroin; no difference. I’m an addict and I couldn’t stop until I suffered the pain of recovery. Once I found my way through the pain my life changed for the better. All recovery has a low success rate so cold turkey is no different. I stopped smoking after I stopped nicotine replacement. Putting off the pain of change will make no changes. Stop procrastinating and embrace the pain. As long as there is suboxone doctors and drug companies to provide they will make money off of you!