I found this site called "The Buprenorphine Hideaway." A guy by the name of Nephalim worte a summary (information sheet) on his experience and knowledge of Buprenorphine, et al. Coming from the perspective of someone who was on Bup..I found it to be all the more informative..interesting and believable. He seems to be pretty well informed. If anyone cares to comment after reading it I'd like an opinion.?
From the pages of :
The Buprenorphine Hideaway.
The Buprenorphine FAQ - Version 2.01 WIP
By Nephalim27
Introductory Notes:
(bupe = buprenorphine, 'done/mdone = methadone, as far as this document goes)
First and foremost:
Bupe is not a wonder drug! While I am writing this from a bupe advocate position generally speaking, I will keep the facts objective, and my goal is an easy to read compendium of relevant information. I have had mostly wonderful experiences with bupe and as such it is only natural that I would think it's a good drug for maintenance (not getting high, although that doesn't mean a maintance "buzz" isn't included, although it appears to happen rarely in most people.) Neither bupe nor mdone is better, period. It all depends on the person and their goals (not just their goals, however, as bupe can work wonderful in certain people as a lifelong maintenance drug.) In general, using the limited facts and studies we have at the current time, it appears that 'done “works�?on more people than bupe does, but by only a very small factor, and only at higher doses of 'done (90mg+).
Secondly, and most importantly:
Opioids are can be extremely individualized in their subjective, and even sometimes objective, effects. Some work for some, other work for others, all with different effects. With buprenorphine this is multiplied by infinity. Every aspect of the drug can be VERY individualized (even the science of opioids is poorly understood in a large regard, especially so in buprenorphine's case). One of the large reasons for this is the fact that the drug is a "partial agonist." These words ring fear into the ears of pharmacologists, as they try to this day understand the puzzle (progress has been made, which I will address, but in this layman’s humble opinion the science of bupe is still poorly understood). On top of that, one person's experience with bupe will likely vary from day to day. I will get into this further later. Nothing said in this FAQ can necessarily be true to you. Please keep this in mind.Note: All of the technical information in this FAQ is relevant only to the USA unless specifically stated otherwise.
Disclaimer:
I am not a doctor. I am not a pharmacist. I am not a scientist. I am not a licensed professional of any kind, nor do I possess any relevant degree. I have absolutely no qualifications to provide medical advice. This FAQ is for informational purposes and should not be treated as medical advice. All medical advice should come from your doctor, and if the case is that you doubt what he is saying for whatever reasons, then a second opinion is the next step, not disobeying his orders to follow anything in this FAQ. You may, however, discuss what you may have found in here with him/her, and I encourage you to try to find as much evidence of what you are trying to tell him/her as possible. Try to do this as gently as possible, as no doctor enjoys being told he is wrong.
What is Buprenorphine? What is the DATA?:
Buprenorphine, exactly like methadone, is a medication given to keep people off of heroin and improve their, and society in general's, quality of life. Buprenorphine's major clinical importance is as an agonist. Buprenorphine is *not* like naltrexone (in terms of a treatment for opioid addiction). It's antagonist/partial agonist nature is only important in the regard that it might effect how well it can do it's job as an agonist, and as a side bonus that it can blockade very effectively (at least as far as most medical literature says, however this has found to be not true (it being effective) by at least anecdotal evidence and at least at the lower end of the dose spectrum,) other opioids, much like ‘done. This IS like Naltrexone, but it is not the primary clinical importance of the drug. For the reason it's a "partial agonist," it's regarded with less abuse, addiction, and diversion potential, and is schedule III under the controlled substances act which allows it to be prescribed by qualified physicians out of their offices as per the Drug Addiction Treatment Act of 2000 (abbreviated as DATA, and called as such for the rest of this FAQ
What the DATA is, From SAMHSA (the Substance Abuse and Mental Health Services Administration):
[The Drug Addiction Treatment Act of 2000 (DATA 2000) expands the clinical context of medication-assisted opioid addiction treatment by allowing qualified office-based physicians to dispense or prescribe specially approved schedule III, IV, and V narcotic medications for the treatment of opioid addiction. In addition, DATA 2000 reduces the regulatory burden on physicians who choose to practice opioid addiction therapy by permitting qualified physicians to apply for and receive waivers of the special registration requirements defined in the Controlled Substances Act.]
What this means is that drugs approved for maintenance (which currently only included Methadone, LAAM, and Buprenorphine) that are in schedule III or above (which only includes Buprenorphine, in the Subutex and Suboxone formulations,) can be given by qualified physicians (usually psychiatrists and certain clinics) directly out of their office (via prescriptions that can be brought to your pharmacy of choice). This law was inacted (in 2000!) in order to help get more addicts into treatment by loosening some of the "klinik" restrictions, by eliminating the "klinik" completely in certain situations.
Eliminating the fat:
Can any doctor prescribe buprenorphine? What are the requirements?
No. Only doctors who meet the (simple) qualifications, and then apply to SAMHSA (who then follows through with the DEA, who issues the doctor a second, special DEA number) may prescribe maintenance medications. See the "Practical Information" section for more...practical information, including finding a doctor. The qualifications are more of a red tape then anything else. All that is necessary at minimum is an 8 hour course (if the doctor meets none of the other requirements) and a short application. If you have a doctor or psychiatrist you know and like whom isn't a part of this program, perhaps you can convince him to sign up. There is a short waiting period, which the doctor can waive by checking a box on the sign-up form. Finally, there currently is a 30 patient limit. There currently exists a bill in congress to remove this limit, due to the problems it has been causing (doctor’s using the limit as an excuse to scam patients into constant detox at high prices, and angry doctors that they have to follow such a rule they are unaccustomed to.) Stay tuned for more information on that.
Does this mean that qualified doctors can prescribe methadone or LAAM?
No. Both methadone and LAAM are in schedule II. Only Schedule III, IV, or V drugs may be prescribed by office physicians under the rules of the DATA. The drug must also be FDA approved for *opioid dependence*. Buprenorphine is the only drug that meets this criteria. There is no other drug your doctor may legally prescribe for maintenance.
UPDATE: LAAM is no longer available in the United States. Forget about LAAM. It’s bad news anyway, in this humble writers opinion, except in very very rare situations.
It is possible, and likely, that other drugs will come forth in the future that will meet this criteria, although most likely not anytime in the immediate future. Perhaps even methadone or LAAM will be rescheduled. That is fairly far out for the USA, however, although it is true of certain countries (Australia, for instance? - VERIFY). It is doubtful that mdone (or LAAM) will be rescheduled due to the highly profitable kliniks that will go out of business alone, despite the fact that both have very little abuse potential (although fairly high diversion/addiction potential.) They (the 'done lobby) are partially responsible for buprenorphine taking, what was it now, 10+ years to be FDA approved, despite it's already proven safety and it's efficiency in other countries for maintenance. They (the kliniks) were afraid of going out of business, with all their patients lining up for buprenorphine. The thought that might happen is laughable, and the possibility of them using buprenorphine in-house (as an option), without the stringent rules, would likely boost their revenues significantly.
Note: just as Methadone Maintenance Treatment is abbreviated MMT, Buprenorphine maintenance treatment is abbreviated BMT.
Bupe vs. Methadone:
A lot of heroin addicts or methadone maintenance patients have preconceived notions that bupe won't work. That is just not true. Bupe is not in general inferior to Methadone. That is a widely believed myth. It's different, but not generally inferior. It all depends on you, personally. For some people 'done will work better, for some 'bupe will work better, it's that simple. While the ceiling level for bupe is only equal to about 30mg 'done in potency, you can get it so that *you dose that twice a day or more*, and it reduces your tolerance! This mostly due to it's antagonistic/partial agonist nature. Because of this, it makes what would be equal to 30mg of 'done a hell of a lot more effective, in some people. *I am not saying bupe could ever be more potent than a full agonist. I am saying due to other factors it CAN in SOME cases work better, especially over time* Granted, it is likely very rare that bupe will get someone "higher" than 'done in general. It *can* work better though, if you give it time, and give you more flexibility. If you are on it long term and you are successful with it I am nearly positive you will get a buzz, given the fact that you were successful with it. This as always is individualized, and there are plenty of people who don't receive a buzz, but are usually on lower dosages. (UPDATE: It seems that there are a lot more people who don’t receive a buzz than I thought, but oddly enough they are happy with that, that was their aim (very little side-effects seem to go along with not getting a buzz). You shouldn’t rule out bupe because of this, but if getting a buzz is of #1 importance to you, then that should definitely effect your choice). I strongly believe either it'll work or it won't, once you give it time and find the right dose. Struggling on buprenorphine therapy is unlikely. If it doesn't work, it doesn't work, and switching to methadone is a fairly simple process, the klinik will probably be happy to have you.
Luckily there have been a lot of addicts in the community who have had good experiences with bupe and have shared those experiences, so that the community is more informed. Street addicts, however, are not, and bupe is still grossly underused. There is also the prevailing belief that bupe is for pill addicts not for heroin addicts, and this is totally bogus, minus the fact that I wouldn’t recommend a hydrocodone addict to get on methadone, of course,
A simple example of the possibilities of maintenance treatment: (4 possible scenarios of dependence, not including the guy who suceeds at abstinence the first go around. I don't think I've ever met him :P)
Person A has an "ordinary" opioid dependence. He needs a dose of agonist to keep him maintained. Methadone works, at doses most likely anywhere in the double digits, and he is happy. Buprenorphine works, and he is happy. He is the most likely to succeed with abstinence, but not necessarily so. Don't rule yourself out of this spot so quickly. This also includes the person who wants the least "opioid" necessary, he doesn’t want to get a buzz or get high, and he doesn’t want side effects. (If that’s the case, while it is totally possible bupe can give you a buzz and give you side effects equal to methadone, the chances of it not doing so warrant it being your first choice IMO).
Person B has an "ordinary" opioid dependence, but her tolerance and addiction level is sky high. She needs a high dose of agonist to keep her happy. Methadone at normal levels isn't enough. She needs a dose (most likely) of 100mg or more to be happy on methadone. Had she tried buprenorphine, it would have never reached her level of opioid dependence. She would have failed, and she would have relapsed or switched to methadone.
Person C has a "special" opioid dependence. Methadone at any dose doesn't work. Buprenorphine doesn't work. I feel bad for her. Let's hope she can get into Holland.
Person D has a "special" opioid dependence. He has a certain predisposition that makes him a good candidate for bupe. He is *likely* to have a high level of addiction, although this could depend on how long he has been using opioids, and which ones. He also is quite likely (but far from definitely, it's individualized like everything else) would have failed on methadone. Buprenorphine lowers his tolerance and addiction level, and seems to fit right, and gives him the proper maintenance that he needs.
Now, the Person A and Person B scenarios I gave you are very typical. It's what you would expect. Person C is less typical, but is still there. However, the Person D scenario tends to be overlooked. While I can't prove that certain people have a predisposition to having success on buprenorphine, I don't see how you could argue against it. Just look at how individualized opioid use is in general, and the responses people have to which drugs. What could be argued is just how often Person D comes strolling along.
Exactly what criteria Person D is likely to fall into I don't know for certain. It is entirely possible that they would have failed on methadone. Don't rule out bupe because 'done didn't work. Also, I strongly believe tolerance has nothing to do with it. I can say this from personal experience among other things. Hopefully future research will give us answers to these questions.
I will give reasons for my beliefs as to what people would fall into the "Person D" category throught this FAQ. See my personal experience and partial agonist (in pharmacology) sections especially for more information.
Effectiveness of treatment:
In many studies done SL (sublingual) 8mg buprenorphine (a low-average maintenance dose) was shown to be slightly less effective as a maintenance drug than ~90mg 'done (keeping people in treatment and having clean urine). It was shown to be much more effective than low dose mdone (~20mg.) It was also, interestingly, shown to be more effective than LAAM, which is a full agonist. (PROVIDE REFERENCE.) Given that 8mg is basically the lowest line in terms of dose for maintenance (4mg for maintenance is possible, even lower is possible but not generally speaking,) it can be fairly safely assumed that bupe is generally as effective as 90mg of 'done in terms of effectiveness as a maintenance medication, and can also be somewhat assumed that bupe, once it your body adjusts to it, at an optimal dose, is equal to about 90mgs mdone in potency for you vs. potency for some guy on 90mgs 'done, however this is a major simplification.
The 48 hour rule:
There is one other difference to be noted. Bupe has an extremely high affinity for the opioid receptors, which means it “blockades�?them, not allowing other opioids to bind to them and forcing other opioids that do bind to them off pretty quickly and unpleasantly.
What I wrote previously was, �?I>This means (in this case) that within 48 hours of dosing, you won't be getting high on any other opioids. So if you still plan to get high "once in a while," then bupe isn't for you. It's fairly easy to do and i've done it before without much issue, but it's not "fun." It's like the 'done blockade, but stronger. The only case where this "48 hour" rule doesn't apply (generally) is in the case of doses under 8mg. However, this is, like everything else, individualized. Just don't expect to be the exception. Generally speaking, it can take up to a week before another opioid agonist can exert it's 100% full effects.�?/SPAN>
This has recently found to be largely untrue. If you are on a dose of 16mg or more, you really can’t get high for a solid 48 hours-72 hours, this is true as it was written. You get what is called an “attenuated rush�? You get a small rush, and then feel like crap. It’s like the ‘done blockade, but with an antagonistic backlash that is VERY unpleasant and I strongly recommend you don’t test the waters. However, if your dose is 12mg or less, more-so with 8mg or less, and extremely so with 4mg or less, you can get a solid 75% effect from stronger opioids, namely heroin or oxycontin, about 24 hours later. I do believe the reason this holds true is after being on buprenorphine for a long period of time, which the studies regarding this do not properly account for, your tolerance is lowered to such a large extent that you can get high easily. This is merely hypothetical, however.
If you do this however, there is the potential for an antagonistic backlash that must be mentioned. Even after those 24 hours, that bupe will be sitting there in your system for a solid week, even after taking other opioids. Occasionally it can decide “hey, get out of there, those receptors are mine!�?(not literally of course, drugs can’t “decide�?anything,) and push the other opioid off the receptors and retake it’s space. This causes nausea mainly, and other unpleasant symptoms, although they do NOT clearly resemble opioid withdrawal. This can easily be fixed by another dose of your drug of choice, even a tiny one (if you are going to do this, I strongly suggest a tiny one, opioids can kill you ESPECIALLY in the scenario I have just described! You are a prime risk for overdose, DO NOT FORGET IT).
Finally, I will mention that if you do this, which *I am not suggesting, I am merely providing information*, switching back to buprenorphine is fairly easy, if you binge for 2-3 days, just wait until you are sick (WAIT) and then take your bupe, and *hopefully* the transition back will be smooth, but there are no guarantees. I have personally found that quite ironically the higher your tolerance is, up to a point, the better bupe works.
Of course, this, again, is individualized, and your tolerance and metabolism will play a large role in all of this.
Less than daily dosing?:
With recent data, it seems that buprenorphine can be given with less than daily dosing, with every other day to tri-weekly (three times a week) still being effective in some people (PROVIDE REFERENCE). However, as always, this is very individualized, and with the recent laws in the US there seems to be no reason to attempt such a dosing schedule unless for some reason you want to (having a very slow metabolism for buprenorphine for instance, which could possibly *lower* your ability to be maintained on buprenorphine (more != better once you reach that ceiling level,) in which case less than daily dosing would be a good idea.) Discuss it with your doctor.
Continued in next post..not enough space left in this one.
Next: Update
Source and credit to:
Nephalim of
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