Wondering how to tell whether your Suboxone dose is too low? Here’s a closer look at this question.
Suboxone (buprenorphine/naloxone) basics
Suboxone (buprenorphine/naloxone)—and other brands with that combination of drugs, like Zubsolv, Bunavail, and Cassipa—are prescribed to treat opioid use disorder (OUD). The buprenorphine in these meds is one of three medications approved by the FDA to treat OUD. It binds to the mu opioid receptors in the brain, but only partially activates them. Because of this, buprenorphine is a partial opioid agonist that does not create the rush of euphoria or high that full opioid agonists can. It forms a tight bond with the opioid receptors, reduces cravings, and relieves withdrawal symptoms.
The other ingredient in Suboxone, naloxone, is a full opioid antagonist. This means naloxone binds to and blocks opioid receptors without stimulating them, dislodging other opioids in the process. You may have heard of Narcan, which is a naloxone medication administered to stop and reverse an opioid overdose. Naloxone isn’t absorbed well through the mouth, and Suboxone, Zubsolv, and other buprenorphine/naloxone medications come in the forms of pills or tablets that are dissolved under the tongue (sublingually) or against the cheek (buccally). Because naloxone isn’t absorbed well that way, the naloxone in these meds basically does nothing when taken as directed. However, if the medication is misused (for example, if someone dissolves and injects it in an attempt to get high), then the naloxone will kick into effect, overriding and blocking the buprenorphine.
Suboxone comes in doses between 2mg buprenorphine and 12 mg buprenorphine. Other buprenorphine/naloxone meds for opioid use disorder are available in doses of 2 mg buprenorphine to 16 mg buprenorphine (depending on brand and form). The amount of naloxone varies, but in most of the medications, it is .25 as much as the buprenorphine (e.g. 8 mg buprenorphine/2 mg naloxone).
Signs your Suboxone (buprenorphine/naloxone) dose is too low
The most common indication of your Suboxone (buprenorphine/naloxone) dose being too low is if you are experiencing opioid withdrawal symptoms despite taking your dose as directed. These are the symptoms that are measured by the Clinical Opiate Withdrawal Scale (COWS), which is commonly used to assess the severity of opioid withdrawal:
- Rapid pulse
- Joint pain
- Excessive sweating
- Runny nose/watery eyes
- Restlessness
- Digestive distress (stomach cramps, diarrhea, nausea, vomiting)
- Dilated pupils
- Body tremors
- Excessive yawning
- Anxiety/irritability
- Goosebumps
The COWS provides guidance on how to rate these symptoms along a severity scale, which can help determine if you need a higher dose. Not all providers use COWS, but they should be attentive to what you’re experiencing. If you’re having more than very mild withdrawal symptoms and your provider hasn’t given you an assessment (whether that’s COWS or a different tool), don’t be afraid to bring it up! Talk to them about what you’re experiencing.
What’s a normal Suboxone (buprenorphine/naloxone) dose?
Dosage depends on a lot of different factors, so there’s a wide range that would be considered a “normal” dose of Suboxone (buprenorphine/naloxone) or other buprenorphine/naloxone medication. Everyone is different in their history of opioid use, their sensitivity to medications, how long they’ve been taking buprenorphine, their body composition, and more. This post is not medical advice, so be sure to discuss your dose with your clinician.
Suboxone dose during induction:
Most providers start low, beginning induction with 2 mg/.5 mg of buprenorphine/naloxone after the person has stopped using other opioids and has begun to experience withdrawal symptoms. The dosage is then increased in steady, considered increments over time until they reach a level that works best for that individual. This allows the person and their provider to gauge how they respond to the medication.
There are alternate approaches to induction. Microdosing involves starting with very small doses of buprenorphine/naloxone (for example, 0.5 mg/0.125 mg) before the person stops using other opioids. The dose of buprenorphine/naloxone is increased slowly over a week or more, and the other opioids are discontinued. At the other end of the spectrum, some providers use a strategy called macrodosing, which is when they start with a large dose right away (sometimes over 28 mg/7 mg in a single day). Macrodosing is more commonly practiced in emergency departments than in office-based care and especially when the person has a high tolerance for opioids.
Whatever approach is taken for your induction, you should work with your provider throughout the process.
Maintenance dose of Suboxone:
Once induction is completed and the person is stabilized on the medication, the maintenance phase begins. According to the official prescribing information for Suboxone (buprenorphine/naloxone), the target dosage is 16 mg/4 mg once a day. That dosage—16 mg/4mg—is the most common maintenance dose of Suboxone (buprenorphine/naloxone), but it’s also very common for an individual’s dose to settle anywhere between 12 mg/3 mg and 16 mg/4 mg. But as I mentioned, everyone is different. For some individuals, the maintenance dose may fall as low as 2 mg/.5 mg to as high as 24 mg/6 mg. It is rare to need a maintenance dose higher than 24 mg of buprenorphine per day due to the ceiling effect of the medication—after a certain threshold, increasing the dose does not increase the effects, as the opioid receptors are all occupied.
Is it better to take a lower dose of Suboxone (buprenorphine/naloxone)?
The goal is always to take the lowest dose that is effective. It makes no sense to take a lower dose than works for you, because then the medication won’t be doing its job. Taking a lower-than-effective dose increases the likelihood of experiencing cravings and withdrawal symptoms, which makes relapse more likely. Taking a too-high dose is pointless due to the ceiling effect, but taking a too-low dose is dangerous.
If I take a higher dose of Suboxone, is it more likely to show up on a drug test?
No. Most opioid panels test for two specific metabolites of opioids: morphine and 6-acetylmorphine (the second one is unique to heroin). Buprenorphine does not metabolize into either of these compounds, so it will not show up on a general opiate or opioid panel. This is true whether you take a small dose or a large one.
Tests that are looking for buprenorphine specifically (BUP on the drug test) are looking for a metabolite called “norbuprenorphine.” If you take a buprenorphine medication—Suboxone, Zubsolv, Subutex, Sublocade, generics, whatever—that metabolite will be present in your urine even if you take a relatively small dose. The amount of norbuprenorphine will be proportional to the amount of buprenorphine in your dose.