Can sub cover a 350 to 500mg habit?

[ProdigalGirl]

Dear Doctor,
I am trying very hard this evening to find an answer to this difficult question. Can the highest dose of suboxone work with w/d for at the very most 500mg opiate addiction? What is the ceiling of opiates that sub will cover? I have a friend in desperate need of sub treatment. When I started sub, I was a 320mg a day maximum oxycontin user (mostly 160mg)but tapered down to 80mg 5 days before induction and did fine. My friend is taking oxycontin in very high doses along with anything else she can get her hands on. I found out she has been a long time user as well. She informed me she will not taper as she has nobody to help her and I for sure cannot hold the pills. Would she be a better candidate for methadone? Also, she does not swallow them whole and on accasion snorts them. I am very worried for her and need an answer quickly. She is spiraling out of control fast.

[J T Junig, MD PhD]

In my experience the dose of Suboxone needed isn't related closely to the dose of agonist being abused--  Suboxone hits the 'maximal effect' at a dose of about 2 mg-- and higher doses don't result in any greater opiate effect.  The problem is that a person on that much agonist will have withdrawal when starting any dose of Suboxone-- she needs to get her tolerance down a bit before taking Suboxone.  That can be done by tapering down over time- or it can be done more quickly by a period of abstinence.  Specifically, I would have a person taking that much oxycodone stop using for about 5 days, and give her clonidine and immodium to manage as best she can.  After that 5 days, the Suboxone would likely relieve her withdrawal and she would do well going forward.  If she only goes 24 hours, her tolerance will still be so high that Suboxone would precipitate withdrawal.  It wouldn't necessarily be dangerous, but it would be pretty miserable.

[worried878]

would it be possible to cover this high of a dose 350-500 mgs) oxy with methadone?  just asking, doctor as curious..I do know u favor sub, but in some cases would methadone be the better choice if the person was in utter fear of wd?