The Commission on Accreditation of Rehabilitation Facilities (CARF) has much to say about the dosage of methadone for clients in medication-assisted treatment (MAT) programs, but it offers little instruction about Suboxone dosage. That’s because methadone is actually administered on site at the MAT facility, while Suboxone prescriptions are provided to the clients to be filled at their local pharmacy of choice. Whether people take either methadone or a Suboxone, however, they should be carefully monitored to ensure that they are adjusting physically to the medication.
For facilities providing methadone, the CARF Standards specifically describe the initial daily dosage of methadone to be determined for each patient on an individual basis by the physician, after the patient has been examined. The Standards also require that if an initial daily dose exceeds 40mg there must be documentation that lower dosages up to 40mg did not quiet the withdrawal or abstinence symptoms experienced by the patient. But while Suboxone is identified as the only other medication approved for use in MAT programs, there are no specifics given about Suboxone dosage.
Who Sets Suboxone Dosage Guidelines?
Suboxone dosage guidelines can be found on the website of the Substance Abuse and Mental Health Services Administration (SAMHSA). Certainly they are available on the websites of the companies that manufacture buprenorphine in its various formulations, but SAMHSA is the last word on Suboxone dosage for MAT programs.
Previously, dosages of buprenorphine or Suboxone were not available unless someone’s treatment for opiate addiction could be documented over the duration of a year. In recent years, that requirement was waived, which meant that a doctor certified according to the DATA 2000 requirements could write for a Suboxone dosage immediately upon a patient’s admission to an MAT program.
In 2012, legislation further expanded Suboxone prescribing guidelines so that treatment programs that have met licensure and certification standards would be the official prescriber and eliminate the need for physicians to obtain DATA 2000 waivers. However, just about all physicians who work in MAT programs and write for Suboxone dosages have taken the recommended training. Those who have not may have become Board certified by the American Board of Addiction Medicine.
Your Initial Suboxone Dosage
Even if you tell the assessment counselor at the MAT program that you want to be on the Suboxone program, in most cases it will be up to the MAT program physician to make the final decision whether you can take Suboxone versus methadone. Certainly the doctor wants to take your preference into consideration, but the decision will be based upon your past history of opiate use plus your treatment attempts. Even your insurance will come into play. If you start on the Suboxone program but you fail to comply with program rules, you can expect that the doctor will switch you to the methadone program.
The initial Suboxone dose for most people is 4mg or 8mg, and you will have to return to the MAT program clinic within a couple days for re-evaluation. If you still complain about withdrawal symptoms, don’t expect the doctor to immediately increase your dose, because the effects of Suboxone increase as your body adjusts to it. The increasing effectiveness should level off when you are still in a moderate Suboxone dose range of somewhere between 8mg and 20mg. Few people take a Suboxone dose greater than 24mg.
When Suboxone Causes Danger
The side effects of buprenorphine formulations including Suboxone include nausea and vomiting; achiness and cramping of muscles; distress, irritability, and restlessness; constipation; and cravings. You must also be very aware that Suboxone can depress the respiratory system. That can make it dangerous for the person who has asthma or COPD.
Many of the people who battle opiate addiction pay little attention to the state of their general health. They are so preoccupied with getting their drug of choice that they fail to notice how a combination of nutritional neglect and poor lifestyle habits, such as smoking cigarettes, impact them negatively.
A Boston physician became curious about the statistics for people who overdosed but did not die and whether they continued on the medication that caused the overdose. Specifically, the doctor looked back over a dozen years at nonfatal overdoses and what happened to the patients afterward. Surprisingly, 91 percent of those who overdosed on pain pills resumed the same pain medication after they were treated for their overdose. And in the case of 70 percent of those patients, they continued to get their medication from the same doctor.
The red flag, here, that everybody missed, is the fact that the pain medication dosage was too high, or that the person was taking more than the dosage recommended by the prescribing doctor. In 70 percent of cases, the doctor failed to change their medication or even take them off medication and substitute an alternative therapy such as physical therapy or acupuncture.
Think of the danger that poses, however, for someone who takes a Suboxone dosage that depresses their respiration. What if they end up in a hospital emergency room, have a few respiratory treatments, and are then released, with no change in their Suboxone dosage? The doctor included those cases in the research.
In some cases, the patient failed to communicate that they were on Suboxone therapy. But even when the patient shared their medical history of participation in an MAT program, the doctor failed to recognize that the Suboxone dosage could be the cause of the respiratory depression. In fact, the hospital and emergency department doctor often failed to notify the MAT program that the person had been in the emergency department. The restrictions that govern communication about MAT treatment worked against those patients, increasing the odds of a repeat episode of respiratory depression.
The big danger would be that the next instance of respiratory depression could be the one that sends someone to the morgue. Adjusting the Suboxone dosage can do wonders to relieve respiratory depression as well as any other side effects. That’s why communication with your doctor is so important.
Communication Is Key
Suboxone therapy is all about communication. SAMHSA and other professional and regulatory agencies all agree that medication-assisted treatment works best when it is accompanied by individual and even group counseling sessions. Participation in 12-step meetings or guidance with a peer specialist or mentor contribute to overall success in MAT programs.
But the most important factor in your success is communication with your team of substance abuse specialists. Tell the counselor, the nurse, and the doctor when you don’t feel just right—it could amount to a simple Suboxone dosage adjustment. You could avoid a trip to the emergency department. And you will return to a life in which you fully participate—a world where you live, work, and play with happiness and pride. Make the decision to participate in a Suboxone therapy program, and make your first phone call today.
