Medication Assisted treatment

  THE EVIDENCE SEEMS QUITE CLEAR. MAT (SUBOXONE/METHADONE) GREATLY REDUCES OVERDOSE MORTALITY RATE IN COMPARISON TO ABSTINENCE BASED TREATMENT, FOLLOWING DETOXIFICATION.

Receipt of opioid use disorder treatments prior to fatal overdoses and comparison to no treatment in Connecticut, 2016–17 - ScienceDirect

“Our analysis was based on exposures to treatment, not their completion or retention, therefore our findings indicate that exposures to agonist MOUD treatment convey more benefit that non-MOUD even if the treatment is incompletely adhered to or terminated.”

Prevalent Misconceptions About Opioid Use Disorders in the United States Produce Failed Policy and Public Health Responses | Clinical Infectious Diseases | Oxford Academic (oup.com)

“Similarly, detoxification, the first step in abstinence-based approaches, has been associated with increased risk of opioid overdose when individuals resume nonprescribed opioid use [60, 61]. With this compelling medical information, one must conclude that detoxification followed by abstinence is neither a safe nor effective treatment.

In contrast, opioid agonist–based treatment sharply reduces overdose mortality. A recent meta-analysis found that the overdose risk for those in methadone treatment is 21% of that for individuals not in treatment, and for those in buprenorphine treatment the risk is 30% of that for individuals not in treatment [62]. “

My personal take on Suboxone and room for improvement on guidelines and communication:

- I only have experience taking suboxone and prefer to stick to talking about things where I can use my own experience AND data/literature, so I will not cover Methadone in my discussion. 

- I also want to include the caveat that the first time I was given Suboxone I was titrated up to 24mg, with my doctor (addiction 'specialist') knowing my daily oxycodone use was 180mg-240mg.

 

My issues with Suboxone which I strongly feel limits/restricts its beneficial potential and often results in negative experiences for people like myself are the following:

1. Generalization/nonspecific induction & recommended dosing guidelines

“Dosing and Administration” on page 1 states “The recommended target dosage of SUBOXONE sublingual tablet for maintenance is 16/4 mg. (2.4) “

I feel that target dosage should be tied to specific opioids/average daily consumption. A 2 gram heroin habit and a 60mg oxycodone habit should have different recommended target dosage. While many doctors have understanding of conversion, some doctors that I have met (and based on conversations with other users) do not have understanding and therefor do not dose appropriately. Additionally, given the diversion and self medication of Suboxone by users, there should be guidelines for these individuals to follow to set them up for better success.

2. A. Lack of smaller than 2mg dosing options

    B.  Lack of discussion of longer withdrawal timeline (compared to most full agonists) due to longer half-life and the downplaying of withdrawal symptoms in general, and in comparison, to full agonists.

Section 2.5 titled "Method of Administration" specifically states that "sublingual film must be administered whole. Do not cut, chew, or swallow SUBOXONE sublingual film"

From my experience and that of others I have spoken with (and online anecdotes) 2mg is more of a halfway point for a taper. I had to cut 2mg strips (which guidelines says are not allowed) into 10+ pieces to have a manageable taper without overwhelming symptoms of withdrawal. When you get to cutting the 2mg strip to more than a few pieces it becomes hard to be precise with sizing and therefor accurate with planned taper schedule. 

I feel that  there should be several additional formulations available including:

- 1mg

- .5mg

- .25mg

.1mg

When I asked CHAT GTP " based on peoples' experience with Suboxone, are withdrawal symptoms experienced after tapering to 2mg? " it responded with " Yes, withdrawal symptoms can still occur after tapering Suboxone (buprenorphine/naloxone) to 2 mg, but the severity and duration are often influenced by individual factors and the tapering process. Here's a closer look based on clinical understanding and anecdotal reports: 

• For many, tapering below 2 mg can significantly reduce withdrawal symptoms.
• Micro-doses (e.g., reducing in 0.25 mg increments) or switching to low-dose buprenorphine patches can provide a smoother transition off Suboxone.
• At doses of 0.5–1 mg, the body adjusts to very low levels of opioid receptor activity, making the final discontinuation easier.

1. Ceiling Effect at Higher Doses:
   
   • Suboxone’s effects plateau at higher doses (e.g., 8 mg and above). However, at doses of 2 mg or less, the tapering process often becomes more noticeable because the proportion of receptor activation decreases more significantly with each reduction.

1. Length of Suboxone Use:
   • Prolonged use (months or years) can lead to more noticeable withdrawal, even at lower doses.

1. Tapering Speed:
   • A rapid taper may increase the likelihood and severity of symptoms.
   • A slower taper (reducing by 0.25–0.5 mg every 1–2 weeks) minimizes symptoms.

1. Individual Differences:
   • Metabolism, overall health, psychological resilience, and prior opioid use history play a role in withdrawal experiences."

THE FACT THAT CHAT GTP SEEMS TO RECCEOMDND REDUCING BY .25-.5mg every 1-2 weeks to minimize withdrawal symptoms, yet the Suboxone guidelines clearly state you are not to cut a 2mg strip at all, is deeply problematic to me. 

In terms of the intensity of the withdrawal and the timeline itself, I feel that the guidelines do not match the experience I had (and many others I have spoken with).

Section 5.7 titled Risk of Opioid Withdrawal with Abrupt Discontinuation states: “Buprenorphine is a partial agonist at the mu‐opioid receptor and chronic administration produces physical  dependence of the opioid‐type, characterized by withdrawal signs and symptoms upon abrupt discontinuation  or rapid taper. The withdrawal syndrome is typically milder than seen with full agonists and may be delayed in onset [see Drug Abuse and Dependence (9.3)]. When discontinuing SUBOXONE sublingual tablet, gradually taper the dosage [see Dosage and Administration (2.8)]. “

When trying to ‘jump’ off of the lowest available 2mg dose during a ~45-day long taper from a 8mg maintenance dose that was maintained for ~2 months (not abrupt or rapid by my standards) I still experienced significant withdrawal symptoms, hence why I ended up ignoring the guidelines and cutting strips into small pieces. 

In terms of the withdrawal being “milder than seen with full agonists” while the first few days of oxycodone withdrawal were more intense than the first few days of suboxone withdrawal, overall, I felt the suboxone withdrawal to be worse, mainly because it lasted longer. While the guidelines speak to the delayed onset of withdrawal, they do not mention the extended duration of withdrawal due to the long half-life. Sublingual suboxone strips have a half-life of 24-42 hours and Oxycodone has a half-life of  4-6 hours (even shorter when snorted which was my method of consumption). The most difficult stage of acute withdrawal from Oxycodone for me was over after ~4 days, while Suboxone withdrawal off of 2mg dose lasted well over 1 week. It was so difficult to where I eventually went and bought Oxycodone from the street to taper off of the Suboxone. 

There should be more details of the longer withdrawal timeline of Suboxone compared to that of full agonists, so that people have a better idea of what they may experience.  

Just a few minutes with Chat GTP provided the following comparison: