Suboxone question

[refusingbondage]

Dear Dr. Junig:  I have a question.  Without getting into the pros/cons and good vs. evil debate regarding suboxone and its use--this seems to be a topic that is extremely heated with many people with many different experiences and opinions on each side of the argument.  I think one thing we can all agree on is its usefulness and how it can be such a useful tool in the recovery process for many.

So on to my question - could you please tell me about withdrawal from suboxone.  If someone is only using for short term detox --  maybe 30 days or less.  And long term treatment withdrawal.  If someone spends a few years taking suboxone.. from 24 mg, down to 1 mg or even .5 mg - how difficult is it to finally quit taking suboxone?   Thank you.

[J T Junig, MD PhD]

That is a difficult question with an answer that is-- you guessed it-- controversial!  I talk about this at length on my Suboxone Talk Zone blog-- I mention it because I can't reproduce the discussion on the topic that has gone on there for months and months.

I have helped and followed a number of patients as they tapered off Suboxone, after both short and long-term use.  I have observed some interesting and even conflicting things-- most patients have significant withdrawal symptoms, but not always.  I have had two patients, including one that I just talked to a few days ago, who claimed to have no significant withdrawal whatsoever.  I have come across that report on the web as well.  More common, though, are the angry posts from people claiming to have horrible withdrawal and very difficult times trying to stop the medication.

I do not believe the posts that 'Suboxone withdrawal is the worst I have ever had-- worse than methadone, heroin, oxycodone, etc'.  I am not saying the people are being dishonest;  I think that the opinion comes from human nature-- that in general people don't remember bad things as much as they remember good things.  People have 'euphoric recall' for active addiction, remembering the rare nice times and forgetting all of the misery;  similarly the current withdrawal seems worse than anything they have experienced before.  I see a clear difference between how people do going through withdrawal from oxycodone or methadone-- when they miss work, miss appointments, etc-- and how they experience Suboxone withdrawal-- when they make their appointments while complaining about how miserable they are.  I am also aware of the many research studies that demonstrate less-severe withdrawal from Suboxone compared to withdrawal from agonists in 'blinded' research trials.  Finally, a number of treatment centers use Suboxone as a 'tapering agent' to help people get through opiate withdrawal.

Again, I talk in greater detail on the blog, but one final comment:  the withdrawal is unusual in several aspects from what people usually expect.  First, because of the long half-life, the withdrawal takes 2-5 days to start when Suboxone is stopped abruptly.  Because of the ceiling effect, there is little withdrawal when tapering down within the high range of doses-- above 8 mg.  The worst part is the last 4 mg, when you enter the 'steep part' of the dose/response curve.  Many patients cruise through a taper and then get stuck at the last 2 mg.  

Finally, some people seem to confuse 'untreated addiction' with 'withdrawal'.  After coming off Suboxone, a person who feels irritable and depressed for months cannot blame Suboxone if he is an untreated opiate addict-- the depression and irritability may represent cravings for escape from reality and nothing more.  And most important-- the people who are on Suboxone are people who could not stop taking other opiates.  Since they could not stop other medications, why would they expect Suboxone to be any different?  Suboxone is useful to induce remission of opiate addiction.  It didn't come with a 'cure' attached, nor did it come promising to be 'easy to stop after taking it'.  It has opiate effects, and opiate addicts love opiate effects-- they LIVE FOR opiate effects!  So of course it will be difficult, if not impossible, for them to simply walk away from Suboxone.  But that is not a problem in my book, as that is not what Suboxone is for.  More and more, Suboxone is becoming a chronic medication for a chronic illness.  

[refusingbondage]

Thank you for responding.  I am not a doctor and it has confused me to no end to read of such conflicting experiences people have coming off suboxone.  I was on for a little over  2 years and definitely suffered a long, pretty bad withdrawal from it - but I am now 120 off of it and all together feeling really good and happy about life.  I think many people are being told there is no withdrawal coming off suboxone and it seems a lot of anger comes from that.  I treated with an amazingly supportive doctor once a month for over 2 years- with therapy too.  He was extremely supportive and on our last visit we both had tears in our eyes.. I stopped at 1mg (and you are right the last few taper times 4mg to 2mg to 1mg were pretty rough and I was stuck at 1mg for at least 6 months) At that last visit we hugged and he promised me little to no withdrawal.  Unfortunately that wasnt the case and that's when I got really angry.  I didnt quit it expecting any withdrawal so I know it wasnt mental- I was actually very scared and thought something was wrong with ME because I was having withdrawal for so long.  I didnt find any support or med forums (this forum in particular) until my 10th day into it I think, but was at least comforted by talking to others with similar experiences and also happy for those who did indeed have no withdrawal coming off (and a bit envious).  In any event - thank you for a very straight forward and honest response.