Target Buprenorphine Dosing

OPIOID ADDICTION

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Adjusting Buprenorphine dosing with your doctor is a complex decision and will involve many factors. Some of these will include such things as:

• Craving Control
• Blockade Effect – Relapse Prevention
• Sedation
• Constipation
• Sleep Patterns
• Cost
• Trajectory – Taper Plans

For many people, a target of 8mg, 12mg, or 16mg per day in total dose is feasible and works well. The medication is FDA-approved to reach a dose of up to 32mg per day safely, but this dose is often excessive. There are some pharmaceutical data that shows buprenorphine has 97% of its response in the first 16mg dose. Dosing above this may be somewhat wasted. The reason to have a patient above this dose usually involves off-label, chronic pain management.

Blockade

All doses above 8mg per day have good ‘blockade’ benefit in that the person will be adequately prevented from abusing painkillers or heroin. The blockade component from buprenorphine is not, as many people think, connected to naloxone medication in the med (as with the brand name Suboxone). The naloxone component is only added as an anti-misuse mechanism such that a patient would experience severe withdrawal if trying to snort, boil down, or inject the Suboxone.

The blockade instead comes from the tight binding properties of the buprenorphine itself on your brain receptors. This tight affinity also describes why the medication can cause precipitated withdrawal if you start it too early from your last opioid use. In this way, the buprenorphine is essentially ‘kicking off’ any residual opioid you have in your system, and this event triggers withdrawal symptoms similar to having run out of your drug of choice.

The medication was initially designed to be taken once daily, but can be taken more frequently based on the person. There are some people in which a split dose of buprenorphine can be helpful. Consider a twice-daily dose of your medication if you struggle with:

• Too much sedation when you take the entire dose in the morning
• Chronic pain management

Chronic Pain Approaches

As you can see, pain issues are important to discuss when we are reviewing opioid replacement therapy. Much of the medical research on this has shown that the pain-relief component of buprenorphine often wears off far before the relapse-prevention benefit. This medication has a long half-life. This means it stays in the body for multiple days, even after the last ingested dose.

It is typically not necessary to take buprenorphine more than twice per day unless specified by your doctor as part of a pain management protocol. There is no physical harm in taking the medication multiple times per day, but there may be some psychological attachment issues which we are trying to change. Repeated buprenorphine dosing can be reminiscent of prior abuse patterns. It may be wise to set up a structured schedule in which you take the buprenorphine med and then move on with your day.

It also is very important to view your medication as a med instead of a ‘drug.’ Using our diabetes metaphor with addiction, buprenorphine dosing can be analogous to taking long-acting insulin. While some diabetics are able to live without such medication, many require it.

Interference to Effective Buprenorphine Treatment

Many people have difficulty stabilizing on buprenorphine medication. Your doctor should address the different factors involved in this issue. Examples of interfering pressures include:

• Financial issues around paying to see your doctor or fill your buprenorphine prescription
• Emotional issues that surface such as unrecognized trauma issues or depression
• Family conflicts such as a significant other who also has an addictive disorder and has fallen back into relapse
• Discouragement that the change process is slower than you guessed
• Ambivalence about fully quitting opioids and being in recovery
• Overconfidence that you’re “good to go!” and might not need to keep your buprenorphine treatment going

Identifying ways in which one can fall out of treatment is imperative, especially if you are relatively new to something like opioid replacement therapy and buprenorphine. The medication approach can help you stay safe, stop using opioids, and make life changes. Frantic efforts to come off the medication often go poorly and can lead to relapse or death. Coordinate well with your doctor if you are starting on a buprenorphine program.

Buprenorphine and Recovery

Taking buprenorphine medication alone does not constitute being in recovery, nor does it prevent you from being in recovery. When we work with people at CeDAR to identify what addiction recovery overall entails, we describe it as a state of being in which you accept your disease of addiction, accept your need to collaborate and heal with the support of others, and commit to a change process for your life as a whole.

Many people who take buprenorphine are not in stable recovery. If this happens, the goal should be a deeper discussion with your provider. Adding psychotherapy approaches or a Peer Support program may be very beneficial to you. We utilize these additional avenues of care to achieve the best treatment result.

Read more CeDAR Education Articles about Opioid Addiction including Coping with Cravings.