Why do some people say a lower dose of Suboxone will work better? Our nurse practitioner Dana Forman explains the thinking behind this common myth.
Suboxone is a combination of two different medications, buprenorphine and naloxone. The buprenorphine portion works by displacing other opioids from the mu receptors they occupy in the brain. Next, it binds tightly to these receptors, and will not allow other opioids to occupy them. The naloxone portion reverses opioid overdose by binding to and blocking opioid receptors. Naloxone was added to buprenorphine to discourage injection and diversion.
There is a theory that “less is more” when it comes to buprenorphine (Suboxone). As with anything in medicine, there are many different viewpoints regarding this.
The “less is more” theory is simply not correct. However, there is a “ceiling” effect with buprenorphine. What is a ceiling effect? It means that after a certain threshold, increasing the dose does not increase the effects. We know that at 16 mg of buprenorphine, 97% of the mu receptor sites are occupied. Therefore, if we increase the dose from 16 mg to 24 mg of buprenorphine, there really aren’t many more receptor sites that will become occupied.
Nonetheless, our goal of treatment is to minimize cravings. We want our patients to experience little to no cravings and we titrate them up to the dose necessary to achieve this effect. Therefore, if a patient is still experiencing cravings at 16 mg of buprenorphine, it is in my professional opinion and congruent with the current guidelines and standards of care, that it is appropriate to increase the patient dose.
Our goal is always to use the smallest amount of medication to achieve the desired effect. So whether that be 2 mg or 24 mg of buprenorphine daily for our patients to have little to no cravings, then that is what we do. We understand that all patients are different and unique and that treatment is not a one size fits all type of deal. We tailor each patients treatment to them and their needs.
In our practice, we do not prescribe more than 24 mg of buprenorphine per day because of the ceiling effect. Keeping the maximum doses at 24 mg of buprenorphine reduces the risks of diverson and results in a lower risk of overdose. We understand that overdose is greatly increased when buprenorphine, especially at high doses, is combined with alcohol, benzodiazepines, or other opioids
At WorkIt, our goal is for our patients to be on buprenorphine for 2 years. Studies show that those that have the best success in the long run are patients that have been on buprenorphine for 2 plus years. Of course, if a patient comes to us and requests to be weaned off sooner, we will never deny them of this right. We believe in working collaboratively with our patients and want them to have a voice in their treatment and plan of care.