Why do some people say a lower dose of Suboxone is better? A nurse practitioner 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. It binds tightly to these receptors, and will not allow other opioids to occupy them. While bound there, buprenorphine partially activates the receptors. The naloxone in this formulation reverses is there to discourage injection and diversion. If Suboxone is misused, the naloxone prevents opioid overdose by binding to and blocking opioid receptors, stopping all opioids (including the buprenorphine) from occupying those receptors.
What does “less is more” mean in relation to Suboxone?
There is a theory that “less is more” when it comes to buprenorphine (Suboxone)—that a smaller dose is better and everyone should be aiming to take a lower dose.
The “less is more” theory is simply not correct. However, there is some logic behind it. Buprenorphine has a “ceiling” effect. 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 simply aren’t many more receptor sites left to occupy. So the effect at 24 mg is often not much different fro the effect at 16 mg.
The ceiling effect of buprenorphine is one of the reasons it is so well suited to addiction recovery treatment. Because the effects cease to increase after a certain point, people don’t have the impulse to take more and more, the way they might with other opioids.
Is there an ideal Suboxone dosage?
Our goal of treatment is to minimize cravings and relieve withdrawal symptoms. We want our patients to experience little to no cravings and no physical withdrawal symptoms. To achieve this, we titrate them up to the dose necessary to achieve this effect. “Titrate” means that we slowly increase the dosage in small increments until we find the level that works best. So while 16 mg is the most common maintenance dose, 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 (with all medications) 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 patient’s treatment to them and their needs.
Is there a limit to the Suboxone dose a provider will prescribe?
In our practice, we usually do not prescribe more than 24 mg of buprenorphine per day because of the ceiling effect and because many states set that as the maximum allowable dose. Keeping the maximum dose at 24 mg of buprenorphine reduces the risks of diversion and results in a lower risk of overdose. Buprenorphine overdose on its own is very rare, but the risk of overdose is greatly increased when buprenorphine (especially at high doses) is combined with alcohol, benzodiazepines, or other opioids. (Note that there may be some individuals who are prescribed higher dosages, but 24 mg or lower is most common.)
At Workit Health, 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 taper off sooner, we will never deny them this right. We believe in working collaboratively with our patients and want them to have a voice in their treatment and plan of care.
Signs your Suboxone dose is too low
Everyone is different, so there is no one-size-fits-all dose for every person taking a buprenorphine/naloxone medication like Suboxone. If you’re having cravings or withdrawal symptoms even when taking your medication as directed, your Suboxone dose may be too low. Talk to your clinician about what you’re experiencing. We strongly advise that you not experiment with changing your dose on your own! Learn more about this in our blog post, “How Do I Know if My Suboxone Dose is Too Low?“.