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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:
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.
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 that is laced into 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:
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 what is called 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 opioid 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.
Many people have difficulty stabilizing on buprenorphine medication. There can be different factors involved in this issue, and these should be addressed with your doctor. Examples of interfering pressures include:
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 is designed to 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.
There are many people who take buprenorphine who would not be considered to be 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. To achieve the best treatment result with buprenorphine, these additional avenues of care need to be utilized.
Read more CeDAR Education Articles about Opioid Addiction including Coping with Cravings.