Disclaimer: While most if not all of what is contained in the following couple of pages is consistent with the federal intentions for Suboxone, listen to your physician first. If you feel that your doc is incorrectly dosing you, then pursue a second opinion. But whatever you do, do not self medicate this or any other prescription medication ever.
Introduction to Suboxone
Suboxone is a medication federally approved for detoxing opiate addicts. Whether you have escalated on opiates because of underlying chronic pain or surgery, or from substance-abuse without any underlying opiate requirements, Suboxone is a nice alternative for detox (or maintenance if there has been decades of abuse).
But there’s word on the street it’s a box 1 is itself addictive. Probably the most significant thing that might lead to a dependence and addiction on Suboxone is multiple dosing of it per day.
There is growing resentment against Suboxone because in so many patients it doesn’t seem to be working.
And the other word on the street is that Suboxone is addictive.
I think I may have figured out why so many patients experience treatment failures using Suboxone. You’ll find most of these patients complaining of being dependent on it or finding that it is no longer working are taking it more than one time per day.
Following induction and often times multiple doses those first few days where we determine how much Suboxone you will be on… It should be dosed only once a day. And the reasons why are described below.
Its dosing schedule is regularly dosed incorrectly even by well intending physicians, respected psychiatrists, and approved rehabilitation centers. This review highlights some of the important features of correct Suboxone prescribing and dosing.
To start with, please remember, Suboxone is an opiate. Unlike most opiates though, it has an extremely long half life. And, unlike most long half-life opiates like methadone, Suboxone also has an extremely strong affinity for the opiate receptor. So, super long half life, PLUS super strong affinity for receptors.
The combination of these two pharmacokinetic properties makes Suboxone an ideal choice for once a day dosing, preferably in the morning, and this is what the federal government recommends. And I agree. For many reasons.
The feds really like this because you don’t have to take it with you to work or school. Thus, this opiate can totally stay off the streets. Less loss, less risk for diversion.
The opiate dependent patient likes a once a day in the morning dosing because they can just take their dose in the morning, and they’re on their way. They won’t need it again until tomorrow morning. Convenient.
The biochemistry rationale behind this single dosing is quite simple. It’s a receptor explanation. And here is a nice analogy that I heard in a seminar many years ago that helps me teach patients why it’s valuable to dose Suboxone only once a day.
If you, for a moment, can liken the opiate receptors in an opiate dependent patient’s body to fish in a fish tank, then small fish represent weak receptors and large fish represent strong receptors. If you feed fish of many sizes several times a day, the big fish will alone always eat the food you are giving them each at each and every feeding. If instead, you feed your many sized fish once a day first thing in the morning only, i.e., the total acumen of the daily feedings at the one time only, then not only will the large fish get to eat at that feeding, but the small fish will also get to eat at that feeding because of all the trickle down.
Similarly, If you dose Suboxone three or four times a day, or twice a day even, then only the large fish, sorry the large receptors, will get saturated. The weak receptors never will. If you are never saturating all your receptors, you are never feeling complete care, and you seek more drug. I think everyone knows this leads to increasing your receptor load. That leads to an ever increasing need for more drug as well.
So quite quickly, if you dose Suboxone multiple times a day, you will need higher and higher doses to feel normal. The WRONG doctor and sad patient thusly goes up and up and up on their Suboxone dose. And everybody’s confused as to why. Except you now.
Meanwhile the patient who is on only once a day dosing is saturating all his or her receptors, the dose stays conservatively low, and eventually the patient can be detoxed from Suboxone, the original plan for most patients.
And even if maintenance is considered, if once a day dosing is maintained, then the minimum dose of Suboxone remains adequate essentially forever. Escalating never happens.
The whole country’s learning about Suboxone right now. And unfortunately, it’s paying for the sins of its opiate predecessors. But more unfortunately, it’s being mis-dosed by ignorant physicians. Of course, the patients just do as they’re told. If these physicians tell their patients to take it two or three times a day, and I hear this every week several times, then those patients consistently report needing to go up and up on their doses, never coming off the Suboxone when they wanted to. And then when they do come off, they wind back on traditional opiates a few months later because of relapse which occurs more so in patients that had been dosed Suboxone multiple times a day than the patients that had doses it only once per morning.
And the word gets out that a patient was detoxed using Suboxone, and then there was a treatment failure. And Suboxone gets a bad reputation! Everyone scratching their heads lashes out against poor old Suboxone. But the real problem was the doctors who are prescribing it, making their patients take it multiple times a day. They simply had created too many receptors by the two or three time a day dosing.
So, regardless of its use, and there are a few including the federally approved opiate detox indication as well as some other off label uses including chronic pain and chronic anxiety (none of which are federally approved, none of which are covered by most insurances) — in all of these settings, it should not be dosed multiple times a day if you want to avoid problems with it like addiction. Once a day, first thing in the morning is likely the best Suboxone dosing.