Guinevere Gets Sober

Recovery news, reviews and stories, by Jennifer Matesa.

Suboxone Detox and Post-Acute Withdrawal Syndrome

We seem to have opened a little tin of worms here with the posts about Suboxone, starting with my interview with Dr. Steven Scanlan, a Florida detox doc who uses Suboxone and Subutex to detox patients off opioids.

People are writing in about Suboxone. It’s great that folks are asking questions! I need to emphasize (this also appears in my “About” page) that I’m not an expert or practitioner. I don’t dispense professional advice; I share personal experience. I’m a person with addiction who has been through the mill. I write from the place of “beginner’s mind.” The experience of detox—choosing a method; committing to it; literally waking up and smelling the roses—is still fresh for me, and the feeling persists in my daily life of being lucky to be alive. I write this blog because I used to take so many different drugs, and had lost control, and am now able to stay sober. I know there are solutions out there, some of which don’t involve being on drugs for the rest of one’s life.

And I seriously used to think I’d just have to be on drugs for the rest of my life. I’m only 46.

So a reader wrote in with a question about feeling really crappy post-detox. This person had been taking OxyContin for a little over a year, at between 90 and 400mg per day, but usually around 90-120mg. They ran out of cash and got their doctor to prescribe Suboxone. They were able to taper from, as far as I can tell, 16mg per day to one-quarter of a tablet or a film (they used both)—which, depending on whether they were taking the 2mg or the 8mg formulations available in the U.S., means they were dosing at either .5mg or 2mg per day at the end. It’s unclear from the way the email is written exactly what dose they jumped from at the end.

This is important, though: the jumping-off dose. Get to that in a minute.

They write:

In the last two days I have altogether stopped taking it. The problem is I have been experiencing extreme tiredness; major digestive issues, especially gastric reflux and an on and off “lump in my throat”; and muscle weakness. I am a middle-aged cardio athlete and I now have extreme sensitivity to air conditioning or temperature change between rooms at the gym. Overall I feel like I gotta be dying of cancer or something is really wrong with me! I am not sure how long this is going to last and have yet to come across an article describing Suboxone withdrawal and how long it may take for me to feel “normal” again or if that is even going to be possible? I am kind of determined to stay off the Suboxone as I believe is causing me lots of physical problems I don’t read about in the “side effects” articles. Is what I am experiencing “normal” and if so how long do you think it may be until these awful sensations and other problems go away?

The experience this person is writing about is called “post-acute withdrawal syndrome” (PAWS). What this means: after we’re done with the “acute” detox—the period of time in which the body is getting rid of the remnants of drugs still in our systems—there can be another phase of detox that is “post-acute,” when the body is still working to heal from the effects of our addiction.

Suboxone, like methadone (or any drug with a long half-life), takes a long time to be excreted by the body. It’s not like the day you stop taking it, your body is free of the drug. One nurse I know who detoxed from Suboxone put herself through urine tests, and could detect Suboxone in her blood up to three weeks after jumping.

One critical thing to remember about the healing process after detox: Opioid drugs hijack our body’s ability to make its own opiates, called endorphins. When we’ve hijacked our body’s ability to produce endorphins, and we detox, it takes a while to heal.

So ALL withdrawal symptoms mean the body is healing. Withdrawal is a healing process. (It sux, but it’s healing. :))

The symptoms of opiate PAWS include some of the ones mentioned in this email:

  • Persistent fatigue: endorphins help regulate the body’s energy; when we take extra opioids, it can affect our endocrine systems, which regulate our metabolism and sex hormones (many opiate addicts have experienced lack of sex-drive, women sometimes go into menopause, and men sometimes demonstrate low testosterone levels). When we detox, these systems don’t just switch back to “normal” immediately.
  • Digestive problems: this person has gastric reflux and a feeling of a lump in the throat; other people have persistent loose bowels and lack of appetite. Did you know that the brain isn’t the only place that has opiate receptors?—the entire GI tract is lined with them, especially the “gut” or intestines. Which is why opiate addicts usually experience constipation: opiates slow down the body’s “autonomic” functions, including digestion (and breathing, which is why ODs can be lethal, and why morphine is standard treatment for people at the end of life experiencing “dyspnea,” or breathing problems). When we detox, suddenly the GI system is shocked back into action, because there’s nothing numbing it anymore. It takes a while to settle down.
  • Temperature sensitivity: endorphins help regulate the body’s thermostat. When we take extra opioids, the body’s ability to perform this function on its own is compromised; when we detox, it takes time for the body to regain this function.
  • Sadness, anxiety, and pessimistic feelings: This person says they feel like they might have cancer, or that “something is really wrong.” Just as opioids numb certain physiological systems, they also numb our feelings. (Candace Pert, the neuroscientist who discovered the opiate receptor, calls opiates the “molecules of emotion.”) One of the main reasons opiate addicts choose opioids over other drugs is because these drugs are so efficient at numbing emotional life. But when we detox, all the feelings numbed out by the drugs come back, and because our native endorphin production is out of whack, it takes a while for our body-mind to begin to “feel” in normal ways again.

Who gets PAWS: There’s a ton of stories from people who have detoxed or tried to detox from Suboxone demonstrating that many of us experience PAWS. On the other hand, some people don’t experience much PAWS at all. A great deal depends on the differences between each of our bodies and minds, as well as how long we were taking drugs, what level we detoxed from, how low a dose we tapered to, how well we’re taking care of ourselves, and how much support we’re getting.

 

Tae Kwon Do

Tae Kwon Do: “Lies My Mother Never Told Me,” a memoir by Kaylie Jones, describes how the author recovered from her alcoholism in part through this discipline.

Some common-sense tips for managing PAWS:

  • Shorten your detox: If you want to use Suboxone to detox, try to stay on it a minimal amount of time. The many personal accounts I’ve heard, as well as some professional opinion, suggests that people using Suboxone to detox should try to use it no more than three to four weeks. Beyond that, the body begins to get used to Suboxone (just as it becomes used to any opioid after such a time), which can become a problem in and of itself. Again, this doesn’t seem to be the case for everybody.
  • Taper as low as you can before jumping, especially from long-acting drugs such as Suboxone. In Europe, buprenorphine is made in doses of .2mg, which is helpful for tapering to minute doses. In the U.S., tapering this low has to be done by splitting 2mg tablets into slivers of a quarter or an eighth-milligram, or securing the films, which can be cut to facilitate very low tapering. As an example, I tapered to .125mg (one-eighth) before jumping. Those who jump from even 1mg usually have a rougher ride. It’s estimated that 1mg Suboxone equals about 33-40mg morphine (in binding power). I wouldn’t want to jump from 35mg morphine.
  • Begin serious daily aerobic exercise, as soon as you know you want to detox. Exercise is one of the best ways to help the body restore its own endorphin production. … I detoxed in the fall. I was exhausted, but I loaded upbeat songs on the iPod and dragged myself for a 20-minute walk every day, going as fast as I needed to go to sweat. I also rode a stationary bike. My sleep and temperature regulation wasn’t great when I finally jumped off Suboxone, but today I sleep normally. Even better, I can cycle 30 miles, play 2 hours of tennis, clean the house; and two days ago I scored my first pull-up. (Yaaaah!) We do heal.
  • Ask for some kind of 3-D support. Work some kind of program of recovery. The way I look at it: when I broke my elbow, I had to do PT, right? I can’t numb out my body and feelings without doing some kind of repair work. I started going to 12-step meetings, and sharing my experience with and learning from others who had been through the same thing helped ease the anxiety and let me know I could get better. It doesn’t have to be meetings; it could be therapy, or a spiritual community, or a physical discipline such as Tae-Kwon Do—anything that helps us enlarge our perspective and grow.

A great resource and support for those detoxing from Suboxone is the Suboxone Forum at Opiate Detox Recovery.

Please share your experiences here, too. And if there are any physicians or researchers who can point to studies about PAWS and Suboxone, please give us a heads-up. I checked Ovid this morning and couldn’t find any. … Not that studies tell the whole truth, but this reader was looking for “articles.”

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7 Comments

  1. I’m so thankful that you people know of exactly what I’m feeling and can tell me the common symptoms and lengths of time generally involved.
    I “Jumped” 4 days ago and unfortunately I have a severe knee injury that’s 7 days old and still have to work. I have no other option..
    Working with Paws and knee injury for 4 days..
    I absolutely must get through this but I had no idea how long the withdrawal would take.
    I’ve been on bupenorphine for about two years.
    This is the first time I’ve read others accounts.
    One more question?
    What about relentless nightmares???
    Ps. I’m also working on my alcoholist addiction.
    Thanks again.

  2. For the past 2 weeks I’ve kinda been tappering off I was prescribed 16mg a day for 2 years taking them for almost 4 years I lost my health insurance in March since then I’ve been buying from friends recently it’s become impossible to find them. I’ve tried before to get off and gave up after 2 days I’ve been mentally done with subs for awhile just never had the courage or time to get off of them. I’m 23 work 2 jobs 5 days a week 18+ hour days I’ve detoxed from opiates on my own after 3days was fine. I’m currently taking .007mg a day for the past week and still when I wake my body wants it. I’ve been having horrible intense stomach pain that come and go. Tried all the time, walking up a few steps I start sweating. I’m either burning up or freezing. I go back to work Sunday night and I’m honestly scared I’m going to give in I need to work. Hopefully it gets better!

  3. Great advice. How long were you taking suboxone before you quit?

  4. Hey everyone – I read a lot of your stories, good reads I’m proud of you guys/gals! I’m a 27 year old male – was on suboxone for just shy of 3 years @ 8mg a day along with 3mg a klonopin and was doing 10-20 perk 30s per weekend. It was a viscous cycle. Today I’m 25 days sober and have had my ups and downs. I jumped off the subs at 2mg, kpins at 3mg. When I got to treatment they detoxed me with phenobarbital for 14 days, along with clonodine. Days 15 when I was off all meds I felt like hell – couldnt sleep for a minute, chills, anxiety through the roof, bad fatigue and my hands sweat all day long while i wasnt trying to sleep, along with minor headaches. I got my sleep back around day 21 – started getting about 6-7 hours a night – been gaining each day. My main symptoms now are minor sweats, bad fatigue, some anxiety. Just take it one day at a time! This is the longest ive ever been sober and I will NEVER take suboxone again, would rather have dealt with perk withdrawl on my own! Goodluck!

    Joe

  5. Joe, how wonderful for you to kick Suboxone and Klonopin. I’m willing to support anyone who wants to get off Suboxone, which is why I write these pieces. I hear from so many who no longer want to be taking that drug. If you can get your body to exercise, it’s the best beginning toward regaining your energy. Take a look at my book for more information. /G

  6. Well, here’s the dirty little secret that you only find by reading the “product data insert” and doing a little math. Suboxone has a mean (average) half-life of thirty-seven hours but it is prescribed on a twenty-four hour basis. Generally, most opiates have an average half-life of only four hours. Simple math tells you that half the drug is still in your system after thirty-seven hours, so if you take another dose in twenty-four hours you are adding drug to you body’s total serum level. This paradox is vaguely explained in the product data sheet. It explains that you eventually reach a “saturation ceiling”, a blood serum level where any additional dosage cannot be used by the body, the extra being wasted. So, if you take 8mgs/day, every twenty-four hours, you have only excreted 2.59mgs the first day, so when you take 8mgs more you now have a blood serum level of 13.41 mgs. The buildup becomes exponential from there until you become saturated. This phenomenon is the reason why you can taper almost immediately, saving you money with no ill effect. However, if you want to quit Suboxone by tapering, you must take into account the thirty-seven hour half-life and forget about dosing every twenty-four hours. You must reduce your blood serum level over time in order for a timed reduction to be effective. If you try to taper by halving and forth-ing until you have the smallest of partitions using the twenty-four hour schedule you will never have reduced your blood serum level at all. You will have the illusion that you will have minimal effects when you jump but you will get the big surprise. You should have saved your money and jumped at 8mgs/day…there would have been be no difference.

    Here’s another dirty little secret…reducing you blood serum level by taking into account the long half-life has its own misery. As your blood serum level actually drops there comes a point that saturation no longer occurs so the withdrawals will start at some point after that. The longer you take to reduce your blood serum level the prolonged the misery. Once your body falls out of saturation you will start to have some withdrawal symptoms, how bad depends on the person and how long they took Suboxone, how obese they are, how old they are and what state of health they are in, all are factors. Remember, your body was saturated, each person has their own dosage level where they became saturated, so reducing the dosage based on half-life may require time to reach a symptomatic level and the symptoms may be tolerable to some degree. Naloxzone , the ingredient in Suboxone that prevents the use of opiates, only lasts for hours, which means you can manage those symptoms with some mild painkiller like Vicoden. That’s like robbing Peter to pay Paul but most people who have successfully jumped have used something to minimize the misery but only when absolutely necessary.

    Most people, after having quit for thirty days, usually call the doctor for some additional Suboxone thinking that they can take a little portion to reduce their misery but end up putting themselves back into saturation, prolonging the misery, not reducing it. There are some experts that say that prolonged use of Suboxone causes damage to receptors and other parts of the neurological/psychological system of the body, so to have success with Suboxone one must only use it initially, no more that twenty-five days, tapering almost immediately upon the initial start. It is a designer drug and does not fit the neuro transmitter/receptor pathway like endogenous (naturally occurring) endorphins created by the body itself. Although this potential hazard is not mentioned in the product data insert, there are some prescribing doctors who postulate this anomaly. It is possibly why it is so hard to return to normal after Suboxone for some people. Others have suggested that it causes permanent damage suggesting disability.

  7. It has been 3 weeks and I an still sick in way not like Opiates or methadone.I was on this for 9 years they said for pain management. What a lie. Not sleeping starting to holucinate see weired things with very bad headachs.Plus my back pain has worsened and I am looking into that finally. Aii I can say at 64 this stuff is BAd BAd BAd and I thought methadone was bad. Jack W

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