Why do some people say a lower dose of Suboxone will work better? 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 patient’s 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 diversion 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 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 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!
What is the ceiling effect?
The “ceiling effect” means that after a certain point, increasing the dose no longer continues to increase the effects. For example, at a dose of 16 mg of buprenorphine, 97% of the mu opioid receptor sites are occupied. That means there are only 3% of receptor sites left unoccupied, so adding more and more buprenorphine will not have an effect. This aspect 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.
