One of my friends “passed out” while smoking fentanyl. No big deal, right?

Not all passing out is the same

Some drugs cause unconsciousness (passing out) if you take too much – for example alcohol and benzodiazepines like valium or clonazepam (there are many others in this family). In general this excessive dosing is not life threatening. People seem to be tolerant of extremely high doses of benzodiazepines and when someone dies from too much alcohol it is usually a result of vomiting while they are sleeping and being so intoxicated they can't clear their airway. They basically choke to death.

Direct respiratory effect

Opiates are special – they directly effect the respiratory center in the brain. The threshold for respiratory depression is very close to the threshold for loss of consciousness. This means that as your blood level rises first you get high, then as it goes higher you become unconscious, then stop breathing.

This can be a concern with massive oral overdoses but usually only if someone is opiate naive or trying to harm themselves. It has been reported with transdermal fentanyl patches worn on the skin – someone passes out because of the fentanyl but the drug level continues to increases because it is still being administered "automatically" unless the patches are removed. In the past hitting opiate blood levels high enough to crash through the consciousness and respiratory threshold with an single administration of the drug was usually related to intra-venous (iv) use.

Rapid increases in opiate blood levels

The two fastest way to increase your blood levels of a particular substance is to take it intra-venous or smoke it. In fact smoking may achieve higher blood levels faster than using iv. Smoking fentanyl patches can give very high blood levels very fast.The dose you are taking can be hard to adjust – what size piece of what size patch did you smoke and how long you hold in the vapor makes a difference. This is where the danger lays.

A tale of 4 curves

In the figure below there are 4 curves. On the upright axis is blood level. Two horizontal lines represent the threshold above which the blood level is high enough that you lose consciousness and the threshold above which you stop breathing. Both of these events happen instantaneously if you pass the threshold. The horizontal axis is time.

So we can see that when you take a toke of fentanyl your blood level increases, peaks and then falls off over time. The lowest curve represents a smaller dose. Basically you get high.

The next curve crosses the consciousness threshold. This person passes out but does not stop breathing, however because the two thresholds are so close these people usually have slow breathing. This person survives.

The next curve crosses both thresholds for a short period of time. These patients pass out and stop breathing or breathe so shallowly that they are not moving enough air to survive. At this blood level of fentanyl the patient will die unless they are stimulated and encouraged to breathe. If you are alone or your friends are too high to notice you are down and blue, you are dead.

The last curve crosses both thresholds for a longer period of time. You have 3-4 minutes – in this time you have to be intubated and put on a ventilator. By 5 minutes you are brain damaged, a few more and just plain dead. If your friends fool around with CPR and slapping you or throwing water on you they have just wasted the precious time you needed for the ambulance to get to you and get you back to the emergency department. It becomes the same outcome as if you were alone -you are dead. The only difference is that they will be haunted knowing they could have made the difference but instead made wrong choices – choices with fatal consequences. It is hard to stay calm and make the right choices when someone is dying in front of you – especailly if you are high.

fentanyl graph

Bottom line

Please recognize how dangerous smoking fentanyl is. Passing out is a pre-death experience. If someone passes out, call an ambulance immediately. There is no time to wait and see.

 

 

Top

Is opiate addiction different from other addictions?

The answer is yes and no. No, in the sense that all drug addictions have in common an effect at the reward center of the brain – if you are interested in this read about the nucleus accumbens and ventral tegmental areas of the brain.

Opiate addiction however is very different in a practical sense for a number of reasons:

  • Quitting has a very low success rate even if 12 step programs like AA or NA are used, if the person has good family support and even if they try withdrawal management (detox) and inpatient rehab programs. The success rate of staying clean for a year is as low as 5% – far lower than with other substances.
     
  • The relapse rate is much higher than other drugs. Even people that have been clean for 3 years have up to a 50% lifetime relapse rate. This is as much as 3 ½ times the lifetime rate for relapsing to alcohol.
     
  • Aside from the addiction itself there are no long term physiological effects to regular oral opiate use that are not reversible when the opiate is stopped. There are obvious medical problems associated with smoking, snorting and injecting any drug but alcohol, cocaine and crystal methamphetamine are all inherently harmful physiologically even when taken orally.
     
  • Tolerance is significant and develops very rapidly. The dose that used to provide a mood altering effect no longer works within a week or two. At first people increase the dose and then they experiment with other routes of administration that provide a more rapid increase in blood levels – snorting, smoking and injecting. These routes are not only more addictive but they also have health risks including increased chance of overdose. Tolerance does develop with other substances but nothing like opiates. An alcoholic might drink 2 or even 3 times what a normal drinker does before he starts to appear intoxicated but many opiate dependent people take the equivalent of 50 Percocets per day or more, just to function. Most people that are not opiate tolerant feel altered with a single Percocet.
     
  • Profound physical and psychological withdrawal – much more so than other substances. Although the withdrawal from alcohol and benzodiazepine drugs can be more dangerous (for example withdrawal from both can cause seizures) opiate withdrawal is considered the most uncomfortable. The physical withdrawal from opiates can last 10 days to 2 weeks. The time of onset to full withdrawal depends on how long the particular opiate you are using lasts in your system (the half-life). For example full withdrawal develops 24 hours after last use of short acting opiates like morphine compared to 5 days after stopping methadone. Although many people can soldier through the nausea, diarrhea, vomiting, cramping, muscle and joint aches, malaise, restlessness, sweating, flushing, chills etc what they aren’t prepared for is the weeks to months of the more psychological symptoms including insomnia, irritability, depression and lethargy. In some people these symptoms don’t ever completely resolve.
     
  • There are different paths to opiate addiction. All substance abuse and consequently addictions are more common in the children of addicts and in those with certain traumas like sexual abuse. People that use most substances are looking to get high although they may express many reasons they feel they need to get high. Unlike other substances some of the people that become addicted to opiates may not have been trying to get high. Consider these examples:
    ​

     

     

    • High overtime hour workers or shift workers are sometimes exposed to opiates at work. Co-workers offer them a small dose of opiates for energy. This helps the shift pass faster so they buy some for the next shift. Tolerance develops rapidly and at some point thy feel the amount spent on the higher doses is no longer worth the money. When they try to quit they discover they get withdrawal. They are hooked but were only looking to get through their shifts.
       
    • 50% of people with treated depression may have only partial or limited relief of their symptoms with their medication. Those that have undiagnosed depression of course are not treated. Similarly, many people have untreated anxiety. When people with depression or anxiety are exposed to opiates, either recreationally or through a limited prescription, they often have an astounding experience. They describe feeling “normal”. This makes sense when we remember that one of the effects of opiates is euphoria (a feeling of intense happiness or well being) which is the opposite of depression or anxiety. Many feel they have discovered the answer to their problem. However tolerance develops very rapidly requiring increased doses to continue to provide the desired mood elevating effect. As the price becomes too much they attempt to quit and discover they go into withdrawal and experience a return of their depression or anxiety as well. They are hooked but were only trying to live without depression or anxiety.
       
    • Many people are initially exposed to opiates through a prescription from a dentist or doctor. Especially in the case of prescriptions from physicians for long term opiate therapy for chronic pain. If the patient moves or the doctor’s practice closes or the patient and the doctor have a disagreement the patient often finds themselves without a prescriber to continue their opiate prescription. They go into opiate withdrawal and although they may not have manifested addictive behaviors before they will now rapidly start to develop these in the quest to get the opiates they need for pain control and to function. They are hooked but were only following their doctor’s recommendations.
Top

Is methadone only for intravenous drug users?

No, most of the patients at BMC are not i.v. users. Methadone and Suboxone are effective for opiates by any route of administration – oral, snorted, smoked or i.v..

Top

Are methadone and Suboxone harder to get off of than other opiates?

It is very rare that someone starts methadone or Suboxone without having tried to quit opiates on their own or with the help of a withdrawal management service (detox) or another method. None of our patients have been able to quit opiates (and stay quit) before they start at BMC – they would not be at our clinic if they could. 

Remember that methadone and Suboxone are opiates. If you have not been able to stop using other opiates then it should not surprise you that you are not able to stay clean once you stopped Suboxone or methadone.

However, things are not that bleak.

Most of our patients that desire to can successfully stop using methadone and Suboxone. We help guide those interested in eventually stopping treatment through what is called a taper. Tapering the medication must be done slowly to be successful. Avoiding any significant and persistent withdrawal seems to be important. We at BMC use various strategies to help patients achieve this goal if that is their desire.

So the short answer to the question Are Suboxone and Methadone harder to get off than other opiates is no.  Most, but not all, patients are able to stop taking methadone or Suboxone if they taper off these medications with the help of the experienced team at BMC.

Top

I also have pain. Will methadone or Suboxone help my pain?

The answer is maybe.

Methadone is a powerful analgesic (pain killer). It is often used for severe pain, typically in terminal cancer patients. When methadone is used for pain it is given every 8 hours – it is effective to prevent withdrawal if given every 24 hours but for pain it must be given more often. 

The physicians at BMC have the federal exemption for methadone for the treatment of addiction but not the federal exemption for methadone for the treatment of pain. These exemptions are required to prescribe methadone and they restrict physicians to only prescribe within the context of their specific exemption. In short, we have to follow the rules set out by the College of Physician and Surgeons of Ontario for methadone for addictions – it is expected we will use once daily dosing and take home doses are prohibited for several weeks to months. Not too many chronic pain patients would be willing to go to the pharmacy 3 times each day!

We do have some patients that seem to have both and addictive and pain component to their problem. Sometimes they find once daily dosing of methadone resolves their pain because the residual pain they have is mostly due to withdrawal. In cases where there pain has not resolved we also try ancillary agents like anti-inflammatory drugs, oral cannibinoids (synthetic pot), and agents that work at the level of the nervous system like certain antidepressants (amitriptyline, duloxetine or Cymbalta) and anti seizure medications (gabapentin and pregabalin or Lyrica). 

Occasionally we will try split-dose methadone on stable patients that have earned carries but this is not typical and usually used as a strategy for acute pain – like having just had surgery or a fracture.

The doctors at BMC do not prescribe opiates for methadone patients with chronic pain.

Suboxone is considered a moderate analgesic. However like methadone it must be given in split doses to be effective. There are problems with using Suboxone for pain.

First, there is a maximum dose of 24mg. Doses above 16mg have only a minimal additional effect and doses above 24 mg have none.

Second, Suboxone also effectively blocks other opiate pain medications so “rescue” medications do not work.

Third, some insurance companies will not pay for split-dose Suboxone. We generally reserve split dose Suboxone for short term acute pain like fractures or extensive dental work.

In short, if you consider yourself purely a chronic pain patient then BMC is likely not the best answer for your problem. However, you are welcome to make an appointment to talk to one of the doctors to find out more.

Top

How does the doctor decide what my dose of medication will be?

For methadone this is done by starting with a dose likely considered to be safe in your situation (depending on other medications, medical conditions and other factors). Then we will see you again in 3-4 days and make a determination on whether your dose is good, too high or too low. If it gets raised we will again see you in 3-4 days. We keep doing this until the dose is working well. This is a process called stabilization.

For Suboxone this process is called induction and occurs over the first 24 hours. We start most patients at 9 a.m. with a determination of whether or not they are in withdrawal (see info on Suboxone). If you are determined to be in withdrawal we provide a small test dose and see you again in 45-60 minutes. If you are not feeling worse after this time and are still in withdrawal then we add more Suboxone and again see you in 45-60 minutes. By the third time we see patients most are starting to feel better. If you are still not quite right we may provide another dose and then will ask you to return that afternoon. When we see you in the afternoon it is to make a determination of whether more Suboxone is likely to be necessary so an additional dose may or may not be given at that time. We will then ask you to return again in the morning to see if the dose lasted through the night and will then decide on what your daily dose will be. Most people are then seen a week later just to confirm the dose is working properly.

Top

I know what dose works for me. Can I avoid the stabilization process?

No. Methadone is potentially dangerous and there is a definite potential for overdosing during stabilization. Many people that buy street methadone are not buying the dose they think they are.

Even if the bottle is sealed or the patient is certain of their dose we have to follow the standard protocol – it is an issue of safety and not a BMC rule. It is a requirement of the College of Physicians and Surgeons of Ontario (CPSO).

Also be aware that if you have methadone in your initial urine sample BMC will not be able to start you on the program until the CPSO sends a fax notification that you are not enrolled in another methadone program. Again this is their rule not ours.

Top

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.

Top

Will I get used to my dose and need have it increased over time?

No. The development of the tolerance to opiate drugs depends on what effect is being sought. For example the tolerance to the euphoric effect (a feeling of intense happiness or well being) develops very rapidly. The tolerance to the analgesic effect (pain control) develops slowly if at all. Tolerance to the withdrawal prevention effect of opiates does not develop.

Top

I know someone who was stable at one dose of methadone for months and then needed an increase. What happened?

Most people can stay at the same dose for years. In fact dose changes the other direction are most common in stable patients – we decrease the dose so someone can taper off methadone or Suboxone. However there are some situations when the methadone or Suboxone dose needs to be increased:

  • Increased physical activity. Endorphins (your body’s “opiates”) are basically a stress neurotransmitter. They are released during periods of physical stress (e.g. the “runners high”). The responsiveness of this system is lost when people have overloaded the body with opiate medication and drugs. Therefore if you get a new job more physical job or start strenuous workouts you may find you dose is not lasting as long.
     
  • Increased emotional or situational stress. Endorphins (your body’s “opiates”) are basically a stress neurotransmitter. They are released during periods of emotional stress (e.g. battlefield bravery). The responsiveness of this system is lost when people have overloaded the body with opiate medication and drugs. Therefore if you find yourself in a stressful period in your life like a marital break-up or trouble with the law you may find your dose is not lasting as long.
     
  • Significant weight gain. Basically, if you get bigger you may need more methadone or Suboxone.
     
  • Medications. Many medications affect the metabolism of both methadone and Suboxone. Some may speed the metabolism resulting in the need for an increase. Some slow the metabolism. Slowed methadone metabolism can become dangerous – a previously stable dose now becomes too high resulting in sedation or nausea. Always tell you methadone physician about new medications whether prescribed, over-the-counter or herbal.
     
  • Pregnancy often results in an increased methadone requirement for a few reasons. The pregnant woman gains weight, has more circulating blood volume and especially in the third trimester (week 27 to 40) increases the rate of metabolism of some compounds including methadone. Our experience at BMC is about 60% of pregnant women need an increased dose. The same percentage decreases their dose – usually a few months after delivery.
Top

Can my family doctor prescribe Suboxone?

The College of Physicians and Surgeons of Ontario (CPSO; the licensing authority for all medical doctors in Ontario) has made recommendations for which doctors should prescribe Suboxone. The CPSO recommends that to prescribe Suboxone a doctor should:

  • have taken a specific Suboxone training course,

  • have experience in treating opiate addiction,

  • take continuing medial education in the treatment of opiate addiction, and

  • in most cases should probably be methadone prescribers so that patients may be offered a choice

The doctors at BMC meet all these requirements for Suboxone treatment.

Top

What are the side effects of methadone and Suboxone?

During stabilization or induction patients might feel high, energized, sedated or nauseated. These symptoms should be discussed with the BMC physician as they can be symptoms of too much methadone or Suboxone.

During stabilization or induction patients might feel typical symptoms of withdrawal including, stomach cramps, nausea, diarrhea, lethargy, restlessness, irritability, anxiety, depression, disrupted sleep, muscle or joint aches, stiffness, chills, sweating  etc. These symptoms should be discussed with the BMC physician as they can be symptoms of too little methadone or Suboxone. These should resolve as the correct dose is reached.

It is important to realize that long term treatment with methadone and Suboxone is safe. There are no effects that are not resolved by stopping the medications – they do not cause permanent damage to organs or tissues. 

Once you are at the correct dose you may experience some side effects. It is also worth remembering that the side effects are usually dose related – lower dose means less side effects. 

Only some patients get one or more of these symptoms. The most common side effects methadone patients complain of:

  • Weight gain. May be related to eating habits. Some patients have obvious weight gain and some none.
  • Sweating. Not related to other withdrawal symptoms and may occur at any time of the day. A couple of different medications often help and will be prescribed if desired.
  • Constipation. Several different medications often help and will be prescribed if desired.
  • Sexual side effects. Opiates block testosterone production. This can affect libido (sexual drive) in both men and women. Other symptoms may develop in men such as decreased energy or strength. If this is determined to be the result of low testosterone we can prescribe a replacement treatment in men (delatestyrel).
  • Decreased saliva (spit). This happens with all opiates and many other drugs. Long term effects of decreased saliva include gum disease and tooth decay. This is usually managed with proper dental hygiene, staying hydrated and chewing gum. Methadone and Suboxone do not directly damage teeth – this is an effect of methamphetamine (crystal meth).

In general side effects are less common with Suboxone than methadone. Only some patients get one or more of the following symptoms when taking Suboxone:

  • Constipation. Several different medications often help and will be prescribed if desired.
  • Sweating. Not related to other withdrawal symptoms and at any time of the day. A couple of different medications often help and will be prescribed if desired.
  • Headache. May be present for the first few days but often resolves.
  • Nausea. May be present for the first few days but often resolves.

Note that if patients are unable to tolerate one medication we will try to use the other however it is much easier to switch from Suboxone to methadone than from methadone to Suboxone.

Top

Can I overdose on opiates while I am taking methadone?

Yes.

Methadone is an opiate so if you add opiates on top of opiates you are more likely to overdose.

Methadone is not an opiate antagonist but it does tend to block the euphoric effect (intense pleasurable feeling) of other opiates when it is at an appropriate dose. This can be dangerous if people use even more opiates to try and get the effect they are looking for. 

You also increase the chance of overdosing while you’re taking methadone if you mix it with sedatives like benzodiazepines or alcohol. 

Top

Can I overdose on methadone?

It is definitely possible to overdose on methadone. Methadone prescribing physicians work carefully to adjust dosages so that they are safe for each individual patient. It is very important to understand that the amount of methadone that is right for you has nothing to do with how much you weigh and is only partially related to how many opiate drugs you can tolerate. A small woman using less opiates than her husband may require more methadone than he does. 

The reason for this is there is a tremendous variability in how each of us metabolizes methadone. If someone metabolizes methadone slowly then it will accumulate in their system and an overdose is possible after several days. This is the reason that there is no formula or table to calculate how much methadone to give someone that is taking a certain amount of morphine or oxycodone. These calculations do exist for switching between other opiates.

Most often a methadone overdose is related to using other medications or drugs. See this section in the FAQ

Top

Is there any problem with using other medications or drugs while on methadone?

There are many good reasons not to use drugs. You are probably considering methadone because you have found drugs to be a problem in your life. People that have had a problem with one drug are at risk of developing a problem to another. Drug switching (e.g. opiates to cocaine or crystal or alcohol) becomes a significant problem for some patients.

Using other opiate drugs can cause problems. Because methadone is an opiate using additional opiates can result in an overdose. Methadone tends to block the euphoric effects of opiates. Additional opiates increase the chance of toxic effects – most people find they “nod” or pass out. If a patient tries to use opiates and doesn’t get high they may try to use even more which increases the chance of a fatal overdose. Of course using opiates on top of methadone also increases your opiate tolerance. Patients quickly notice their methadone is not lasting the whole day if they start using opiates a few days per week.

Using cocaine speeds the rate of methadone metabolism – your methadone won’t last as long.

Using alcohol can increase the chance of passing out or blacking out. Because alcohol is a respiratory depressant (as are opiates) drinking too much while on methadone increases your chance of a fatal overdose. You are OK to use alcohol but should do so with caution – you may not be able to drink what you could in the past. Most people are fine if they drink no more than 1 drink per hour and it is not recommended to ever drink more than 5 drinks in a day even if not on methadone. People that drink alcohol lose their inhibitions – this can lead to other drug use.

Using dimenhydrinate (Gravol and over-the-counter sleep aids) can increase the rate of methadone metabolism so your dose does not last as long.

Using benzodiazepine drugs like lorazepam (Ativan), diazepam (Valium), clonazepam, oxazepam (Serax), alprazolam (Xanax), temazepam (Restoril), nitrazepam, chlordiazepoxide (Librium) and others for sleep or anxiety is extremely dangerous with methadone. Family might notice some intoxication but the patient usually does not. Death occurs during sleep – people just stop breathing. If you are having problems with your sleep or anxiety please talk to your BMC doctor.

Top

What happens if I start taking methadone or Suboxone again after I have stopped?

It is very dangerous to go back to the same dose of an opiate after stopping it for several days. This is a well known cause of an overdose.The reason this happens is that your tolerance to opiates drops off rapidly when you stop taking them. The same dose that you could tolerate previously could now cause respiratory arrest and death.

If you stop taking methadone even for 3 days your dose will be decreased to 1/2 what it previously was. If you miss 4 days your dose will be decreased to 30mg or less. BMC is required to make these adjustments. It does not matter if you have been using street methadone.

We will get your dose back to your previous dose as fast as we can (usually faster than your initial stabilization). Many people don't end up all the way to their previous dose because they did lose some tolerance to opiates.

During this period of adjustment we must temporarily remove carries but in many cases they can be given back to you once you are back at a stable dose.

A similar thing happens if you miss 3 or 4 days of Suboxone however there is an extra layer of safety inherent in the pharmacology of Suboxone.

Needless to say it is much easier for everyone if you do not miss multiple doses. In fact even missing one dose leaves you with a blood level of the medication less than normal for 5 days – so missing the occasional day can leave you feeling unwell for most of a week.

If you can't make an appointment call the clinic and ask for an extension – unless you make a habit of this it will usually be granted.

If you know you are going out of town and don't have carries we can work with you to send your prescription to a pharmacy close to where you will be.This takes advance notice.

If your prescription ran out and the clinic is closed (e.g. a weekend) try going to a BMC pharmacy. They have access to your medical record and alternative ways of contacting us and you can provide a sample if necessary.This can help the Dr on call provide you with an extension. 

Top

Will I get kicked off the program for continuing to use drugs?

No.

BMC believe in following a Harm Reduction Strategy (HR). We believe that you, your family and society are all better off if you are spending $50 per week on drugs as opposed to $500 per week. Many people that are in our HR program eventually decide to quit doing drugs.

Top

What if I miss a dose or doses?

Missing one or two doses in a row is not a problem except that it will take 5 doses in a row to get your blood level back to where it was. Missing doses also frequently leads to using.

Missing 3 or more doses in a row should be avoided. This requires a restart. Restarting involves lowering the dose of methadone or Suboxone and then being reassessed several days later. The concern is because tolerance to opiates drops rapidly and going back to the previous dose could lead to an overdose.

For methadone patients restarting can result in a huge change in dose and can take a couple of weeks before you are back at the stable dose. While you are restarting all carries (take home doses) are suspended because of the concern of patients “dipping” into the next day’s dose.
Patients must attend clinic and see a Dr to be restarted because they have to be assessed in person first. BMC staff will cooperate to get you in for a restart as soon as possible. Do not delay calling.

Remember that with Suboxone and methadone the maximum effects of withdrawal happen at 5 days. Some patients doing well in recovery have missed 2 days and do not feel too bad so they think it might be a good opportunity to get of the program. If because of weekends or holidays they can’t get into clinic until 5-6 days after their last dose most have either relapsed or feel very uncomfortable by the time they are restarted.

If you miss or are going to miss an appointment call BMC and ask for an extension of your prescription. If the clinic is closed you might try BMC pharmacy. BMC pharmacy has access to the medical record which can help the physician on-call. They may be able to get an extension for you. Also, if you have missed a sample you can provide one there before your dose is given. 

Top

What if I stop going to my methadone or Suboxone program?

The following discussion assumes you have not tapered off of your medication.

One common scenario is a patient misses an appointment or doesn't get to the pharmacy and misses a dose or two of their medication. They notice their withdrawal is not as bad as they had expected after the first 1-2 days. Then they think that perhaps they don't need the medication any more because, after all, they haven't used any opiates or had the urge to use opiates for weeks or months.

Unfortunately there are at least two things that haven't been considered in the decision process.

First, is the fact they have not had the urge to use and have not used in weeks or months is in part because their opiate needs are being met by the medication. They still have an opiate deficit. The medications work so well to fill the opiate deficit that people sometimes forget this – because they feel perfectly normal, not at all like they did when they were using every day.

Second, is that although it is typical when using street opiates to have withdrawal within 24 hours if you don't get another dose of opiates both methadone and Suboxone are much longer lasting medications – maximum withdrawal does not occur for most people until day 5.

Almost inevitably the outcome of stopping methadone or Suboxone is a relapse. Just like stopping illicit opiates usually leads to a relapse. Sometimes it is right away, sometimes it is weeks later.

Relapse should be avoided if possible – sometimes it results in people dramatically increasing their use of opiates. Other times it results in a change in the route of administration – perhaps moving from snorting to intra-venous use. And then sometimes it results in a life changing experience for example a loved one or boss that finally gives up on you or getting arrested. These things follow you for a long time after the relapse has passed.

In any case where you have relapsed please contact BMC as soon as you decide to restart the program. We will do our best to get you in right away. 

 

 

Top

Will methadone affect my baby if I am pregnant?

Pregnant women on methadone have less miscarriages and larger healthier babies than babies born to mothers addicted to street opiates. Consequently, the expert advice is that if a woman is an opiate addict she should be started on methadone as soon as possible. Methadone does not cause birth defects. Longitudinal studies (investigations following a study group for a period of time) have found that children born to methadone mothers develop the same from infancy through grade 1(this is where the study ended).

So, the evidence suggests that you are more likely to carry your pregnancy to term and your baby is more likely to be healthier at birth and there is no evidence of long term effects from being exposed to methadone during pregnancy. Remember also that methadone has been used to treat addiction for more than 50 years so if there was a problem it would likely have been exposed by now.

Babies do develop Neonatal Abstinence Syndrome – NAS. This is a withdrawal syndrome and can be present in babies born to mothers who are dependent on any drugs including tobacco. NAS may take a week to develop so these babies are monitored for a week which is longer than babies not exposed to these medications. At BMC our experience is about 60% of babies born to mothers on methadone end up requiring morphine to help with the withdrawal syndrome. Many get discharged home with morphine for mom to administer. It is very important to understand that the chance of the baby developing NAS is NOT related to the dose of methadone the mother is on.

Breast feeding is encouraged for mothers on methadone unless you use cannabis (marijuana or pot or hashish). Breast feeding is dangerous for mothers that use cannabis because the amount of THC (an active ingredient in marijuana) concentrates 8 times in breast milk – therefore if you smoke 1 joint the baby gets 8. THC definitely affects the developing brain resulting in decreased intelligence.

Top

Will Suboxone affect my baby if I am pregnant?

Please read the section on methadone and pregnancy. Most of this applies to Suboxone as well. Suboxone has not been around as long as methadone so there is not quite as much data from studies however the use of buprenorphine in pregnancy and during breast feeding is still recommended.

Most physicians experienced with pregnant opiate dependent patients feel Suboxone is probably OK, however the official policy is that patients that become pregnant on Suboxone (buprenorphine and naloxone) should be switched to Subutex (buprenorphine) because there is insufficient data to support naloxone in pregnancy even though naloxone is not absorbed orally. BMC follows the practice of switching patients that become pregnant from Suboxone to Subutex.

We must access Subutex through a federal program that allows doctors to bring in drugs in special situations that are not licensed in Canada . It takes about 2 weeks and we continue the patient on Suboxone during this time.

It is OK to breast feed while on Suboxone or Subutex.

Interestingly, one study showed that compared to babies born to mothers on methadone, babies born to mothers on Subutex had less NAS (withdrawal). 

Top

I am pregnant. Should I try to get off methadone or Suboxone before the baby is delivered?

This is not recommended for a few reasons. In fact expert opinion suggests the opposite – pregnant women should be put on methadone as soon as possible.

During the first trimester of the pregnancy (week 0-13) going into a withdrawal state is associated with an increased chance of miscarriage.

During the third trimester (week 27-40) many mothers require more opiate support because the mom and baby get bigger. Also during this time the mother's enzymes are induced. This speeds the metabolism of many compounds including methadone and Suboxone.Our experience at BMC shows about 60% of the mom's increase their dose of medication. The same amount of mothers decrease their dose a few months after delivery.

Mothers are at a much higher risk of relapse once they are off methadone or Suboxone than while on these medications. They are also at a higher risk of relapse when they are under stress – like the stress of delivery and having a new baby at home. Given that methadone and Subutex are safe in pregnancy it makes more sense for most people to wait until a few months after the delivery when things settle down. At this point they can start a taper at a rate that will keep them comfortable and drug free. A relapse definitely affects your ability to care for a child. 

Top