Talk To Me!
I am an expert about psychiatry and addiction for the new web site by Time called TheFix. Because of the nature of that site, most of the questions below are related to addiction– but feel free to ask questions related to general psychiatric issues as well. Questions about my specific practice are best asked in the ‘contact me’ part of the web site. Thanks!
{ 28 comments… read them below or add one }
Good Morning, I have a husband with a long-term (20 + years) of substance abuse. Started with vicodin, graduated to oxycotin 80 mg, and crack . Is now on suboxone, 8mg, 3 times a day. He is abusing this stuff, he goes 3-7 days early every month. He is also on effexor. Too many brain drugs in my opinion, the brain is on overloadth. Now they just added chantix so he can stop smoking.
During the first 4 months, he really abused the suboxone. He kept going back saying he was losing his prescriptions, took way too many each day. Who knows. Does this stuff make you lie? Why doesn’t the psychiatrist do thing about this?
My son is also on sub for heroin. Neither of them go to meetings. They both need to be evaluated by an outside neutral psychiatrist who can evaluate what other issues may be going on in the brain. You cannot do that in a 5-15 minute setting. Do you agree?
What should I do? I am losing my mind!! How does a sane person deal with all of this? Do you know anyone in the greater Cincinnati area? I really need some help here.
Thanks for your time and consideration
In Christ,
XXXXXXXXXXXXXXX
Yes, I agree with your comments. One ‘job’ of the psychiatrist is to make certain that the medication is being used properly. While a doctor cannot be everywhere and know everything that his/her patients do, there should be an effort to keep scripts on time, avoiding early refills, and openly addressing any shortfalls or other irregularities. Many people who don’t do perfect will eventually get things together– IF there are efforts on both sides to keep the communication flowing. And I agree 100% that a 15-minute appointment– let alone shorter– is worthless for the purpose of understanding a person’s symptoms and problems.
I don’t know Cincinnati– I’m sorry. But consider seeking out a doctor who spends more time with his/her patients. They are out there– sometimes you need to interview doctors to find one who is responsive.
I wish you the best,
Jeff J
PLEASE RESPOND ASAP!! I just found out I’m pregnant, about 4 weeks along. Unfortunately I live in Canada where SUBUTEX is not available. I am on suboxone (4mgs a day) and have been told I have two choices: Taper off suboxone over a 3 week period OR go on methadone. I don’t want to be on methadone and so I’m set to taper off sub. But because it’s so early in my pregnancy I am worried about my babies exposure to the naloxone component in suboxone. I know you are VERY knowledgeable in suboxone and would like your opinion. My doctor has decided to taper over a 3 week period. I am praying for minimal wds as I know going into wd puts my baby at risk. I’m terrified doc, I did not expect this to happen and abortion is not something I want to consider. That being said I need to know what I’m dealing with here. I am angry with my governments decision to essentially force me onto methadone by making subutex unavailable. I worry about the taper. I am extremely motivated but all my motivation cannot avoid wds if they happen. My doc has basically planned a 2 mg drop every week. It seems to me that wds will happen – then what? Please please respond! I need someone who is an expert in sub to give me guidance. Thanks suboxdoc, you’ll remember me as “freebird” on the forum site. Well, I don’t feel so free right now. I feel downright awful about this. Hope to hear from you soon!! Jodie
Hi Jodie,
I can’t substitute for your doc, of course, but I’ll share my thoughts on the issue. Naloxone is NOT thought of as a particularly dangerous drug for pregnant women. It is classified as ‘B’– more favorable for pregnant women than many medications that are taken throughout pregnancy with little concern for toxicity. Prozac and most SSRI’s for example are ‘C’– a level that is more dangerous toward pregnancy. ‘B’ means, by the way, that ‘animal studies show no risk or adverse fetal effects but controlled human first trimester studies not available or not confirmatory, and no evidence of 2nd or 3rd trimester risk; fetal risk possible but unlikely’.
I come across people occasionally, in the US, who used Suboxone during pregnancy without problems– and I’ve never met a person who had a baby with birth defects while taking Suboxone. Of course, that is only ‘anecdotal’ evidence, and not something to rely on– but my point is that you are certainly NOT in a position where harm has even LIKELY occurred. Even in the real bad drug exposures– women on lithium or depakote, for example, which are much more strongly contraindicated in pregnancy, the chance of having a baby with NO problems is over 95%– the risk for abnormalities being in the 3% range. Naloxone is NOWHERE near as dangerous.
Even with ‘dangerous’ meds, limiting use to after the 1st trimester removes the vast majority of risk.
Each pregnancy is a roll of the genetic dice, and bad things happen for no reason at all. The biggest risk is that something will happen that has nothing to do with Suboxone, and you will torture yourself over it.
You can minimize and virtually eliminate your intake of naloxone by dosing a certain way– naloxone is not absorbed in the mouth, and is typically destroyed by the liver as soon as it is absorbed from the intestine. You can avoid it even more surely by crushing the tab when you dose and spreading the dissolved solution over the oral surfaces in your mouth for ten minutes, then spitting out the remaining saliva (and the naloxone). I’ve used that approach for patients who think naloxone is causing headaches. It works– but I think that in most cases the headaches were ‘psychological’, not from naloxone– since naloxone is effectively destroyed by the liver before reaching the systemic circulation.
Perhaps you can have another talk with your doc; have him/her look up ‘first pass metabolism of naloxone’ by the liver, and look up the very low blood levels of naloxone in the circulation of people who take Suboxone. That, along with the ‘B’ rating of the drug, would suggest to ME that you are better off staying on Suboxone.
I wish you the best!
Hi Dr.
I don’t have a question and I don’t want to waste your time but I wanted to contact you and express my gratitude. I am an opiate addict and I used pain medications for close to 4 yrs. I was a “closeted drug addict” and so not many people knew of my addiction which made it extremely difficult for me to seek help. I had heard of suboxone but I had been afraid that it wouldn’t work for me and thus leaving me hopeless with no way out of my predicament. However, once I came across your YouTube videos my fears were lifted and I was finally able to give this medication a chance. Anyways, I am now almost 2 weeks clean and I wanted to thank you for inadvertently being there for me and for saving my life. I will never be able to truly express my gratitude in words, but I did want to contact you and thank you. I wish you all the best and I hope that you realize what a wonderful person you are. Thank you!!!
Sincerely,
Isabelle B.
That is very kind of you, Isabelle– thank you very much, and best wishes to you.
JJ
Hi,
I have a really bad drug addiction to heroin and to oxy codone ers. I been doing drugs now for half my life. I started at 12 and im now 24. And I just recently started shooting up. I was wondering if I could set up an appointment? I got a 6 month old son…and I know if I continue using I probably wont make it to see my child grow up.
I’m really sorry– they only allow each doctor to have 30 patients the first year, and 100 after that; I’ve been at the 100-patient limit for a couple years now. I do have a waiting list, but it moves slowly. I wish so much that we could help more people… please check out the ‘doctor finder’ web sites like naabt.org, or suboxone-directory.com . I strongly urge you to keep looking– there IS a way out.
Jeff
Hey Dr.J i wanted to say thank you for all the work you’ve put into your videos and websites. Its really helped me decide to take suboxone as part of my treatment. I go to intensive outpatient treatment three times a week and meetings almost daily now. Even though some people say, “your not actually clean if your on that stuff”, i dont care. Im off opana’s now and im finally getting my life on track. Im finally paying my bills instead of my old drug dealer! Im in college for the first time after my year long relapse. I feel good and i couldnt do it without the suboxone to keep my mind off of it.
MY PUPILS DILATE THOUGH I AM ON A HIGH DOSE OF SUBOXONE. Hi I have an important question here are the meds I am on 75mg effexor, 50mg topomax, 75mg lyrica, and imitrex as needed, suboxone three times daily 8mg. My doc has me space the dose because of my meds have caused me to metaboloze the suboxone quickly so it does not last 12hrs as normal. My question is that I am quite alarmed in the morning when I get up and 7 and my pupils are totaly dilated? I take my last 4mg around 12am. What can be causing this? No matter what I have tried , lowering, highering, it keeps happening.
Yes, your dose IS high. Frankly, the usual dosing interval is 24, not 12 hours, and some studies show equal success when dosing every 48 hours. My first question is whether you are in ‘withdrawal’, or are your pupils just enlarged? Some meds/substances will enlarge pupils without having any connection to Suboxone. Afrin nasal spray in the eye, for example! I could see situations where waking from sleep could lead to dilation of the pupils as well. Do your pupils get large before EVERY dose, or only your MORNING dose? If the issue is related to Suboxone breakdown, then they should be large at the end of every dosing cycle– not just in the morning.
24 mg (the same as 2400 micrograms) is a VERY high dose, and I would be very surprised if you were actually metabolizing it to such an extent. Are you sure you are dosing correctly– i.e. not swallowing it, and not rinsing your mouth after taking it for at least 15 minutes, to allow for complete absorption? Have you had blood tests to look at the level of buprenorphine in your blood 24 hours after dosing? That would be a first step to check things out.
Finally IF it is truly being destroyed quickly, consider taking a medication that prevents breakdown of buprenorphine, such as prozac (fluoxetine). You could use that instead of effexor for depression/anxiety, and that would extend the half-life of buprenorphine.
Good luck!
My pupils are large between doses. I do the paint method that u reccomend maybe not corectly? How do I paint with strips ? I bet if I could paint better that would help. I think it may be that it is not absorbing.
My gp just put me on lyrica for migraines and she said it will help with sub breakdown? Is this true? I ask u as she really seems to know little about sub
Hi Jess. I certainly do not know everything…. but I am unable ot find data that supports that assertion. There are some medications that are metabolized at the liver— including buprenorphine (in Suboxone). Other medications that are also metabolized at the liver may delay the breakdown of buprenorphine, if the exact same enzyme is involved (there are dozens of different enzymes that break down medications). Prozac, for example, inhibits breakdown of buprenorphine.
But Lyrica is not metabolized at the liver. I just looked it up in the classic pharmacology text, Goodman and Gilman’s ‘pharmacological basis for pharmotherapeutics’— something every med student at least USED to own. I found that 98% of a dose of Lyrica is excreted unchanged at the kidney– meaning NO interaction with buprenorphine.
Again, I don’t know everything, and she may know something that I’ve missed– but I know Suboxone pretty well, and cannot find a way to agree with her comment.
JJ
I need help desperately. I am mentally disabled, bipolar, major depression, borderline personality and schizoid behavior. I am also an opiate addict on Suboxone. I was diagnosed about 10 years ago, and when my boyfriend committed suicide in 2006, I started seeing his psychiatrist because he “understood” me. He put me on SuboXone four years ago and even though I have struggled to pay $250 per month, it has been a miracle drug for me. For the first time since I was a teenager, I have enjoyed a year of feeling normal with Prozac, Seroquel, Xanax and Suboxone. About 15 days ago, two weeks after my monthly Dr. visit, his office manager called me and told me that my ins. co. had started an investigation into my doc’s billing practices due to a call I made, and I was dropped from the practice. All I did was call my insurance co. and ask if I could file a claim for my Suboxone treatment since it was covered and my dr. would only file the psychiatric portion of my visit. I ran out of meds and I can’t get help.
I feel for you, but don’t know how I can help. A couple parts of your message are confusing– the part about the ‘psychiatric portion of the visit’, for example, as usually addiction is considered part of a person’s psychiatric condition. I wonder if the doc was doing something illegal– when doctors join insurance panels, they agree to accept what the insurer pays as full payment. I wonder if your doctor was ‘double dipping’– i.e. collecting from the insurance company and also collecting from patients.
If that is the case, you should report what happened to your state’s medical board, as discharging a person to punish that person is, simply, wrong. But in any case, it sounds as if you should find a new doctor who can prescribe Suboxone. I have a directory linked from my forum, http://www.suboxforum.com — go to the top of the page and click on ‘suboxone doctors’. There is also a doctor finding service at naabt.org.
I wish you well, Rachel,
JJ
Hello sir- I have had a sinus infection for about two weeks. I just have been put on antibiotics for it. During this time the suboxone has not been absorbing, I usually wait with it under my tongue for ten minutes then paint. But now nothing is working it just will not dissolve into my mouth. I am wondering if this maybe due to the fact that I have some mucous built up from this infection. Have you come across people with colds and sinus infections who have had this problem before? And what advice can u give?
Hi again! I could imagine that mucous may surround the tablet, making it slower to dissolve…. buprenorphine is a ‘lipid-soluble’ molecule, and mucous contains fatty substances– which is why mucous does not dissolve well in water. I would expect the tablet to ‘attract’ and stick to mucous. Worse, the dissolved buprenorphine is likely to enter the mucous, making it less available for absorption through mucous membranes (i.e. the lining of the mouth).
Please refer to this section of one of my other blogs: http://suboxonetalkzone.com/2011/09/optimizing-buprenorphine-absorption/
Swallow or spit out any mucous– perhaps brush your teeth (and MOUTH) with a toothbrush before dosing– then take the steps suggested at that link.
Good luck!
JJ
Hello there. I have a question that perhaps you will have an answer to. I have been on the generic subutex 8mg 3x day for about a year. I moved out of state and was unable to find a new doctor right away, so I was off the meds completly for about three weeks. When I found a doctor, they would only prescribe suboxone, so that is what i started up on. (same dose as the generic subutex) I have been on it for two days, and I am finding that right after I lay down at night, I start having disturbing “dreams”, but it seems as though I am not even asleep yet. I just lay there for awhile, having these strange, disturbing thoughts, and it almost feels like i cannot move. I finally have to force myself to come back to reality and get up out of bed. It is disturbing. I have had vivid nightmares since starting the subutex initially, but never anything like this. I don’t know if this is common or what about the suboxone could be causing this? Any insight would be greatly appriciated doctor. Thank you for your time.
You are having something called hypnogogic hallucinations and hypnogogic sleep paralysis; the symptoms can be caused by a number of factors, although the difference between generic buprenorphine vs Suboxone is not one of them (the two substances are actually clinically identical). Opioids can cause these effects, and perhaps simply going back on buprenorphine is what is doing it…. they can also be caused by stress, changes in sleep schedule, and other psychotropic substances.
The symptoms are a general sign that a person’s sleep schedule is off track, and sometimes things get better by enforcing a very regular schedule. Sometimes medications can accomplish that as well. Another trick– if you are paralyzed, you will find that you still can control your breathing; if you remember to take larger and larger breaths, that will supposedly wake the person out of the state that he/she is in.
Look up ‘sleep paralylsis’ and you’ll find plenty” ‘hynogogic’ means occuring while falling asleep, whlile ‘hypnopompic’ are things that happen as a person is waking from sleep.
JJ
I live in Vancouver Bc. I currently have been self medicating myself being that I havent found a doctor that will tend to my chronic pain. I cant afford to buy oxys off the street anymore so I have no choice to get off of the at the cost of being in constant pain. I want to know if I do find a doc to prescribe me subs will it red flag me from ever being prescribed narcotics again???
Ideally no, but I suppose that it could. I do know of people who believe that they have been ‘labelled’, and now cannot get the pain medications that they believe that they need. The problem, of course, is that we are both assuming that the medical profession will fail you– that if doctors know the absolute truth about your situation, they will NOT use that information in a positive way– but will instead judge you, and treat you in a way that is not consistent with your health needs.
I wish I could say that such an idea is ‘poppycock’- but I don’t know if that would be a truthful response.
You could, of course, not share that info with a future doc…. I don’t know if that is something one could rely on, in an era of health systems and computerized records.
To be frank about pain and Suboxone, if you truly have severe pain– and only you know the truth of that situation– then you will likely be disappointed by buprenorphine/Suboxone. But if the pain is at all secondary to other things– to fear of withdrawal, for example– then by all means, change to Suboxone, and you’ll never look back.
I have been on Suboxone for quite a while now (years) and I have this issue I need to understand better and I hope you can help. Every single morning I awake to feeling completely sick and so sick it freaks me out and I am jumping up to get my medicine in me as soon as possible. This would not be such a bad thing, except that I also feel the same if I take a nap in the afternoon. The longer the sleep, the more severe the sickness. I was on Methadone a very long time ago and they did some tests on me that proved I was metabolizing the methadone so fast I needed a split dose. I often take Suboxone in the evening, so that I may have a decent night of sleep, because sometimes I need to take a dose in the evening also. I do not take a dose in the evening every day, but some days are different than others. I need to know if this is normal, or if I have some kind of super metabolism for opiates. When I was on heroin, I definitely needed more than most others, but everyone thought that was just the addiction talking. I am unsure if heroin, methadone and Suboxone all metabolize the same. Please help me, this is kind of upsetting and I need to understand why it is happening.
Kristina, I will write a reply on my blog, Suboxone Talk Zone.
JJ
Hi again Dr. Junig,
I forgot to thank you for your nice reply. I like the thought that you are an expert on the brain because I have seen my primary that believes this is all behavioural and that ADD is just because of those behaviors. I can link my past to ADD type behaviors and I have done so much research on the neuro side of it, and have seen that people treated for ADD helps them to get through recovery to stop bingeing/purging and on to cognitive behavioral therapy…etc. I hope you will consider helping me.
I talked to a pharmacist this morning (Walgreens) and he assured me that the generic version on Suboxone is not availabel in the US. But I could find it in Mexico or China…????? How true is this statement?
There is no generic Suboxone that I am aware of. There IS generic buprenorphine, which works exactly the same way, and costs as little as $2.50 per tab at some pharmacies— but some doctors won’t prescribe it, afraid people will inject it. I think that fear is overblown for most people on buprenorphine.
I don’t know about China or Mexico, whether they have a generic form of Suboxone. I have never read or heard about that medication being produced by any generic companies– but it might be out there somewhere!
I was on methadone when I gave birth to my daughter. Unfortunately I had to have a c-section. I went through this whole process with NO pain management as they treated me as an opiate seeker and said there was nothing they could do fr me. I was also treated this way when my gall bladder was removed and actually walked out of the hospital an hour after surgery becausee I thought if they aren’t helping me I might as well go home and watch Desperate Housewives. I was given 3mg of morphine for both surgeries and told that was all they could do. Why is there not a better way to treat pain for people who are legitimitely needing pain relief, especially for severe pain such as a c section or car accident. I fear every day something will happen as I don’t want to go through another surgery with no pain management.