Ask an Expert: Should I Go Off Suboxone? If So, How?
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In all of healthcare there is no better place to understand the need for a biopsychosocial approach than addiction treatment. By definition, substance use impacts both brain and body, and the developing field of addiction medicine now has a variety of agents with specific application to the treatment of past or current substance misuse. As will be noted below, experts in addiction medicine must factor in a variety of forces and factors—biological, cognitive, societal, interpersonal and psychological—in order to fully understand the individualized approach that any given individual client requires to attain and maintain an optimal recovery.
For a “relaunch” of The Fix’s popular “Ask an Expert” feature, we have asked many of the country’s leading addiction medicine providers to respond to a reader question that focuses on two of the most vexing questions in the field: Does it make sense to come off Suboxone, and how should it be done for those who want to go that route? - Richard Juman
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Question: I have been on Suboxone for several years at a very low dose. I feel like it dulls my intelligence and personality, that I have lost my spark and walk around feeling a little bit like a zombie. I'm not using any heroin or pills, so most of my family and friends are happy, but a few people can tell that I'm pretty flat and humorless. Some people have said it's the lesser of two evils. In speaking with others who are on Suboxone, it's hard to find somebody who is having a really positive experience, and yet we are all being told to stay on the medication. How can I know when I should stop taking it? What would you suggest as a way for me to safely get off of Suboxone?
Answers from our panel of experts:
Dr. Mark Willenbring: The first question to ask is whether you've been taking an adequate dose of Suboxone. Remember that the goal of Suboxone therapy is not the lowest dose, but the right dose. So one possibility is that your current dose is too low to provide adequate replacement for the brain opioid deficiency that results from opioid addiction. The first thing I would recommend is to increase your dose of Suboxone to see if it helps establish a sense of well-being. I tell my Suboxone patients that they know they are on the right dose when they take their daily dose and don't feel any different after their daily dose than they did before. If they feel any effect, it suggests that their current dose of Suboxone is too low. Remember: the goal of Suboxone treatment is not the lowest dose, it's the optimal dose. I have many patients who feel normal, energetic, and who are very functional on the correct dose (the average dose of buprenorphine is 16mg daily, with some people needing 24mg daily.)
If you are on an effective dose of Suboxone (not less than 16mg bup daily) but are still feeling bad, consider these steps:
1) Talk to your provider about increasing the dose of Suboxone.
2) Consider transitioning to a methadone maintenance program. Some people who don't respond well to Suboxone do well on methadone.
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3) There is no indication to stop opioid maintenance with either methadone or buprenorphine. There are no other proven effective treatments for opioid addiction.
4) If you really want to stop taking buprenorphine, do so gradually and with the help of an experienced doctor. If you start to experience cravings, preoccupation and/or withdrawal while tapering, it strongly suggests that you should stay on opioid maintenance, perhaps with a dose adjustment or change to a different medication. Unfortunately, if you stop opioid maintenance therapy, your chances of recurrence are > 90%. All the best.
Mark Willenbring, MD, is an internationally recognized addiction psychiatrist who is a leader in implementing new research findings into treatment for substance use disorders. Full bio.
Dr. Anna Lembke: I occasionally hear this complaint of feeling "dulled" or lacking in "personality" from patients on Suboxone, as well as patients on antidepressants. However, it’s difficult to tease out whether the patient’s personality is altered due to the medication, or whether their life without the drama of doing drugs is simply different than the life they knew before. One of the hardest aspects of recovery is learning to grapple with the ordinariness of everyday life. The best way to differentiate which is which, is to decrease the dose of Suboxone by a very small amount and wait at least one month for the brain to readapt. After one month at the lower dose, the patient and health care provider should reevaluate. If "the spark" seems to have come back a little, and the craving has not returned, then perhaps it makes sense to stay at that lower dose, or even try lowering further. In any case, it’s always important to weigh the risks and benefits of any drug, and not be afraid to discuss this with your doctor.
As for the best way to get off of Suboxone? The answer for most people is—slowly. I’m disappointed to hear that you’ve not met anyone who has had a "good experience" on Suboxone. Let me say that I have seen many patients over many years whose lives have been transformed in a positive way with Suboxone treatment. There is no treatment that works for every patient, but decades of accumulated evidence show that Suboxone is a lifesaving treatment for many, can improve not just drug use but also overall quality of life, and reduces the transmission of deadly diseases like HIV (see Strang et al., Lancet, 2012).
Anna Lembke, MD, is the program director for the Stanford Addiction Medicine Program and Chief of the Stanford Addiction Medicine Dual Diagnosis Clinic. Full bio.
Dr. Adam Bisaga: It looks like you feel that the benefits of living in abstinence from opioids with the help of buprenorphine is significantly dulled by the experience of losing the “spark” and feeling unwell, overall. In my clinical experience, and from the experience of many addiction treatment doctors that I talk to frequently, this is not a common occurrence. Most patients that remain on buprenorphine, and are completely abstinent from opioids and other substances, report a significant improvement in their mood (no anxiety or depressive symptoms), and have increased motivation and enjoyment of life’s attractions.
There might be several reasons why you do not feel well. First, the dose of buprenorphine may be too low, and you may feel better on a higher dose. There seems to be a minimum maintenance dose of buprenorphine below which patients become unstable and experience withdrawal-like symptoms. Second, you may be one of those people that have additional psychiatric disorders that actually preceded your dependence on opioids but have now reemerged, as is the nature of those syndromes. In that case, evaluating and treating your symptoms with a combination of psychotropic medications and therapy might be very useful. And finally, some patients do not feel well being on buprenorphine on a long-term basis and may feel better being in an opioid-free state. For such patients, we recommend detoxification and transition to an opioid antagonist (naltrexone tablet or Vivitrol—a long-acting naltrexone injection). Treatment with naltrexone will not only protect you from relapse (as it is a very potent blocker of opioids) but may also decrease cravings and improve your mood, both of these are well known effects of naltrexone.
I do believe that one of those three strategies will be helpful for the majority of patients who find themselves in a situation like yours. I encourage you to speak with your doctor to better understand how the treatment plan can be altered to help you through these symptoms. Alternatively, you and your doctor may seek a consultation with an expert in addiction psychiatry.
Adam Bisaga, MD, is an academic psychiatrist, educator and clinician. He is a Professor of Psychiatry at the Columbia University Medical Center, and a research scientist at the New York State Psychiatric Institute. Full bio.
Dr. Steve Scanlan: The first question you need to ask your current Suboxone doctor is whether he has ever taken anyone completely off Suboxone or Subutex. If he says that he just tapers a patient down after they have been on it long-term and they are fine, then he is disingenuous or at least ill-informed. If he tells you that he is going to put you on 16mg sublingually for six months while your brain stabilizes and heals and then taper you off it, he is purposely or unknowingly misleading you. How can your brain heal if you are still taking an extremely potent opioid that is classified as a pain medication and approved by the FDA as a medication to treat severe pain? On the other hand, if he tells you about the symptoms I discuss below and has previously helped people get off Suboxone when they are ready, then stick with this doctor and do what he says.
When I detox patients off Suboxone, I follow them for approximately five or six months, seeing them once a week during that time. I make sure to follow up with them for at least two months after we stop the Subutex. I do not use Suboxone, only Subutex, and I will explain why not. (Please click here to read the rest of Dr. Scanlan's response.)
Steve Scanlan, MD, is board certified in general psychiatry and addiction medicine and practices in Boca Raton, Florida. He specializes in office based detoxification from alcohol, opiates (heroin, methadone, vicodin, oxycontin, percocet, fentanyl, etc.), and benzodiazepines. Full bio.
Dr. Damon Raskin: You are definitely not alone! I see several patients a week who have been on Suboxone for far too long, and who have a great deal of difficulty getting off of it. Suboxone is still a “partial” opiate, and for some patients, the detox of getting off Suboxone can be nearly as bad as heroin. Although it is true that I would rather have my patients on Suboxone than on heroin or other opiates, I tend to use Suboxone as a way to make the detox of heroin and other opiates more comfortable, not as a long-term substitute. Since you are clearly having negative symptoms associated with its use, the time to get off is now.
The easiest way to get off Suboxone is to do it slowly and under the care of a doctor who specializes in addiction medicine. Depending on the dose you are currently on, I would wean you off over a four-to-six week period. As symptoms of detox develop, I treat those with other non-addictive medicines to help combat chills, aches, nausea, insomnia or restlessness. If this is too difficult to do as an outpatient, then I strongly advocate inpatient treatment. All of this should be done in conjunction with addressing the psychosocial components of addiction meaning individual or group therapy, AA or NA meetings, or all of the above.
Once the detox is complete, I highly recommend the use of once-monthly naltrexone injections to help prevent relapse. This medication is completely non-addictive and blocks the opiate receptors in the brain, making relapse much less likely and helping with opiate cravings.
Damon Raskin, MD, is a board-certified internist who has been specialized in addiction detoxification for the past 12 years. Full bio.
Dr. Michael Ascher: Thank you so much for your question. My first question for you would be how much Suboxone (buprenorphine-naloxone) are you taking? What may be low for someone may be high for another person. It sounds like you are suffering greatly and the cause may be multiply determined. Your symptoms could be the result of a protracted withdrawal now that you are no longer using illicit opioids. Protracted withdrawal symptoms include insomnia, fatigue, irritability, anhedonia (inability to experience pleasure), and anxiety. Protracted withdrawal symptoms, if left untreated, can last up to two years for some individuals with an opioid use disorder. The emotions you may be currently feeling could also be due to an underlying depressive, anxiety or traumatic disorder that was masked by the illicit opioid use before starting Suboxone. The symptoms could also be due, in part, to an underlying medical condition such as thyroid problems or vitamin deficiencies (B12 and folate).
The most important thing to remember is to find a physician who you feel you can trust to listen to you openly and non-judgmentally. The role of counseling or psychotherapy in the treatment of opioid use disorders is paramount. Suboxone and other relapse prevention medications (naltrexone and methadone) are only a piece of the full treatment that can include individual or group psychotherapy, 12-step programs or other forms of psychosocial support. You may want to consider regularly discussing the role of Suboxone in your treatment with your prescribing doctor. Despite common misconceptions, coming off of Suboxone should be done with the help and oversight of a physician who can personalize the taper based on your needs.
Michael Ascher, MD is a board-certified psychiatrist who serves as a Clinical Associate in Psychiatry at the University of Pennsylvania and is in private practice. Full bio.
Dr. Edward Paul: People have extremely varied reactions to Suboxone, not the least of which is cultural expectation—but more of that later. If you have been drug free all this time, and are at a low dose, there are a variety of pharmacologic candidates, including very low-dose naltrexone, which are gradually increased to "reset" the receptors. Some people who have serious restless legs have responded to Cogentin (had one patient stop using that), or Requip. I have heard two cases of prednisone helping. Yoga retreats, or some inpatient rehabs offer help. Check for underlying depression though. Suboxone sometimes works as an antidepressant. Attitudes toward opiate replacement therapy, as opposed to medication-assisted therapy, may play a role.
Edward Paul, MD, has been working in addiction psychiatry for almost three decades (unless you count his eighth-grade self talking a friend out of trying heroin.) Full bio.
Dr. Howard Wetsman: First, are you sure that the symptoms you relate are due to the Suboxone and not due to the lowered dose? Most people I have met with addictions have been able to identify symptoms of lowered dopamine tone (blunted affect, can’t think sharply, poor attention, don’t connect with others, etc.). These symptoms don’t go away with abstinence in everyone, and some people notice these symptoms come back when lowering the dose of buprenorphine. Some people are able to get greater dopamine receptor density from a recovery lifestyle, and for some that is enough. Others need medication even with a recovery lifestyle. Before you make a decision to get off meds, please talk to your doctor.
Now to answer the question, I have found that some people who have trouble getting off the last 1mg or 2mg of buprenorphine actually need something else. I’ve met people with genetic problems related to dopamine release that couldn’t get off until we gave them the specific treatment they needed, like L-methylfolate for MTHFR polymorphisms. There are others I don’t have room for here. In full disclosure, let me add that I have colleagues that I greatly respect, but with whom I disagree on this point, that say it’s easier to stop 8mg than 2mg because buprenorphine becomes a full agonist at low dose. I haven’t had success with their methods but they say they have. Again, what’s most important is to speak to an addiction medicine doctor who understands the total illness and total treatment, not just buprenorphine.
Howard C. Wetsman, MD, is a clinical assistant professor at LSU Medical School and a fellow of the American Society of Addiction Medicine (ASAM) currently serving on that organization’s national board. Full bio.
Percy Menzies: First of all, congratulations on being off heroin and opioid pills. Do not consider Suboxone the lesser of the two evils—this drug has helped tens of thousands to lead normal lives. We encourage our patients to get into activities that rejuvenate the endorphin system—the "feel-good" chemical we all need. The best way is to get into healthy activities—exercise, bicycling, walking, running, etc. Start with light exercise and gradually build up. Other healthy activities could be reading, journaling, taking up new hobbies, healthy relationships, etc.
The next step is to gradually reduce the dose of Suboxone. At our clinics, patients are tapered down by 2mg over 8-10 days, sometimes as long as two weeks.This gradual tapering down along with the other healthy activities allows for the endorphin system to regain normalcy. It is critical that you have eliminated all the triggers and cues of past drug use. These include people, places and things.
Good luck with your recovery.
Percy Menzies has worked closely with drugs courts and provided training on the use of anticraving medications to reduce recidivism within the criminal justice population addicted to alcohol and opioids. Full bio.
Dr. Jeffrey Junig: Since you have the general sense that "you are being told to stay on the medication," I doubt my answer will ring true to you. Because of the strength of the placebo effect—where even clinical depression responds to changes in attitude—how you "feel" is strongly impacted by what you think and do. I screen for potential patients who are desperately ready for sobriety, and those patients talk for years about how blessed they are to have found buprenorphine. On the other hand, the patients I accept who were "on the fence" about treatment usually find something to dislike about the medication.
Being "flat" and "humorless," from my experience as a recovering addict and as a psychiatrist, is a function of factors other than buprenorphine. All recovering people know about "dry drunks," or people who stop their addiction but neglect to cultivate the things in life that bring pleasure. I encourage all of my patients to work their hardest to grow hobbies, repair relationships, initiate exercise programs, and progress in the workforce. People who do those things are more likely to feel happy and content, regardless of whatever medications they are taking.
We know that relapse is almost 100% after only one year on buprenorphine, counseling or not. Stopping buprenorphine exposes you to the withdrawal you would have had if you had never started buprenorphine. The biggest safety issue from stopping the medication is the high rate of relapse with opioid dependence—and the attendant mortality rate associated with overdose.
Jeffrey T. Junig, MD, PhD, is Assistant Clinical Professor of Psychiatry at the Medical College of Wisconsin. Over the years, his clinical practice has approached opioid dependence from a range of perspectives including residential, outpatient, and medication-assisted treatments. Full bio.
Dr. Ricardo Borrego: Quitting Suboxone involves both clinical and practical considerations. Clinically speaking, Suboxone is a medically-assisted maintenance therapy, designed as much for community safety as it is for patient efficacy. Suboxone’s opioid component, buprenorphine, has a long half-life and tight adhesion to opiate receptors in the brain—properties that help to prevent the onset of withdrawal symptoms, but also make the drug more difficult to quit. How long Suboxone withdrawal lasts varies—it may be more intense and last longer if you’ve been on the drug for a long time or at a high dosage.
Practically speaking, the least disruptive way to get clean is medically-assisted detoxification (or infusion detox as we refer to it) therapy, followed by a naltrexone regimen and counseling for at least one year. Detoxification takes a few hours at most and eliminates the painful physical symptoms of withdrawal. After a day or two of rest, you can return to work, etc. Naltrexone is a non-narcotic drug that helps to reduce physical cravings and risk of relapse.
Another option is to reduce the dosage of Suboxone very slowly—a process called titration—before attempting to quit altogether. Physical withdrawal symptoms will likely be present for at least 1-2 weeks and you should plan to be away from any major responsibilities during this period.
Regardless of which path you choose, counseling is highly recommended. The “dulled intelligence” and “humorless” personality you describe will likely be replaced with elevated emotional experiences following detoxification and you will need time to adjust.
Ricardo Borrego, MD, is a board-certified anesthesiologist and co-founder and director for the Eagle Advancement Institute (EAI) in West Bloomfield, Mich. Full bio.