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Unread 03-01-2010, 05:12 PM   #1
Hinkasaurus
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Default Precipitated Withdrawal

Hello,

Has anyone here actually experienced this? I have read and understand the necessity of being in moderate w/d before begining suboxone treatment.

It seems like our docs use the COWS form to determine whether or not to begin treatment and if we don't "qualify" we don't get the first dose. Is this pretty much correct?

What I'm wondering is what would happen if ones score were not sufficiently high and dosing began anyway? Obviously, precipitated w/d would begin and our symptoms would be different based on degree of addiction, type of drugs used, etc. But, if one started suboxone treatment and had w/d, would the doc continue administering suboxone until the w/d symptoms stop? Or how does suboxone work if one has started precipitated withdrawal?

As I've mentioned in a previous thread, I'm a methadone user about to begin suboxone treatment. Thanks everyone!
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Unread 03-01-2010, 06:28 PM   #2
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Hi Hinkasaurus, there have been a few people here who have suffered precipitated withdrawals. You're right, the severity differs from person to person.

Hopefully the doctor would know to just keep administering Suboxone until they subsided. Unfortunately, I've read where some doctors say that the patient should tough it out, it will be over in a day or so. That leaves a huge possibility of relapse, just to get relief from the WDs.

http://www.naabt.org/faq_answers.cfm?ID=70
Precipitated withdrawal can occur when an antagonist (or partial antagonist, such as buprenorphine) is administered to a patient dependent on full agonist opioids. Due to BuprenorphineÂ’s high affinity but low intrinsic activity at the mu receptor, the partial antagonist displaces agonist opioids from the mu receptors, without activating the receptor to an equivalent degree, resulting in a net decrease in agonist effect, thus precipitating a withdrawal syndrome.

So by continuing to administer bupe, the bupe will continue to displace more full agonists from the mu receptor and fill those receptors that are unoccupied.

Hope that helps.

Nancy
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Unread 03-01-2010, 08:27 PM   #3
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Hi
I read about your question re precipitated wd and I experienced them. I dont blog very much here anymore, but I do read frequently. This forum answered my questions I had about what my doctor put me through, either from ignorance or neglect/sadism. I wont go into it here, but if you search my posts (only about ten) you will see what happened. Search by thread, I think. Nancy was so knowledgable and helpful.
good luck to you
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Unread 03-02-2010, 09:07 AM   #4
Hinkasaurus
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Thanks for the reply, Nancy. It does help. I think I was just wondering how one comes out the other side of a precipitated w/d.

Hi Ellela. I read some of your posts and am really sorry you had to go through such agony. I certainly hope your experience was a rarity rather than something typical. Hopefully, you're doing much better, now.
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Unread 03-02-2010, 11:03 AM   #5
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Hi Hinkasaurus,
I see you mention you switching from methadone to suboxone. I just wanted to make sure you have read the FAQ on switching from methadone. I will just paste and cut what is said. You may already know but just making sure.

Darrin
-----------------------------------------------------------------------------
It is best to SLOWLY reduce your therapeutic dose of Methadone to 30 mg a day or less for at least a week, before discontinuing it completely for at least 36 hours before starting Buprenorphine. You MUST be in mild to moderate withdrawal before you take your first dose of Buprenorphine. If you are doing well in Methadone treatment it may not be advisable to change treatments at all unless you and your doctor determine it is in your best interest.
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Unread 03-04-2010, 07:44 PM   #6
Hinkasaurus
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Thanks for the info, OpiatesGotMe. I did see that FAQ.

I started suboxone treatment on Tuesday. There was no way I could go 36 hours without methadone, in fact it was not quite 30 hours since my last dose so I was a bit concerned.

The doc started me off with a single 8mg tab and after an hour I was definitely feeling queasy. But it didn't get much worse than that. I got additional half tab doses over the next couple hours and the doc sent me home with a script for 24 mgs per day taking 1.5 tabs 12 hours apart. He gave me the flexibility to take 2 in the morning and one at night if I desired.

So, yesterday I took 12 mgs in the morning and 12 at night. Today I took 16 in the morning and 8 at night with not much difference in the way I feel. I definitely am not feeling good. But certainly am not feeling any withdrawal symptoms aside from occasional mild sweats and a blah mood.

I'm hoping after a couple more days the mood will improve because if it doesn't get better than this I'll be disappointed. Don't get me wrong, I'm very happy about the lack of serious w/d, but am just hoping things will improve from here.

Last edited by Hinkasaurus; 03-04-2010 at 07:46 PM.. Reason: made a type on the hours. Heh, and a typo on the reason. yikes!
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Unread 03-04-2010, 10:46 PM   #7
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Hi Hinkasaurus,
It will get better but it might take a while for all of the meth to work its way out

This is in the Suboxone dosing guide "Patients transferring from methadone or other long-acting opioids to SUBOXONE or SUBUTEX may experience discomfort for several days and dysphoria for up to 2 weeks. It is critical that your patient is prepared for this."
http://suboxone.com/hcp/opioiddepend...e_therapy.aspx

Everyday should be a little better. If you start to feel down remember that it WILL get better and it will be worth it. Hang in there.
Sub
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Unread 03-06-2010, 10:06 AM   #8
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Hi Hinkasaurus,

I transitioned from 17mg of methadone to Suboxone. it took a while for me go into withdrawal to induce, but once I did, I began to feel better right away. I was at 6mg. After about two days, however, I started to feel worse because methadone was deeply stored in my body tissue and it took about two weeks for aches, pains and other minor withdrawal to subside. It took about 10mg a day to get me through that phase. After that I have felt fine since.

Good luck and keep postin'~

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Unread 03-06-2010, 04:23 PM   #9
Hinkasaurus
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Thanks Sub-Zero and Packrat,

I do feel better! Not terrific, but certainly better. It has now been 5 days on subs and here is my delemma: There is none! I can tell, now that it's going to get much better and, like I said, just not having w/d's is so great.

This is funny, I keep having mental conversations with myself asking "well, how DO you feel?" The answer is really "not too bad". I'm almost giddy with anticipation for the future. (but don't tell anyone I actually said that)
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Unread 03-07-2010, 11:58 AM   #10
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Congratulations Hinkasaurus! You're on your way! Next, you'll need to make a plan to systematically change things in your life that cause stress, anxiety or depression. Use this time without cravings or withdrawal, to fix, change, and improve things in your life so when you no longer need the medication you'll be able to keep the addiction in remission. Good luck!
Tim
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Unread 03-14-2010, 12:46 AM   #11
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I have only had one doctor actually adminster a tablet in the office and I really like him. He wants to be sure you are on the right dose before you even leave. The first doctor I saw just wrote me up a scrip and told me to take as many as I needed until the w/d stopped. (this was also the same doctor whose office kept changing the price and tried charging me for drug tests I was never given)
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Unread 03-16-2010, 11:27 AM   #12
Hinkasaurus
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Hello everyone,

I just want to close out this thread with the latest on my journey in suboxone treatment.

It's now been two weeks since I started. All uneasyness, sweating, aches etc. have subsided and I feel absolutely terrific, considering what life was like before.

I do have a couple side effects like constipation and sometimes feeling drowsy at different times of the day but it's nothing I can't easily handle. In fact, when the clock gets to be 10 or 11 pm, I am grateful for the drowsyness. I am actually sleepy at a normal bedtime! I still do not sleep through the night, waking every couple hours but this is a big improvement from staying up half the night waiting to feel sleepy.

Next thing I have to work on is maintaining relationships with other people in recovery. I've been to some AA meetings, the ones I stopped going to years ago but am going to try NA for a change of scenery. You know how most AA'ers feel about ANY medication that keeps you from being totally "clean". Personally, I don't care about how others feel. I consider suboxone to be about the same as taking an antidepressant. And I've been prescribed plenty of those in the past, to no avail. I'm not taking anything now except for the suboxone and don't feel the need for anything else to improve my "mood". Antidepressants always made me feel sort of chemically altered, somehow.

Anyway, I'll continue to post and read threads here as things continue on this wonderful new journey. Thanks for everyone's feedback. It is greatly appreciated.

Until later,
Hink
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Unread 03-16-2010, 11:43 AM   #13
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Hi Hinkasaurus, that's great that you're doing better. You might want to take a peek at this thread, it has tons of people's suggestions on constipation:
http://www.addictionsurvivors.org/vb...ad.php?t=14755

As for the sleep issue, are you still taking 8mg at night? If so, you might want to move it up earlier. There are many people who can't take Suboxone in the afternoon or later because it disrupts their sleep. Might be worth a try.

As for AA or NA, it's no one's business what medication you're taking. So don't feel obligated to say anything because there are still many people in both groups who don't believe in medication-assisted treatment.

Look forward to more updates.

Nancy
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Unread 09-04-2010, 09:07 AM   #14
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this is what happened to me. It took me three shots at induction. The first time I waited five emotionally-draining days and I still wasn't reading high enough on COWS. The second time, four days, same thing and I just went back to methadone. I tried it one last time with a "plan to deal with precipitated withdrawals" with more Sub if necessary. I had the same problem, but we went ahead after 72 hours anyway. In my case, the trick seemed to be to NOT induce on a high dose like 8mg, but to start at 2mg and titrate upwards slowly. I think that this allowed the Bupe to occupy some empty receptors without displacing all of the methadone and as more were emptied, titrating upwards occupied the rest.

The end result was that I was able to induce without any problems at all for a few days, even though I didn't feel much physical withdrawal from methadone. Of course, once I was on sub and methadone started to completely leave my body, I had to go up in dose a bit to deal with the methadone withdrawal lasting about 10 or 12 days.

A methadone to Bupe transfer is tricky, but I had the help of some fine people on this board.

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Unread 09-04-2010, 05:18 PM   #15
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I got lucky as hell for my Methadone to Bupe experience. I only waited 54 or so hours and inducted. I was on 20mg. I was so so so so scared but all went pretty well besides dose adjusting. I'm on 12mg now and I inducted on 8.
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Unread 09-08-2010, 03:34 PM   #16
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Precipitated WD only occur if the level of opiate you are on is higher than the ceiling effect dosage of bupe. The ceiling is different for everyone, I've heard between 8 and 32 mg of bupe but it's the individual who reaches their personal ceiling effect with bupe.
I personally have taken methadone, heroin, painkillers and stopped at night and took the bupe in the morning. I have never felt precipitated WD. I also can take bupe in the morning and get full affect of full agonists within about 6 hours so my personal ceiling dose for bupe must be really high or not exist since I do not having any problem using bupe and opiates together for pain.
Or I might metabolize the drugs very quickly, which I think might be the case because I get regular WD's really bad, with short acting opiates - 4-6 hours and longer acting within 12 hours. When I came off bupe, I was sick by noon the next day with sweating, the runs, throwing up and feeling horrible. So much for 72 hours for me. I also have had UA's that negative for bupe even though I had been on it years.
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Unread 09-09-2010, 06:42 AM   #17
Heath
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Nancy, i've never fully understood this precipitated w/d either. This explanation makes total sense.
Glad i read it.
Heath
ps. All's well with me and my wife. We've been traveling once a month. Golfing, going to church, cooking, biking, hiking, reading, and loving. None of this would have ever been possible if i were still on dope. I actually said to my wife on monday as we were driving down a country road in charlottesville, va on our way home. She was going back to the begining of this year and adding up (dollar amounts) how much money we've spent on accomodations so far this year by taking a vacation once a month. She figured it would be about $10,000 by the end of this year. That's when we looked at each other, laughed, and then both agreed that it was worth every penny. I then made the comment that if we were still on dope we couldn't have done any of this. When we were on dope there was not enough money for both travel and dope, so we made the choice of dope and didn't travel much. She agreed that this was true. I said, "praise the lord", and we drove on down the road.
Eliminating dope from my life has completely changed everything for the better.

Talk to you later. Hope you are doing well.

Heath

pss, sorry i hijacked this thread!
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Unread 09-09-2010, 06:46 AM   #18
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Hi Heath! Glad it helped in understanding precipitated WD.

That is great that you're able to get away every month! Just another good 'side effect' of Suboxone and being addiction free! Glad you're doing well.

Nancy
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Unread 05-21-2011, 04:00 PM   #19
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Seems to always be conflicting views on what to do if precipitated wds happen. To the original poster from everything I have read starting on that high of a dose is contrary to most inductions, in that starting with small 2 mg doses and waiting an hour for the full sub effect and continuing to titrate upwards is the info I have seen. The purposeis to stabilize the patient on the lowest possible dose because more is not better with bupe and when time comes to taper you are at a better starting point. I am about to do the Meth to bupe switch soon as well and I asked my doc what happens if I gointo precipitated eds and she replied ill give you some comfort meds??? And they may or may not help and then I have to wait of out for coupledays and try again. So anyone who could clear up any of this info I would be appreciative because I don't claim to really know. Thanks Noah.
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Unread 05-22-2011, 06:47 PM   #20
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ANYONE?
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Unread 05-22-2011, 06:52 PM   #21
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IMO, it is best to do a induction using a dose of 2 - 4mg at a time! If thrown into WD, continue to increase dose until the WD has calmed.
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Unread 05-23-2011, 07:06 AM   #22
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Hi Noah, the best thing to do is to avoid precipitated withdrawals by waiting as long as possible. With methadone transfers, I've seen people wait as long as 5 days before starting before they were in adequate withdrawals. Use page 2 of this link as your guide as to the depth of your withdrawals:
http://www.naabt.org/documents/NAABT_PrecipWD.pdf

On page 1 of that link is this statement:
The goal of induction is to safely suppress opioid withdrawal as rapidly as possible with adequate doses of Buprenorphine. Failure to do so may cause patients to use opioids or other medications to alleviate opioid withdrawal symptoms or may lead to early treatment dropout.(3) To achieve this, some physicians have found they may need to dose as high as 32 mgs. the first day with some methadone to Buprenorphine transfers.(5)

(3) Dosing Guide Maintenance therapy for Opioid Dependence. Suboxone/ Subutex www.suboxone.com/pdfs/DosingGuides.pdf

(5) Physician Clinical Support System: http://www.pcssb.org/ Transfer from Methadone to Buprenorphine, Paul P. Casadonte, MD, PCSS guidance paper. 8/9/2006
http://pcssb.org/wp-content/uploads/...renorphine.pdf

In essence, the doctor should keep administering bupe until the symptoms are relieved.

Hope that helps.

Nancy
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Unread 05-23-2011, 02:24 PM   #23
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Thanks Nancy I think it kind of says Some drs MAY find it necessary to dose as high as 32 mgs. Which leaves the door open for drs with differing opinions to justify not continuing to dose if precip wds begin. Also the link you left for dosing guide the number 3) one doesn't work do u have another that does? Thanks kindly Noah.
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Unread 05-23-2011, 02:56 PM   #24
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Noahzark,

The treatment for precipitated withdrawal is more buprenorphine…continued dosing until symptoms subside. I would be surprised if a doctor would stop buprenorphine titration solely because a patient began to experience PW. Stopping the titration before reaching that point and treating remaining symptoms with comfort meds increases the chance of patient drop out and isn’t recommended. It’s recommended patients taper down to 30mgs or less of methadone prior to the transfer and wait until they are in moderate withdrawal.

Sure a doctor can place an arbitrary cap on buprenorphine dose and treat symptoms with comfort meds, and some doctors do this. Unfortunately, it is not supported by the clinical evidence and the risk of under-dosing far outweighs the risk of dosing higher than needed. Some methadone to buprenorphine transfers required 32mgs the first day, but that is not a limit although it’s expected that doses above that would be not have additional effect due to the ceiling effect.

We’ve heard stories of doctors limiting first day’s dose to 8mgs, because that was suggested in the early literature. Since then, dosing to eliminate symptoms of withdrawal has become the clinical standard because the faster a patient’s withdrawal symptoms can be suppressed the less chance of treatment drop out or relapse.

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Unread 05-23-2011, 03:06 PM   #25
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This link replaces the one not working above

“…Find the appropriate dose of SUBOXONE® Film by dosing to clinical effect. The recommended target stabilization dose is 12 mg to 16 mg, but patients should be dosed according to what best keeps patients in treatment by managing cravings…”

page 18
http://www.suboxone.com/hcp/pdfs/Phy...d_Brochure.pdf
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Unread 05-23-2011, 03:29 PM   #26
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Yes that all makes more sense to me I hopethe dr does as well. One thing though if that's protocol for dealing with precip wds then really there are no precip wds because Dr will just outdose the wds? Or what happens?
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Unread 05-23-2011, 03:58 PM   #27
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Most of the time there is a dose that stops the withdrawal and its just a matter of reaching it. When the partial agonist effect of the buprenorphine reaches the patients level of tolerance, the withdrawal stops. But sometimes with methadone transfers patients report ongoing withdrawal-like dysphoria that can last for a couple weeks and doesn't appear to be affected by the buprenorphine dose. The action of methadone in the brain is less understood than the action of opioids derived from opium, so reason for this is not entirely known.
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Unread 05-23-2011, 05:37 PM   #28
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Oh great! Heh that doesn't sound good. I'm down to 40-35 mls right now and have some time pressure so I hope I don't suffer as I am bi-polar and have anxiety/panic attacks.
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Unread 05-25-2011, 01:18 PM   #29
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Unhappy Precipitated wd's after dosing sub at 18 hrs post last opiate

Hi, I was skimming for info here and was reminded by my own precipitated wd experience I had 3 months ago. I took my last dose of morphine at 6 pm. And about 11 am next morning started suboxone. I was in bed for almost 3 days fighting a war going on inside me, mind,body,emotion, just everything in chaos. I was so out of it couldn't call or go out anywhere. I thought I read 12-24 hrs after last opiate dose was guideline but I was wrong. I have chronic degenerative disk pain with failed surgery so was taking morphine and noticed continuing rise in tolerance and got scared. Told my doctor to put ,me on sub. Wasn't as bad as Opiate withdrawal, (hardly anything worse than ow), yet for 2 days straight I was in tears and wayyyy out there lost in space ,,don't ever want that..,,just a baad trip. I hope people wait longer than I did even if wd's r tough. It's better than 2-3 days in twilightzone
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Unread 05-25-2011, 01:29 PM   #30
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Noahzark,
If you are prepared and know what to expect it shouldn't be that bad. There have been successful transfers from as high as 60mgs of methadone. The deeper you are in withdrawal before starting, the more noticeable the buprenorphine will be. Also, if your doctor isn't experienced with methadone transfers he/she can get free advice from a buprenorphine expert from http://www.pcssb.org/
Tim
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