Buprenorphine for low-dose opioid use

A reader wrote with a question that I don’t think I’ve addressed on the blog.

Do you have a threshold for how much narcotic a patient must be using before you will put them on buprenorphine? I am concerned about narcotic addicts that are using 6-10 Vicodin (hydrocodone) a day for example.  Many have very mild withdrawal symptoms, but are never-the-less unable to stop on their own.

This is an insightful question that provokes enough discussion to fill at least one blog post.  I don’t have a simple answer, other than to go on a case-by-case basis and try to determine who, if anyone, might be able to walk away from opioids completely (i.e. a person who I would be less likely to put on buprenorphine, as doing so would drive tolerance higher) vs. those who will need maintenance treatment eventually, even if their doses are not yet very high.

Patients have a right to know if they are having their tolerance increased in my opinion, given the misery involved in bringing tolerance down.  It is also important to tell people with lower tolerances that they are going to get a buzz from buprenorphine for a few days because of the potency of buprenorphine.  This opiate stimulation is likely to occur even with a very small piece of a Suboxone tablet; a quarter tab or 2 mg of buprenorphine has almost the same potency as 16 mg because of the ‘ceiling effect.’  The potent opioid effect may make the doctor liable for a car accident, or could even lead to overdose if the patient combines buprenorphine with other respiratory depressants.

In general,  the ‘break even’ point on the tolerance scale is 80-100 mg of hydrocodone or about 60 mg of oxycodone per day.  In other words, if the person is taking 8-10 of the larger-strength Vicodin per day, I would consider Suboxone to be of about equal potency.

In considering whether a person’s use and tolerance are high enough to call for buprenorphine, some people focus too much on the initial potency relationships, and forget that opioid dependence is almost always a long-term condition.  I’m not sure by your last sentence whether you realize or not that the presence or absence of bad withdrawal is a red herring for acheiving sobriety from opioids.  Many addicts mistakenly think that withdrawal is the primary force that keeps them actively addicted.  In late addiction they find that desperation helps them get through withdrawal over and over, but they continue to relapse– as soon as they feel well!  From a scientific perspective, I have not seen evidence of a correlation between the severity of addiction and the addict’s tolerance level (if anyone has seen such a study, please forward me the reference).  At the same time, I don’t think I would feel comfortable starting buprenorphine in a person taking a couple Tylenol 3’s per day.  Luckily (?), this type of situation has been rare in my experience.   I should do chart reviews and publish the exact numbers, but out of the 500 or so people presenting with opioid dependence over the past 5 years, I would guess that the average tolerance level is approx. 120-150 mg of daily methadone (range of 30-400 mg per day), or approx. 160 mg of oxycodone per day (range of 40-700 mg of oxycodone per day).  Yes, I had two people—interestingly, both women– come in at those upper daily doses of methadone and oxycodone.   The methadone patient had been labeled a ‘fast metabolizer’ of methadone as reason for the ridiculously high dosage.  The reason seemed good enough, until I found, when converting her to other agonists for pain, that her tolerance was ultra-high to ALL opioid agonists—telling me that she was not metabolizing the methadone fast enough to prevent her body’s response to the high dosage, and calling the entire ‘fast metabolizer’ issue into question.  The woman taking the large amount of oxycodone had inherited a tidy sum of money; hundreds of thousands of dollars, all gone after one year of using.

Ouch.

6 thoughts on “Buprenorphine for low-dose opioid use”

  1. I was just beginning to abuse opiates when my mother died. Beyond her leaving around fifty left over 80 mg oxycontins from her own medical issues, I was was given about one hundred thousand dollars in life insurance money from her death.

    I had just begun to use pain meds habitually when she passed, and dealing with her death I went into overdrive. Within 2 years I had spent almost the entire $100 thousand dollars on opiates. If I only knew about buprenorphine at the time, and it’s miraculous effects on me,…
    Now I am laid off and living on unemployment, barely enough to survive, but at least I am free from the emotional hell of opiate addiction. The regrets are enough to cause physical pain, however. Losing my mother at such a young age was devastating, and I don’t know how I would have dealt with it without the narcotics.

  2. Regrets and resentments are by far the biggest issue that I hear about– and the issues I struggle to deal with as well. I talk to people all day long who lost huge sums of money, businesses or jobs, and other possessions. People have an even harder time after losing boyfriends and girlfriends– people who the addict NOW realizes was a wonderful person… who will never trust the addict in the same way, no matter how many years of sobriety. Then there are those who lost children and spouses– again, a horrible thing to deal with.

    I’ve consistently writtten about my belief that step programs are not enough for opiod dependence. At the same time, there is certainly a place for step-based recovery. Twelve step programs help one learn to deal with resentmens and other feelings (guilt and shame for example). The question is whether a person on buprenorphine can ever find enough desperation to be motivated enough so that the steps work. I strongly recommend at least trying a few meetings if you haven’t already. They are ALWAYS sort of a bummer the first few times, until you get to know a few people (and find the right meeting for YOU). Understand that real change will always feel uncomfortable, and will always be rejected; if you immediately accepted something, it would not be ‘change’!

    Bottom line– resentments and regrets are life-killers. You deserve to let them go; I hope you find a way. Be sure to try on the forum as well (suboxforum.com); you might find some useful information there about how others deal with those feelings.

    JJ

  3. One concern that I have about low intensity users is that they will escalate their use over time, and other treatment methods have such a low rate of success. Is there any rational for using low dose buprenorphine 2-4 mg in low intensity opiate users?

  4. I share your concern– I think that the main thing in regard to dosing is that the person has to take a high enough dose to get on the flat, horizontal part of the dose/response graph. At low doses, buprenorphine essentially acts as an agonist, where increases in blood levels cause in increase in opiate effect and decreases cause cravings and withdrawal. It is only when the person is beyond the ‘ceiling’ that the unique actions of buprenorphine come out– i.e. as the blood level drops between doses, the opiate effect remains constant, preventing the development of cravings and the obsession to use.

    Because of the ceiling effect, a person’s tolerance does not change all that much as the dose is raised from 4 to 16 mg. Both doses have similar opiate effects, meaning similar tolerance levels. The main problem with being on higher doses of buprenorphine is that it becomes much higher to overcome receptor blockade in the case of injury or surgery.

  5. How long does it generally take to taper someone off 10-20 mg a day of hydrocodone using Suboxone? I understand that each case is different and it depends on how much of the withdrawals a user is willing to expierence, but how long would you say? I’ve gone cold turkey before and after about 6 days I was starting to feel better.

  6. To be honest I probably wouldn’t use Suboxone for that situation. The opioid activity of even a quarter tablet of Suboxone is much greater than 20 mg of hydrocodone; in fact, it would be similar to about 80 – 100 mg of hydrocodone. So you would be taking a huge step up the tolerance ladder by taking buprenorphine. The ceiling effect of buprenorphine would make it very difficult to use even a very small dose of buprenorphine; you would have to take maybe 1/10th of a tablet to start the taper, and even that would probably cause a significant opioid ‘buzz’ that would push tolerance in the wrong direction.

    20 mg of hydrocodone is not a high dose by most standards; in my practice the average dose of addicts seeking treatment is between 100 and 400 mg of oxycodone per day, with the highest up around 800 mg per day of oxycodone. Hydrocodone is weaker than oxycodone; 20 my of hydrocodone is about as potent as 12 mg of oxycodone. So I would recommend going ‘cold turkey’ from your current level, and I would think that by the end of the week you’ll be OK. Of course, the problem most addicts have is STAYING clean, not GETTING clean.

    Good luck,

    JJ