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i have a sponsee who was determined to get off of heroin recently. he went into a detox hospital where he was able to use suboxone for five days and stop. he was discharged on day six. i convinced him that suboxone maintenance was a bad long term solution for a 20 year old guy who was kicking a three year habit. he was then determined to go onto naltrexone, which i am okay with to a degree.
his doctor prescribed him 50mg/day and to start this regimen on day 8 ... three days after his last suboxone dose. i was wary because somehow i have no experience or knowledge regarding the transition from sub to ntx. his doctor insisted that this was fine. i instructed him to take some grist off a tablet that might ad up to 2 or 3mg, take that, wait a couple hours and if there were no withdrawal symptoms, take a quarter tablet for the day.
this did not work out very well at all. he took the sample dose and two hours later felt nothing. then he took the quarter and within two hours was coursing through precipitous withdrawal. this went on four eight hours. horrific.
i am glad to say that the withdrawals ended quite suddenly and he has felt remarkably well ever since. the naltrexone seems to be eradicating all paws symptoms other than insomnia. but wow. what a colossal f*&$ up on the doctor's and my part. i don't understand why he didn't feel any symptoms after the test dose and i don't understand why he was in precipitated withdrawal for eight hours ... when i've used naltrexone to purge it has always lasted no more than an hour. i guess it must take naltrexone that much longer to scrub suboxone out of the receptors?
at any rate the moral of this story is that three days off of suboxone is not enough time prior to starting naltrexone therapy, the precipitated withdrawal is several times worse than with most other opiates and the standard test dose does not necessarily tell you if you're safe.
valid post...giudelines for the transition from sub to ntx are sketch the RCGP one cites 3 days...that said my obs suggest that post sub wd phenomena even though subtle may persist for weeks (typically runny nose,eyes on waking,yawning and showerring saliva.In addition autonomic chills common and esp common opening ones bowels) my guess is most docs dont realise this fact...another point 2-3mg of naltrexone funnily can have aparadoxical effect ie it can actually upregulate endorphins so as not to cause wd...so the waters are murky...typically sub will switch off psychological symptoms ie cravings and drug seeking behaviour and this is usu perpetuated into ntx ie psychological things and paws may be attenuated...sleep or lack therof is the biggest reason for recidivism in the first month or so...anecdotally exercise helps...mood can be low but this is a normal post opiate thing and the ntx should not be blamed immediately...to be fair staying oof dope is behavioural and ntx a fire blanket( doesnt always work)...but it can help...25mg is prob more than enough unless OD is a possibility( isnt it always).Thats aid adventageous effects on PAWS/cravings are seen in my lower doses ie 5mg but this lacks blockade...that said some studies show failure of bloackade in upto 40% on 50mg....
I would say that the effects he experienced from 12.5 mg of naltrexone compared to a lack of effect from 2 or 3 mg would relate to competive receptor binding potencies between these doses of naltrexone and the amount of buprenorphine in his system. Because of the high binding potency of buprenorphine, it can stay in the system for quite a while after dosing, which is why he withdrew so intensely.
It is possible that withdrawal would have been less severe if he waited until day 8 - even if the dose of naltrexone was 4 time higher than what he had on day 3. Having said that, it appears that your sponsee has effectively self-induced a rapid detoxification, although without the sedatives/anaesthesia to dissociate them from the aversive experience.
M'camera could probably offer further insight as he has greater experience working with buprenorphine in a clinical and preclinical setting. However, with respect to this particular case it would be worthwhile to first note the buprenorphine dose your sponsee was receiving from the suboxone prior to and on the day of stepping off.
thanks for the replies m'camera and sheffwed. i buy into the upreg theory regarding why the 2-3mg caused no symptoms. and yes, it seems clear that sub and ntx play in the same sandbox ... very competitively. my sponsee was unfortunately said sandbox for a brutal spell. he would definitely have done well to wait any amount of time longer, and since he was no longer in withdrawal there was no rush other than exposure to cravings and [imo] grossly premature ejection from the detox hospital.
i should post script that he is doing unbelievably well. he complains of no symptoms of any kind other than insomnia. reminds me of how miraculously well i felt the very first time i went on ntx 15 years ago.
sheff - his sub schedule was as follows:
DAY 1: 24mg suboxone [crazy i know ... i set the doc straight thereafter]
day 2: 12mg
day 3: 8mg
day 4: 8mg [this was the day we knew he would get the boot on day 6]
day 5: 1mg
day 6: --
day 7: --
day 8: 12.5mg naltrexone
That is a huge drop from 8 to 1 mg, then to zero. As inferred previously, I would say he had considerable buprenorphine in his system when he took the naltrexone. Glad to hear he's doing alright - in hindsight, he may prefer to have gotten the withdrawal over and done with in one go if he's feeling good now, as opposed to Cat's more protracted withdrawal from buprenorphine.
i too like to pull the band aid off quick [my old behaviors with urod and ntx might argue that point]. in the case of my sponsee, it has all worked out okay so far. for one thing that eight hours has burned a very potent memory into his synapses that will always remind him how sick he was or will be if.
it was day four that we were informed he would be booted from detox on day six, because "his life wasn't in danger"... mind boggling logic. i suggested he try to choke down to nothing if he could on day five to bump his cows scale up, but they didn't budge. my experience was that as long as the sub use stays under 7 or 8 days no taper was necessary. my schedule in april of 08 was as follows:
day 1: 8mg
day 2: 8mg
day 3: 8mg
day 4: 8mg
day 5: --
day 6: 4mg?
Hi SF et al,
not sure i buy the logic of the no taper sub detox....think of detox as high jumping ie getting over the bar but the bar gradually comes down...if the bar is set at 1meter then all the olympic high jumpers wont know what to do....sub is>>>binder than ntx at the opiate receptrors...that said sub <4mg is agonist whereas ntx is almost oure antagonist at 12.5 mg( oddly both naloxone and ntx ca.do have agonist effect-another story)...ntx can be a great help...best start after low/slow sub taper then at low dose....build up id needed
could you expand on why you don't buy the no taper after five day approach? it worked for me. also am i reading it right when you say sub is a more powerful binder than ntx? i don't plan to do any case studies, but my sponsee's ntx booted the sub after a grueling session and somehow i doubt that if sub was taken while on ntx that the sub would boot the ntx. this is starting to sound like a spider man vs. bat man argument ... perhaps there's no 'real' answer.
one more thing about ntx. dr. reznik in new york many years ago when i first took trexan eplained the upreg procedure as follows: the ntx enters body and completely fills the receptors provided a sufficient dose to do so was administered ... perhaps <5mg. however much more is taken will wait in the bloodstream for slots to open in the receptors. it takes roughly 72 hours to metabolize, so if one were to take 100mg of ntx, they would be blocked for 72 hours for sure, and most normal metabolisms would be sufficiently blocked by 50mg for that duration. he calculated that the receptors consumed roughly 12mg/day and the large doses administered ... 50mg/day were purely precautionary. so if one's receptors consumed 12/mg in 24 hours, he believed 6mg was a sufficient blocking dose for 12 hours and so on. curious stuff that he shouldn't have told this drug addict. i tested and used that information with great success/catastrophic failure depending on how you look at the data.
small print stuff naltrexone in essence shifts the sub dose response curve to the right ie you need more sub to effect a given response.It doesnt suppress the curve ie reduce response.The implication you need more sub to displace ntx but at the doses required sub will almost certainly be antagonistic in function ( ancient ref Br J Pharmacol. 1981 Nov;74(3):627-33).5 days works..ive seen it done in 4..the thing is cold turkey well after 5 days the worst should be over you'll feel like a bus ran you over but getting better...sub is designed to slow the bus down if you like..the key is getting the dose right ie enough to take the edge off and then allow some washout..its difficult to gauge how much someone needs and the consequence of this is that it always takes longer ie its easier to get a 10 day taper right than a 5.If 5 worked for you great but the doses you had are not universally applicable.
As for Dr Reznik...well it marries up with my views..5mg is arguably enough for the receptors but we are more than just receptors we are behaviour manifest...the 25-50mg doses actually allow for missing a dose and having some cover...the work of full dose ntx showed upto 500mg of pharma diamorphine was blocked...thats a big dose for a user but remeber the work in theus in the 20s showed c 2gm could be taken with little illeffects in the habituated..500mg is c 100 standard naive heroin doses(in hospital)...how much heroin would kill the naieve? tricky remember there is naieve and recently detoxed and they are not the same...5mg will put most people to sleep-dosing but rouseable...20mg could easily switch of respiration...that said the tox figures are variable ie upto 350mg.In an habituated addict heroin is remarkably safe...in a recent detox or after a day plus of wd or the naieve its dangerous...most OD as you know are after detox...figures also suggest ntx doesnt work that well and the us autopsy data bears that out ie you can have therapeutic ntx on board and still succumb to OD...im not wholely convinced re ntx...the best recipie is to immerse oneself in life in all its positive aspects but since heroin etc often reflects absence of such then its tricky as they may not be there.
man i sure do seem to be where the lightening strikes. my girlfriend relapsed on heroin over the last month. there's plenty of posts in that saga but i'll spare you. she's responded remarkably well to a short suboxone detox as follows:
day 1: 8mg
day 2: 6mg
day 3: 4mg
day 4: 2mg
day 5: 1mg
day 6: .5mg [today]
she wants to go on naltrexone [not my idea, i swear]. of course i'd like not to see a repeat of my sponsee's story above. how can one know when it's safe to start the naltrexone? she wants to get the implant, but i'm pretty sure it's a good idea to orally uptake before that commitment.
i know it's been a few days since you posted. I think it depends on whether your gf wants to induce the detox or let it occur from natural depletion of bup. I would follow the doctors recommendations, but I've seen detox induced with NTX 3 days after the step off. How is she doing so far?
she's doing really well considering. day six was two days ago now. the goal is to avoid any precipitive action. doctors are remarkably unlearned in this area. yet another doctor has said three days is enough, though i've seen first hand recently that this is clearly not the case. i'm wondering if it might not be as much as two or more weeks given that it takes six days for heroin to clear [4-6 hour half life] and sub's half life is so profound [36 hours]?
Information in this forum is not monitored or provided by a medical professional. The information reflects member opinions only. Do not act on advice from these forums without first consulting a qualified medical professional. All content is copyrighted and protected by Aelius Group.