Dr Olowe 7/24/23 Dr Olowe 7/24/23

How to Start Suboxone, Precipitated Withdrawals, and More

How to Start Suboxone, How to take Suboxone, Precipitated Withdrawals, and More

This is for informational purposes only. Do not use any information in this blog to guide your treatment. This was originally written as a reference for my patients. You must follow the instructions of your provider.

Suboxone is Buprenorphine-Naloxone. Buprenorphine is the active part of this medication.

What is Suboxone Induction? This is the process of starting Suboxone which often takes a few days. When this process is done correctly, starting Suboxone is usually straightforward and most people are able to start Suboxone without too much fuss. However, for a number of people, this can be a more difficult process. Do not give up if you have a more difficult time; there are many factors to consider as to why this may be the case for you

How do I start Suboxone? In summary, you stop taking any other opioids and allow yourself to go into opioid withdrawal. Once you are experiencing severe or close to severe opioid withdrawal symptoms start with just a tiny bit of Suboxone, like a 2-0.5 mg tab/ film or a quarter of an 8-2 mg tab/film. After an hour, if you are feeling the same or a little bit better, you can take another 2-0.5 mg. Repeat this process until you are not experiencing opioid withdrawals. Do not exceed a total of 16-4 mg in a day. The real and best version of how to start Suboxone which is the way you need to go about doing it is to follow the instructions of your prescribing provider!

Suboxone 2-0.5 mg tabs Suboxone 8-2 mg tabs

Starting Suboxone

1) Stop taking all opioids for at least 12 to 36 hours before starting Suboxone. If you are not in opioid withdrawal by this time, or you were taking a long-acting opioid such as Methadone, you will have to wait longer, up to 3 days plus in some cases. More important than waiting a certain amount of time is that you are in severe or close to severe opioid withdrawal before starting where you are experiencing at least a few of the following symptoms:

Anxiety

Chills

Eyes are tearing

Goosebumps

Muscles and joints ache

Nausea

Restlessness

Runny nose

Shaking

Stomach cramps

Sweating

Yawning

2) When you are in severe or close to severe opioid withdrawal with at least a few of the listed symptoms, put 2 mg of Buprenorphine under your tongue.

This is equal to a quarter of one Suboxone 8-2 mg tab/ film (cut your Suboxone 8-2 mg tab/film into 4 equal pieces, start with one of these four pieces) or an entire Suboxone 2/0.5 mg tab/film.

Keep your mouth closed. Do not swallow the medication, chew it, or move it around in your mouth. Do not talk, drink anything, or smoke for 15 to 20 minutes. Let the medication sit under your tongue; it gets absorbed directly into your bloodstream. Any medication that is swallowed is mostly wasted medication and will not work. After 15 to 20 minutes have passed, rinse your teeth and gums with water and swallow. An hour later, brush your teeth. Also, follow up with a dentist for routine dental care (this medication is bad for your teeth).

3) Wait an hour, if you are feeling the same or a little better, take another 2 to 4 mg of Buprenorphine.

That is, take a quarter or up to a half of a Suboxone 8-2 mg film/ tab, or if you are taking Suboxone 2-0.5mg tabs/films- one or up to two of these.

4) You can keep repeating this process after waiting an hour between doses until you are feeling okay enough to stop or no longer have opioid withdrawal symptoms. Do not take more than the amount that your provider told you not to exceed in a day’s time, often but not always 16-4 mg in a day’s time (two Suboxone 8-2 tabs/ films).

5) Repeat this process for at least 2 to 3 days. Remember the amount of Suboxone you needed on each day. This is how you figure out the lowest effective dose that you need.

Your provider will explain this to you. Day to day, you will likely need anywhere from less than 2-0.5 to 16-4 mg a day of Suboxone depending on the amount of opioids you were taking before. Many people do well with less than Suboxone 16-4 mg a day, few people need more than 16-4 mg a day

Precipitated withdrawals

When you are starting this process, you will already feel lousy because you have to allow yourself to go into opioid withdrawal as described above. If after your first 2mg dose of Buprenorphine, you start to feel significantly worse, you are experiencing precipitated withdrawals, that is, the Suboxone is making you sick because you are taking it too soon. Whatever opioid you were taking before trying to start Suboxone is still attached to your opioid receptors. If you experience this, contact your provider. There are several approaches to this experience.

1) restart the process where you allow yourself to be in opioid withdrawal but wait that much longer before you reattempt starting Suboxone. The longer you wait and the worse your withdrawal symptoms are, the less likely you are to experience precipitated withdrawals. If your provider gave you medications for opioid withdrawal symptoms (often called comfort meds), you may use them as directed by your provider to help this process. I prescribe a number of these medications to my patients to help with this process.

2) Attempt something akin to micro-dosing. Instead of starting with 2mg of Buprenorphine, start with a much smaller dose or a much smaller piece of Suboxone and continue to take very small pieces.

3) Wait as long as you can. If you take Suboxone and it makes you sicker (it is causing precipitated withdrawals), continue to take a dose every hour until you feel better. Still, do not take more than 16-4 mg in a day or the amount that your provider told you not to exceed in a day. If you were given comfort meds, you may be able to use them if instructed as such by your provider

There are other more controversial approaches that you may discuss with your provider if you have ongoing difficulty starting Suboxone.

More Information & Definitions

What are opiates and opioids? We all have opioid receptors in our brain and body. Opiates and opioids are both drugs that bind to these opioid receptors and cause similar effects and have similar risks such as causing euphoria (a state of intense happiness or feeling good), drowsiness, dependence, addiction, and more. The key difference is that opiates are natural drugs that are derived from the opium poppy plant (e.g., heroin, morphine, and codeine) and opioids can be natural, created in a laboratory, or chemically altered natural opioids (e.g., oxycodone, Percocet, Norco, fentanyl, methadone, Suboxone, tramadol).

What is opioid withdrawal? Opioid withdrawal is a set of symptoms that are experienced when a person who is dependent on opiates or opioids stops taking them. These symptoms may include but are not limited to temperature dysregulation with feeling hot and cold, chills, anxiety, watery eyes, goosebumps, body aches, nausea, restlessness, runny nose, shaking, stomach cramps, sweating, yawning, irritability, diarrhea, difficulty sleeping, and a fast heartbeat. A person becomes dependent on opiates and opioids after taking them for a significant amount of time which varies from person to person.

Suboxone Induction. Suboxone induction is the process of starting Suboxone. It is the process of stopping an opiate or opioid such as Heroin, Fentanyl, Methadone, or any number of opioid pain pills and starting Suboxone. A concern is that when you stop an opioid, you get sick, that is, you experience opioid withdrawal; and, if you take Suboxone right after stopping an opioid such as those listed, that is, if you take Suboxone too soon, it will make you sick which is what we refer to as precipitated withdrawals.

Suboxone. For your information, Suboxone is a controlled substance. Suboxone is an opioid that causes physical dependence in the same way that other opiates and opioids cause physical dependence. With that, if you start taking Suboxone and then you stop taking it, due to physical dependence, you will get sick (have opioid withdrawals) the same way any person who stops taking any opiate or opioid would. Some reports state that physical dependence can happen in a few days while others report a couple of weeks.

Start Suboxone treatment with a Suboxone doctor

If you have questions or want to start treatment with Suboxone (or Sublocade) call 219-850-4490 or schedule an appointment online. You can get started with treatment now from the comfort of your home with an online Suboxone doctor. If you prefer, you can come to the office.

Dr Olowe 7/16/23 Dr Olowe 7/16/23

What is Sublocade? All about the Sublocade injection

All about Sublocade., the Suboxone shot. How the Sublocade injection works, coming off Suboxone and Sublocade, Sublocade side effects and risks, finding a Sublocade doctor, and more

What is Sublocade?

For those who know what Suboxone is, the easiest way to think about it is that Sublocade is a once-a-month shot of Suboxone. In actuality, Sublocade is a once-a-month shot of Buprenorphine where Buprenorphine is the active medication in Suboxone. More specifically, it is an extended-release formulation of Buprenorphine that was approved by the FDA on November 30, 2017. Sublocade comes in 100 mg and 300 mg doses.

How do you take Sublocade?

Sublocade is injected into the fat underneath your skin at your belly; this is done every 4 weeks or once a month. This injection must be done by a certified healthcare provider. If someone was to get a hold of Sublocade and tried to inject it into their veins, this would cause a serious risk of death as the medication becomes a solid mass and could cause clotting including in the lungs. This is not a concern when Sublocade is correctly injected subcutaneously (into the fat underneath your skin). After injected, the medication is slowly released into your system at sustained levels throughout the month

Starting Sublocade

You do not have to stop taking Suboxone (Buprenorphine-Naloxone) for any period of time before starting Sublocade. That is, if you are taking Suboxone now, you can start Sublocade. Per the manufacturer, in order to start Sublocade you only need to have been taking Suboxone underneath your tongue for at least a week. The standard approach is for a patient to have been taking at least one or more Suboxone 8/2 mg films or tabs for at least a week where the first injection is with the Sublocade 300 mg dose for the first month. For the second injection for the second month of being on Sublocade, the 300 mg dose is used again. After that, the Sublocade 100 mg dose is used for the third injection and for the remainder of treatment with Sublocade. In some cases, the provider may start with the Sublocade 300 mg injection and stay at this dose for the second, third, and following injections. If a patient is taking Suboxone 4/1 mg a day (or half of an 8/2 mg film or tab), the provider may start with the 100 mg Sublocade dose.

How does Sublocade work?

Sublocade is similar to Suboxone in that Sublocade is used to treat opioid use disorder also referred to as opioid addiction or opioid dependence. The medication works by attaching to opioid receptors. In this way, it prevents cravings, prevents opioid withdrawal symptoms, and also decreases the ability of other opiates or opioids to attach to your opioid receptors. This type of treatment has been shown to prevent relapses.

Using Sublocade to come off of Suboxone

Sublocade is not FDA-approved or indicated for this reason though there are many stories of people using Sublocade in order to stop taking Suboxone. People take advantage of the fact that Sublocade is such a long-acting medication as it takes such a long time to come out of your system. Though it differs from person to person, there are a number of people reporting having very mild to no withdrawal symptoms after stopping Sublocade. In fact, Sublocade may stay in your system for 6 months, 12 months, and possibly even longer after your last injection where Buprenorphine may continue to show on drug tests for this period of time. For those who are stopping Sublocade or any form of treatment, it is necessary to have a relapse prevention plan and support systems in place.

What are the Advantages of Sublocade over Suboxone?

as already described, Sublocade is released into your system all month with no daily ups and downs
there is no need to remember to take the medication every day, this may be easier for many
no more bad taste with Sublocade. Many people do not like the taste of Buprenorphine-based products that have to be put underneath your tongue such as Suboxone, Buprenorphine-Naloxone, Buprenorphine SL, and Zubsolv
opiates and opioids are bad for your teeth. Many consider Buprenorphine-based products like Suboxone that sit in your mouth to be especially bad for your teeth. As Sublocade is an opioid, it too is considered to be bad for your teeth, but perhaps not as bad as Suboxone as it is not sitting in your mouth every day

What are the disadvantages, side effects, and potential risks of Sublocade?

As with all medications and treatments, there are a number of important potential side effects and risks, these include but are not necessarily limited to:

the injection is painful
reaction leaving a large bump at the injection site that may last for longer than months
injection site reaction including pain, itching, redness, and/ or bruising
as Sublocade is an opioid, it causes physical dependence in the same way that Suboxone does. If you stop Sublocade you may have opioid withdrawal symptoms similar to when other opiates or opioids are stopped
headache
nausea, vomiting
decrease blood pressure
constipation
respiratory depression
itching
drowsiness
dizziness
increased sweating
fatigue
increased liver enzymes
may make you tired
injection site bleeding
problems with coordination
irregular heartbeat that can lead to death
soft tissue atrophy/ deterioration
moderate to severe liver damage
difficulty treating pain
opioid withdrawal
insomnia
anxiety
weakness
numbness
flu-like symptoms
upset stomach

allergic reaction
overdose

Sublocade Injection. The Suboxone shot — Sublocade 100 mg injection and Sublocade 300mg injection

Does Sublocade work?

Yes. Remember, Sublocade is a once-a-month injection of Buprenorphine, the same medicine as Subutex; this is the active medicine in Suboxone. Studies have shown Sublocade’s ability to block the subjective effects of opioids. After your first injection, the medication starts working, Sublocade levels peak within 24 hours before decreasing to a maintenance level after several days that is maintained throughout the month where you should not have the ups and downs that some patients complain about with Suboxone taken underneath your tongue.

While Sublocade works after the first injection, there are some people who feel that during the first month, it does not work as well as Suboxone underneath the tongue. Although this can happen, it is not expected. This is good to know in case you have this experience. Although not considered a usual approach due to concerns for increased risks, after the very first Sublocade injection, a provider may prescribe Suboxone to be continued at the same time. Insurance will often continue to pay for the Suboxone prescription in this situation. However, as this is not a usual approach, some insurances will not pay for Suboxone directly after a Sublocade injection (for at least 4 weeks, the amount of time Sublocade is expected to work). To be clear, if you feel that Sublocade is not right for you, after a month, you can choose to go back to Suboxone regardless. Depending on a number of factors, there is a possibility that you may or may not need a higher Suboxone dose.

I want to start Sublocade treatment with a Sublocade doctor

If you have questions or want to start treatment with Sublocade, call 219-850-4490 or schedule an appointment online. You can get started with treatment now. Many insurances including Indiana Medicaid do cover Sublocade. We can work with your insurance to have the Sublocade injection delivered to our office where the injection will be performed. If you are not local or live too far from our office, you may use the official Sublocade website to look for a provider near you.

More information about Sublocade:

Brand name: Sublocade

Generic name: Buprenorphine

Dosage: Once-a-month injection of 100 or 300 mg of Buprenorphine

Administration: injected only by a certified healthcare provider

Indication: treatment of moderate to severe opioid use disorder, opioid addiction

Miscellaneous: Sublocade is a controlled substance and an opioid. Treatment with Sublocade should include counseling

Additional Information about Sublocade:

Official Sublocade Website

Dr Olowe 7/9/23 Dr Olowe 7/9/23

Indiana Medicaid Coverage - Redetermination

Medicaid redetermination. Many people need Suboxone treatment for opioid dependence whether employed or unemployed, insured or uninsured, or having Medicaid insurance or major medical insurance. Better Life MD Suboxone doctor treats many patients who have commercial and Medicaid insurance plans. A number of patients seeking Suboxone treatment with us who use an Indiana Medicaid plan may need to take action to keep their Medicaid insurance. This may include members who have not recently confirmed their information through the Benefits Portal.

If you have an Indiana Medicaid Plan (Healthy Indiana Plan (HIP), Hoosier Healthwise, Hoosier Care Connect, traditional Medicaid, Anthem Medicaid, Managed Health Services (MHS), MD Wise, CareSource Medicaid…) and are unsure of how this may affect you, you can call the office for help at 219-850-4490 and/ or check out these useful links:

Redetermination Process

Benefits Portal - update your information

We hope this helps!