Stretching dose until refill: Can sublingual be halved?

What dose of Suboxone do you take? Does your buprenorphine wear off? Do you have opioid withdrawal symptoms?
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JennyB
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Stretching dose until refill: Can sublingual be halved?

Post by JennyB » Thu Jan 24, 2019 2:32 am

Hey everyone
Is it possible to break/cut/half the 8mg Suboxone sublingual tabs?
It’s almost my 4th week being on Suboxone (yay!) I’m on 8mg 2x a day. Because of my chronic pain condition, I ended up taking extra some days when the pain was really bad. I took an extra 8 mg as a “breakthrough” in between the other regular doses. It worked but I doubt I needed the entire 8mg. Not sure how much extra would work?
I couldn’t go see my doc to discuss first and change anything because she’s on vacation until the 28th.
Now I don’t have enough left to take my 8mg twice a day dose. Aghhh! So mad at myself that I did this becasue it reminds me of running out of my DOC script major early and that addict behaviour however I’m also on Suboxone for pain control.
I’m short full doses for 2 days until I see her. I would have only 8mg a day for 2 days when I’m used to 16mg a day. I plan no to take anything the morning of the 28th and just go see her.
I’m trying to figure out my plan but need to know if I can cut the tab in half?
Thanks!
JennyB

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Re: Stretching dose until refill: Can sublingual be halved?

Post by BlueLight » Thu Jan 24, 2019 7:12 am

Yes, you can cut the tab in half and I doubt you’ll feel any withdrawal given the 37+ hrs of half-life of buprenorphine. I can usually make it 2 full days without, no problem. There is also using a different ROA that increases the bioavailability of buprenorphine but I’m loathe to encourage that method. But if you’re desperate.....

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Re: Stretching dose until refill: Can sublingual be halved?

Post by razor55 » Thu Jan 24, 2019 7:43 am

Jenny, just take the 8mgs daily that you have left for thoses last two days. It ll be enough to get you though till your next dr app. At 8mgs your well over the ceiing effect and the long half life is in your favor also. If your dosing twice a day then go ahead and split the tab in half. But the whole tab at 8mgs will get you though those two days....

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Re: Stretching dose until refill: Can sublingual be halved?

Post by jennjenn » Thu Jan 24, 2019 8:50 am

You can definitely cut the tablets in half, it won’t hurt the tablet. I also agree with the others that 8mg a day for two days is totally fine. Other than maybe psychological, you won’t feel any withdrawal. I know it’s got ya worried but trust us, 8mg will work like a charm :)
Jennifer

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Re: Stretching dose until refill: Can sublingual be halved?

Post by Lillyval » Thu Jan 24, 2019 8:55 am

Also, now that you know that you can split them, when you get your new script start taking your 16mg in 3 doses. That way you can increase your pain control without increasing your dose.

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Re: Stretching dose until refill: Can sublingual be halved?

Post by JennyB » Fri Jan 25, 2019 1:32 am

Thanks for the great advice everyone!
Jenn you’re right it does have me worried because I go into withdrawal so quickly (in the past within a couple hours and it’s not good)
I bought a pill cutter today and will halve the 8 mg and take it that way for sat and sun. That way I can take it in 2 doses and at least psychologically I will feel better.
For example today I took my first dose at 9am and I was out until 10pm without taking my 2nd dose and I was feeling squirrly at about 8pm just like I did on the oxy. I didn’t have pain during this time, just agitated, shakey and fatigue. I’m guessing it was psychological even though the physical symptoms were there and I just wanted to get home to take my dose. Of course I’m feeling just fine now. Addict behaviour?
I need to read the chronic pain section again and see what others are doing. It is hard to wrap my brain around the concept that “less is more” and that splitting what I take (16mg/day) into 3 doses instead of 2 will give me MORE pain relief rather than adding another couple milligrams.
I realize that once you hit a certain dose there is no more effect, but I thought everybody’s “ceiling” is different? That it’s the point at which you feel no more withdrawal? Or is that just during induction?Aghhh! lol This drug is sooo different than any other and there is so much to learn!
I’ll say it again...So So happy this forum exists
Thanks a million everyone!

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Re: Stretching dose until refill: Can sublingual be halved?

Post by BlueLight » Fri Jan 25, 2019 9:26 am

Although the overall half-life of buprenorphine is around 37 hours, the pain control portion of the molecule is from 4 - 6 hrs. So if you are taking for chronic pain, you should split your daily dose into 3x daily dosing. I suffer from chronic pain, and this was one of the reasons I never thought I could get off regular opiates. When I first inducted, I was on 4 mg at 6:30 am, 2 mg at 12:00 noon, and another 4 mg at 6:15 pm for 10 mg per day total. For me the pain control is around 5 1/4 hrs.

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Re: Stretching dose until refill: Can sublingual be halved?

Post by jennjenn » Fri Jan 25, 2019 10:12 am

Hey JennyB!

The thing about the ceiling level, imo it can be a little bit different for ppl. Like myself, I feel like my ceiling level is around 6mg..... after 7 years I trust myself enough to know that. Others have said their ceiling is around 4mg, others have said 6mg and even 8mg...... so basically I always say that the ceiling is anywhere from 4-8mg. Some doctors tell us the ceiling is 4 but once you start talking to ppl who have personal experience, it’s a bit different for different ppl. Regardless it should never be above 6-8 mg no matter what.

When I first started my induction, I remember getting my medicine out of the pharmacy and returning to my doctors office, I looked at the other patient doing an induction the same day as me and said..... this sure is low milligram pills! That’s the first time I was explained that this medication isn’t really like regular opiates at all. I knew it was different but I didn’t really comprehend how different it was. Lucky for me, the person I was sitting with as they did their induction too, they explained a lot of things to me that only a patient can explain, someone with personal experience. The person I was talking with had been in suboxone treatment before and was a return patient so they knew a lot more than I did. I honestly think it’s so important to talk with other patients, it’s so helpful.

Oh and you were talking about psychological symptoms, these symptoms really do feel so real! I’m not saying yours is all psychological but I know from experience that it can make ya physically feel all kinds of things. I get worried about things a lot and my stomach can get in knots, it’s really amazing to know my nervousness and worries can cause such pain.
Jennifer

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Re: Stretching dose until refill: Can sublingual be halved?

Post by BlueLight » Fri Jan 25, 2019 11:12 am

I felt no withdrawal tapering from 10 mg to 6 mg. I spent 2 months at 8, then 3 months at 6 mg. I did though from 6 mg to 4 mg. I’ve been trying this week to get to 2 mg, but that’s a jump too fast. I’m doing ok though at 3 mg. I’ll stabilize at 3 mg for the next month or two before trying to get to 2 mg.

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Re: Stretching dose until refill: Can sublingual be halved?

Post by BlueLight » Fri Jan 25, 2019 11:16 am

I know a lot of my fellow recovery addicts have tapered from 20 mg or 24 mg down to 10 mg or 12 mg with very little effort. They were all heroin users. I “only” abused Oxys and Fent. Not sure if that’s the difference in their need for more Suboxone. I also was very adamant about starting on the lowest dose possible.

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Re: Stretching dose until refill: Can sublingual be halved?

Post by Amy-Work In Progress » Mon Jan 28, 2019 8:53 am

(I'm sorry Jenny, because I'm not really answering your original question with my post. Forgive me for going off on a tangent.) :)

I try to stay away from recommending what dose people should be at because it is so variable. I also don't think that there is any harm to being at a fairly high dose. I think that there are people who need to be on a higher dose for psychological reasons, and if it works for them, who am I to say that they are on too much.

As Bluelight and others have said, it's fairly easy and straightforward reducing your dose from 24mg to 10mg. Being on a high dose for a length of time is not going to make it physiologically more difficult. That's not the way it works.

Also, I'm starting to think that all of this worrying about being at too high of a dose and starting at too high of a dose is, at least partially, from an "abstinence only" mindset. The folks who are most worried about getting on too high of a dose, do not really feel like they should be on it in the first place. They are worried maybe that they will become too dependent on the medication to really get off of it and be completely "clean". We hear this fear echoed around the forum often. Despite knowing some basic things:

1. As long as you are slow and steady with a taper from about 8mg and lower, you can go ahead and follow a plan to get off buprenorphine. We know this because we've seen it happen here.
2. Medication Assisted Therapy is the only intervention that is scientifically proven to prevent relapse and overdose death in those with Opioid Use Disorder.
3. Abstinence based interventions/treatment do not work more than 5 to 10% of the time. And that is after multiple attempts!
4. It used to be considered the fault of the individual with Opioid Use Disorder if they relapsed. (Because if it was the treatment's fault, how could those inpatient rehabs justify charging so much?) We were told this in 12 step meetings, we were told this in treatment.

We are STILL affected by this false opinion to this day. If we can't make it to being abstinent, it is our fault! We have so much guilt from thinking that our addiction is our fault, that we can't fathom a future where we are allowed to take a pill everyday to avoid relapsing!

This thought that we have to be abstinent to truly be in recovery is one of the major drives to stay at a low dose, whether it is our optimal dose or not.

We should be asking ourselves this question. If I had high blood pressure would I try taking a lower dose of medication that doesn't really work at bringing down my blood pressure down in a bid to someday be abstinent from that medication? My answer is "no". I might try behavioral changes that might help lower my blood pressure. But my motivation would not be to get off of the medication that was preventing damage to my circulatory system! My motivation would be to be as healthy as possible.

There are good motivations for being at a relatively low dose of buprenorphine. Not wanting to feel overmedicated. Finding that your best therapeutic dose is a low dose. Avoiding annoying side effects, etc. However, we should not be worrying that we aren't really in recovery if we're on medication!

We shouldn't be operating out of guilt leftover from an era that blamed addicts for their addiction. We have enough guilt from our own actions to go around. We don't need to feel terrible for taking the medication that treats our disorder.

I know this was kind of a rant. I don't even remember what exactly triggered it, since I started writing this yesterday. I think it's a good reminder for us, though.

Amy
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Re: Stretching dose until refill: Can sublingual be halved?

Post by Lillyval » Mon Jan 28, 2019 10:33 am

The ceiling is the dose at which the maximum opiate effect from buprenorphine is achieved. It’s confusing because it really doesn’t have anything to do with withdrawal. Dr. Junig has said that a maintenance dose of bupe is roughly equivalent to 60mg of oxycodone in opiate effect. Whether you’re taking 4 mg or 24mg you will have the same opiate effect. So people transitioning from high doses like 180mg oxycodone per day are going to go through a period of WD in order to adjust to Suboxone.

The dose does effect one’s blood serum level, and the total amount in the body at a given time. When you take a single dose of Suboxone you get a peak blood level, and then it falls over 24 hours. This is fine for most people, as long as they don’t fall below a level that will put them in WD before the next dose. When you break your dose into 3 doses, the initial peak is not as high, but you keep bumping your blood level up each time you dose. This has been found to be effective for pain management. But no matter how much you take, you never get more opiate effect than 60mg of oxycodone.

To Amy’s point, the fact that you’re on a higher dose right now doesn’t matter in the long run. Many people need a higher dose when they start, or continue to need a higher dose because of their metabolism. One time I stated on a thread that when I go off at least I’m only on 3mg. But Dr. Junig replied that it doesn’t make any difference. I’m probably about at the ceiling, so I’m tapering off the same opiate effect as someone at 16mg. I know it’s very confusing. People can usually go from 16 to 12 to 8 to 4 with essentially no symptoms. But everyone’s real tapering process starts between 4 and 2mg.

Even most doctors don’t know this. We are super lucky to have Dr. J and this forum. These are the exact words he wrote to me “If you need to stop buprenorphine at some point, you will manage it. But for now-- try not to even think about it. Taking an effective medication once or twice per day is a good exchange for living with addiction.”

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Re: Stretching dose until refill: Can sublingual be halved?

Post by JennyB » Tue Jan 29, 2019 2:27 am

Hey All,
I’m happy to report that I had absolutely NO physical withdrawal symptoms the last 2 1/2 days going from 16mg (my usual dose) on Friday to 8mg/day Saturday and Saturday and no med until 7pm this evening (Monday) until I got my refill.
I was so worried until I made the initial post and was educated by everyone!
This afternoon waiting to see my Dr. I had psychological symptoms related to not having taken a pill but I think if someone had given me a placebo it would have worked lol.
So THANK YOU to everyone that posted and got me through.
My Dr. had no issue with my reasons for running short (took extra to try to manage chronic pain and she was on vacay so I couldn’t address it with her properly). She renewed my prescription at 16mg/day and also added 5 “as needed” doses of 4mg that I can take if I know the day will be predictably pain inducing. She also said I can split my regular dose into 3X/day too, which is what BlueLight and Lillyval suggested.
Lillyval and JennJenn you explained ceiling effect brilliantly and I totally get it now...at a very basic level lol because this drug is like no other. Especially the part about the equianalgesic dose of Oxycodone 60mg.
Amy you are bang on with everything you wrote about the stigma and the addict brain feeling insecure (although we shouldn’t) when taking a so-called “higher” dose becasue that’s what the abstinence mindset drilled into us. I have no qualms about being on a fairly high dose, that’s what works for me right now. I also don’t care how long I have to be on it. Who cares? It’s what I need just like all my other medications for depression, high blood pressure, etc. I like that BP med scenario and will quote that from you to explain to my friends/family when I try explain this drug. Thank you.
JennJenn that lady that gave you the tips and advice on your induction day is you now...paying it forward to all of us. You’re my “lady in the waiting room”!
Since starting the suboxone I feel mentally and physically better than I have in years and I’m only 4 weeks in! My mom (who knows all of my history and has been there from the get go) keeps telling me how much nicer I am to be around, how much more patient I am, how I look better, and on and on and it’s all becasue of this lifesaver called Suboxone.
JennyB

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Re: Stretching dose until refill: Can sublingual be halved?

Post by BlueLight » Tue Jan 29, 2019 6:17 am

I’m glad everything worked out. I know for me as an addict, anxiety about running out of meds will defeat any attempt at tapering my dose. In fact if I’m running just a tiny bit short, my mind plays tricks on me that I’m in WD, even if I take my full, usual dose. Over the past year I’ve been able to stockpile 2 extra months so that I never have to freak out if I have to reschedule an appt or if something unexpected happens at the pharmacy and it takes a week longer than usual for my refill. 3xs daily dosing really solves my pain issues as well. It sucks having chronic pain AND be an addict.

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Re: Stretching dose until refill: Can sublingual be halved?

Post by razor55 » Tue Jan 29, 2019 7:17 am

Very glad that your fine and now have full understanding of the ceilings. It may be the most important fact about this medication . It is really to bad most drs never talk about it or educate.

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Re: Stretching dose until refill: Can sublingual be halved?

Post by jennjenn » Tue Jan 29, 2019 12:23 pm

Amy that was a great post and I 100% agree with everything you said. It is a shame that in this day and time that we’re made to feel judged and guilty for the course of treatment we decided to take. This day and time is so accepting of other things like sexuality and the issues of same sex marriage, this world is making leaps and bounds in the direction of acceptance but I can’t help but feel like with addiction and MAT, it’s one way or it’s wrong and we’re judged. I guess it’s accepted more than it used to be but nowhere near what I think it should be.

JennyB.... yes! I’m your lady in the waiting room lol! That’s an awesome way to look at it. And just remember, that awful feeling that you’d have when you were in active addiction, when you didn’t have anything to take that day or that desperation you felt...... nobody else took that awful feeling away, so you gotta do what you gotta do to live a better quality of life. If those ppl don’t approve, so be it. Someone is always going to hate on someone for something. You’ll never please anyone 100% of the time. If they want to judge then who cares.
Jennifer

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