What happens if my methadone or Suboxone dose is not high enough. Can I use opiates to decrease withdrawal?

The dose of Suboxone is usually determined within the first 24 hours after the start of an induction. Patients are seen again a week later to ensure everything is still going well and an adjustment may be made at this time but usually not before this.

Using opiates while taking Suboxone typically has no additional effect because of the specific pharmacologic effects of buprenorphine (the active drug in Suboxone) tends to block the effect of other opiates. Buprenorphine is a long acting medication. Because of this the blood level will increase after each dose for the first 5-7 doses – therefore there is more effect a week later even though the patient is on the same dose.

Methadone dosing is determined through a process called stabilization. Patients often have less than 24 hours relief of withdrawal after the initial daily dose of methadone. A BMC Dr will see you every 3-4 days and adjust your dose based on your symptoms. During this time some patients choose to continue to use opiates to help prevent withdrawal for the rest of the dosing day (the 24 hour period after you take your dose of methadone). This is accepted by BMC as a reasonable approach with a few cautions worth mentioning. Failure to follow the following advice may lead to stabilizing at higher methadone doses:

  • Try not to use opiates before you come to get your daily dose (usually in the morning).
  • After taking the methadone wait until you are developing some withdrawal before using another opiate. The more time you can wait the better as even some withdrawal every day for a few days will lead to decreased opiate tolerance. If your tolerance decreases while we increase your dose we can meet in the “middle” – this means a lower dose of methadone for you. Lower doses cause less side effects and take less time when you decide to taper off methadone.
  • Alter your route of administration if you are snorting, smoking or injecting to the oral route. There are two reasons – first, these three methods are triggers to use. You have probably noticed you start to feel better while preparing your drug, even before you have taken it. Removing triggers is important to recovery. Second, all three methods cause a more rapid increase in blood levels than using orally. Rapid spikes in blood levels of one opiate on top of the methadone blood level (also an opiate) increases your tolerance. This means you get stabilized at a higher dose of methadone. Higher doses cause more side effects and take more time to taper off of. We suggest that if necessary you use a dose of opiate orally to help decrease withdrawal. If you need more in a few hours then repeat the dose. If it is only a few hours before your daily dose of methadone try to tough it out.

After a few weeks most people are at a dose of methadone that leaves them free of withdrawal for at least 24 hours. They are now considered to be at a stable dose and are usually seen in clinic weekly after this point.

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