How to Start Buprenorphine-Naloxone, 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 our patients.  You must follow the instructions of your provider. 

Suboxone and Zubsolv (Buprenorphine-Naloxone). Buprenorphine is the active part of this medication.

What is Buprenorphine-Naloxone Induction?  This is the process of starting Buprenorphine-Naloxone which often takes a few days.   When this process is done correctly, starting Buprenorphine-Naloxone is usually straightforward and most people are able to start Buprenorphine-Naloxone 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 Buprenorphine-Naloxone?  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 Buprenorphine-Naloxone, 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 Buprenorphine-Naloxone which is the way you need to go about doing it is to follow the instructions of your prescribing provider!

Starting Buprenorphine-Naloxone

1) Stop taking all opioids for at least 12 to 36 hours before starting Buprenorphine-Naloxone.  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 Buprenorphine-Naloxone 8-2 mg tab/ film (cut your Buprenorphine-Naloxone 8-2 mg tab/film into 4 equal pieces, start with one of these four pieces) or an entire Buprenorphine-Naloxone 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 Buprenorphine-Naloxone 8-2 mg film/ tab, or if you are taking Buprenorphine-Naloxone 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 Buprenorphine-Naloxone 8-2 tabs/ films).

5) Repeat this process for at least 2 to 3 days.  Remember the amount of Buprenorphine-Naloxone 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 Buprenorphine-Naloxone depending on the amount of opioids you were taking before.  Many people do well with less than Buprenorphine-Naloxone 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 Buprenorphine-Naloxone is making you sick because you are taking it too soon. Whatever opioid you were taking before trying to start Buprenorphine-Naloxone 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 Buprenorphine-Naloxone.  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 Buprenorphine-Naloxone and continue to take very small pieces.

3) Wait as long as you can.  If you take Buprenorphine-Naloxone 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 Buprenorphine-Naloxone.

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, Buprenorphine, tramadol). The term opioid can be used to encompass both opiates and opioids.

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.

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

Buprenorphine-Naloxone. For your information, Buprenorphine-Naloxone is a controlled substance.  Buprenorphine-Naloxone 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 Buprenorphine-Naloxone 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 Buprenorphine-Naloxone treatment with a doctor

If you have questions or want to start treatment with Buprenorphine-Naloxone (or the Buprenorphine injection) call 219-850-4490 or schedule an appointment online.

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 our patients.  You must follow the instructions of your provider.

All about Sublocade (Buprenorphine injection)

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 our patients.  You must follow the instructions of your provider.

What is Sublocade?

For those who know what Suboxone is, the easiest way to think about it is that Sublocade (Buprenorphine injection) is a once-a-month injection 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.

How do you take the Buprenorphine injection?

The Buprenorphine injection is injected into the fat underneath your skin such as at your belly; this is done every 4 weeks with Sublocade (every 1 to 4 weeks with Brixadi). This injection must be done by a certified healthcare provider.  If someone were to get a hold of the Buprenorphine shot 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 why the Buprenorphine injection must be injected correctly, subcutaneously (into the fat underneath your skin) by a health care provider. After injected, the medication is slowly released into your system at sustained levels throughout the month

The Buprenorphine injection underneath the skin

The Buprenorphine injection being released into your body

Starting the Buprenorphine injection

You do not have to stop taking Buprenorphine-Naloxone for any period of time before starting the Buprenorphine shot.  That is, if you are taking Buprenorphine-Naloxone now, you can start the Buprenorphine injection.  Per the manufacturers, in order to start the Buprenorphine shot you only need to have been taking Buprenorphine-Naloxone underneath your tongue for at least a week. The standard approach is for a patient to have been taking at least one or more Buprenorphine-Naloxone 8/2 mg films or tabs for at least a week where the first Buprenorphine injection may be given.

How does the Buprenorphine injection work?

The Buprenorphine shot is similar to Buprenorphine-Naloxone in that the Buprenorphine injection 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 the Buprenorphine injection to come off of Buprenorphine-Naloxone

The Buprenorphine injection is not FDA-approved or indicated for this reason though there are many stories of people using the Buprenorphine shot in order to stop taking Buprenorphine-Naloxone.  People take advantage of the fact that the Buprenorphine injection 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 the Buprenorphine injection.  In fact, the Buprenorphine injection medication may stay in your system for 6 months, 12 months, and possibly even longer after your last shot where Buprenorphine may continue to show on drug tests for this period of time.  For those who are stopping the Buprenorphine injection or any form of treatment, it is necessary to have a relapse prevention plan and support systems in place.

What are the Advantages of the Buprenorphine injection over Buprenorphine-Naloxone?

• as already described, the Buprenorphine injection 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 the Buprenorphine shot. Many people do not like the taste of Buprenorphine-based products that have to be put underneath your tongue such as Buprenorphine-Naloxone and Buprenorphine SL.

• opiates and opioids are bad for your teeth.  Many consider Buprenorphine-based products like Buprenorphine-Naloxone that sit in your mouth to be especially bad for your teeth.  As the Buprenorphine injection is an opioid, it too is considered to be bad for your teeth, but perhaps not as bad as Buprenorphine-Naloxone as it is not sitting in your mouth every day

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

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 the Buprenorphine injection is an opioid, it causes physical dependence in the same way that Buprenorphine-Naloxone does.  If you stop the Buprenorphine injection 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

Does the Buprenorphine injection work?

Yes.  Remember, the Buprenorphine shot is a once-a-month injection of Buprenorphine, the same medicine as Subutex; this is the active medicine in Buprenorphine-Naloxone.  Studies have shown the Buprenorphine injection’s ability to block the subjective effects of opioids.  After your first injection, the medication starts working, the Buprenorphine injection 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 Buprenorphine-Naloxone taken underneath your tongue.

While the Buprenorphine shot works after the first injection, there are some people who feel that during the first month, it does not work as well as Buprenorphine-Naloxone 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 Buprenorphine injection, a provider may prescribe Buprenorphine-Naloxone to be continued at the same time.  Insurance will often continue to pay for the Buprenorphine-Naloxone prescription in this situation.  However, as this is not a usual approach, some insurances will not pay for Buprenorphine-Naloxone directly after a Buprenorphine injection (for at least 4 weeks, the amount of time the Buprenorphine shot is expected to work).  To be clear, if you feel that the Buprenorphine injection is not right for you, after a month, you can choose to go back to Buprenorphine-Naloxone regardless.  Depending on a number of factors, there is a possibility that you may or may not need a higher Buprenorphine-Naloxone dose.

I want to start the Buprenorphine injection

If you have questions or want to start treatment with the Buprenorphine injection, call 219-850-4490 or schedule an appointment online.  You can get started with treatment now.  Many insurances including Indiana Medicaid do cover the Buprenorphine injection.  We can work with your insurance to have the Buprenorphine shot delivered to our office where the injection will be performed.

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 our patients.  You must follow the instructions of your provider.

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!