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Addiction (Expert Forum)
Concerning Suboxone and Ativan
Answered by
Jeffrey T Junig, MD PhD - Psychiatry, Addictions, Chronic Pain Treatment, Anesthesiology, Buprenorphine
Fond du Lac Psychiatry
Fond du Lac - WI
Questions in the Addiction forum are answered by a medical expert.
Concerning Suboxone and Ativan
by ufindme, Jul 31, 2009 06:35AM
My first question is this: I took my last Suboxone on Tuesday, July 28, 2009. I was taking 8-16mg per day (alternating). How long does it take for the Sub to release from your receptors? I believe there is a half life of 36 hours, but does that mean that after 36 hours you start to detox from it? The reason for stopping it is this. I broke my hip back in June and had to have a total hip replacement. The hospital D/C me on Fentanyl 50 mcg/h because my Sub Dr. recommended it. I wore the patch 12 days, and after taking it off (even though the withdrawal didnt seen so bad), I started back on 8-16 mg of Sub (out of withdrawal fear I think). Then I was on it for 2 weeks when my Dr. had to put me back on the patch because of complications and severe pain. I waited 2 days after stopping the Sub when I placed a patch back on. At first the patch wasnt helping to much but now its been 4 days and I'm beginning to feel some relief. Is the Sub out of my system to a certain point now?
My second question is this: Ive been on prozac and ativan for a year and a half now. My Sub Dr. is aware of it too. No complications. Im starting to ween myself off the ativan (with both my PCP and Sub Dr. knowing it). I am taking 2- 1 mg tablets twice a day. The Doc said to take 1 1/2 pills for a week then go down to 1 mg per day for a week, then 0.5 for a week, then break that in half and so on til I quit. Does this sound right to you? I guess I wanted to get a second opinion since I know how bad withdrawal is with benzos. Benzos are very scary to come off of. Sorry this is so long. I just didnt want to write you twice.
Thank you,
Ellen
My second question is this: Ive been on prozac and ativan for a year and a half now. My Sub Dr. is aware of it too. No complications. Im starting to ween myself off the ativan (with both my PCP and Sub Dr. knowing it). I am taking 2- 1 mg tablets twice a day. The Doc said to take 1 1/2 pills for a week then go down to 1 mg per day for a week, then 0.5 for a week, then break that in half and so on til I quit. Does this sound right to you? I guess I wanted to get a second opinion since I know how bad withdrawal is with benzos. Benzos are very scary to come off of. Sorry this is so long. I just didnt want to write you twice.
Thank you,
Ellen
Doctor's Answer
by Jeffrey T Junig, MD PhD, Aug 04, 2009 10:05PM
, Aug 04, 2009 10:05PM
To do the second question first-- that taper sounds reasonable. Many people prefer, though, to switch to a long-acting benzo like clonazepam or diazepam first, as that provides a 'smoother' experience and fewer periods where you feel panicky from a lack of drug in your body. But the pace is appropriate for a 'moderately- paced' detox. You could go much more slowy, or you could go a little bit more quickly-- just a little bit.
A couple things about Suboxone, or more accurately about buprenorphine, since that is the active ingredient. Any reversible ligand (a ligand is something that binds to a receptor) is constantly in a state of binding and 'unbinding' from the receptor, and buprenorphine is no exception. There are 'association constants' and 'dissociation constants' that explain the rates of attaching and separating, and the ratio between the two determines the 'affinity' or potency of the drug at the receptor.
The half-life of buprenorphine can be described as 'effective half life', 'terminal half life', or other terms depending on whether you are referring to drug in the body, drug at the receptor, drug in the brain, etc. The effective half life is dependent on dose with buprenorphine because at very high doses (as I have written about extensively on my blog Suboxone Talk Zone, 16 mg is a very high dose) the enzymes that break it down become overloaded, slowing down the overall process. At 16 mg, I have seen studies showing effective half lives of over 72 hours, but there will be variability between different people.
Fentanyl has very complicated kinetics; in low doses it has short duration actions, but after prolonged use it saturates fat stores and starts to accumulate in higher doses in the blood. It is not unusual for a person to feel one level of opiate intensity for a few days, then 'step up' the intensity after that point from the fentanyl building up.
When you started the fentanyl there were a couple processes going on that both limited your early response to the drug; it takes at least a few hours, maybe a day, for the drug to get through the skin and into the bloodstream in significant amounts, and early on your opiate receptors were being blocked by buprenorphine. The block is competitive, so the ratio of fentanyl to bupe would determine the opiate effect. IT would take at least several days, and perhaps a week or more, for the buprenorphine to be absent from the receptors sufficiently to allow the complete effect from the fentanyl. Even then, your tolerance would be high from the buprenorphine, and so the effects of the patch will be reduced.
A couple things about Suboxone, or more accurately about buprenorphine, since that is the active ingredient. Any reversible ligand (a ligand is something that binds to a receptor) is constantly in a state of binding and 'unbinding' from the receptor, and buprenorphine is no exception. There are 'association constants' and 'dissociation constants' that explain the rates of attaching and separating, and the ratio between the two determines the 'affinity' or potency of the drug at the receptor.
The half-life of buprenorphine can be described as 'effective half life', 'terminal half life', or other terms depending on whether you are referring to drug in the body, drug at the receptor, drug in the brain, etc. The effective half life is dependent on dose with buprenorphine because at very high doses (as I have written about extensively on my blog Suboxone Talk Zone, 16 mg is a very high dose) the enzymes that break it down become overloaded, slowing down the overall process. At 16 mg, I have seen studies showing effective half lives of over 72 hours, but there will be variability between different people.
Fentanyl has very complicated kinetics; in low doses it has short duration actions, but after prolonged use it saturates fat stores and starts to accumulate in higher doses in the blood. It is not unusual for a person to feel one level of opiate intensity for a few days, then 'step up' the intensity after that point from the fentanyl building up.
When you started the fentanyl there were a couple processes going on that both limited your early response to the drug; it takes at least a few hours, maybe a day, for the drug to get through the skin and into the bloodstream in significant amounts, and early on your opiate receptors were being blocked by buprenorphine. The block is competitive, so the ratio of fentanyl to bupe would determine the opiate effect. IT would take at least several days, and perhaps a week or more, for the buprenorphine to be absent from the receptors sufficiently to allow the complete effect from the fentanyl. Even then, your tolerance would be high from the buprenorphine, and so the effects of the patch will be reduced.
