Wasting Resources on Suboxone

Readers of this blog know that I have often questioned whether there is any clinical difference between Suboxone and generic buprenorphine.  Naloxone is an opioid-blocking chemical added to buprenorphine, supposedly in order to reduce intravenous diversion of the medication.  The combination of buprenorphine plus naloxone is branded as Suboxone. I’ve pointed out over the years […]

Withdrawal Symptoms on Suboxone

I struggle with the length of my posts.   I shoot for 1000 words—an amount of reading that most people can knock off in a typical trip to the bathroom— but I find it difficult to limit posts to that size.  So as I have done in the past, I will break this post into a […]

The post Withdrawal Symptoms on Suboxone appeared first on Suboxone Talk Zone: A Suboxone Blog.

Is My Withdrawal Permanent?!

A question from a reader: I am trying to decide what my best course of action might be in dealing with protracted withdrawals from a number of drugs, including benzodiazepines. My history is as follows:  I was snorting Oxycontin for about 6 months and went into treatment to stop.  Before entering the rehab hospital they […]

Withdrawal from Suboxone or Buprenorphine

I received a question from a reader about withdrawal symptoms from stopping buprenorphine. My answer has relevance to opioid withdrawal in general, and to a common misconception about the duration of withdrawal symptoms. The message: Basically I quit Suboxone about 18 days ago. When I decided to quit I was taking about 8 to 12mgs per day. I […]

Avoiding Precipitated Withdrawal

I received the following question earlier today:

Hello Dr. Junig, I am opiate dependent or rather an opiate addict. I want to seek treatment because I can’t continue this life style. I have questions about treatment. Do I have to be in full withdrawals when I go to see a doctor? Is it true that most doctors probably won’t see me because they have too many patients already? I know Suboxone works for my withdrawals. I’ve stuck in this rollercoaster for at least four years and now I know it’s time for me to seek help.

My thoughts:

My comments, as always, are intended to increase general knowledge about buprenorphine and to promote discussion between patients and their doctors.  They are not intended to take the place of a relationship with a ‘real’ doctor!

The appropriate waiting period before starting Suboxone– ‘induction’– depends on the person’s opioid tolerance, and on the specific opioid that the person has been taking.  An opioid-free delay before induction reduces the amount of opioid agonist bound to the receptor, and lowers tolerance to some extent.  Starting Suboxone or buprenorphine is likely to cause precipitated withdrawal when either 1. There is agonist binding at the mu receptor, or 2. There is very high opioid tolerance.

It is hard to give exact guidelines, as every person reacts a bit differently.  But in general, people match up well for Suboxone induction if they are taking about 60-80 mg of oxycodone equivalents per day.  Someone on that amount of agonist, who waits over 12 hours, will generally do well at induction, unless the person has been taking methadone.  In that case, a longer waiting period is beneficial.  How long?  As long as possible, and at least a few days.  Even so, the transition from methadone to buprenorphine is difficult, often causing headaches or minor withdrawal symptoms for several days.  The best response to precipitated withdrawal is to take the prescribed dose of Suboxone/buprenorphine each day, without trying to overcome the symptoms by taking more of an agonist or extra Suboxone.  Doing so only lengthens the period of withdrawal, and considerably increases the risk of death.

If a person is taking a very low dose of an agonist, or taking a weak agonist like hydrocodone, the problem at induction isn’t withdrawal, but rather opioid intoxication, causing respiratory depression and nausea.  Nausea during induction is much more likely to signify relative overdose, NOT withdrawal.  Patients who have nausea and vomiting from buprenorphine or Suboxone should NEVER take a second respiratory depressant or sedative!  When in doubt differentiating between withdrawal and opioid intoxication, the pupils are a good guide.  Withdrawal comes with LARGE pupils.

If a person is taking a very high dose of agonist each day– over 150 mg of oxycodone or methadone, for example— that dose should be tapered down over time, to the equivalent of 40 mg of methadone per day.  Unfortunately, some people cannot carry out or tolerate such a taper.  In those cases, it may be better to have the person in a controlled environment, and wait as long as possible before induction.  Even if tolerance is very high, a person will often do well if off opioids completely for 4-5 days or more.  Of course, that’s easier said than done!

There is a cap on the number of patients that doctors can treat for addiction using buprenorphine.  Doctors can have up to 30 patients at first, and can petition the DEA to increase to 100 patients after a year.  It is frustrating to keep people who are desperate for help on a waiting list— especially when there is no limit on the number of pain patients that a doctor can treat using opioid agonists!

Suboxone relieves withdrawal symptoms when taken properly.  But the main function of buprenorphine/Suboxone is to eliminate the obsession to take opioids, and to allow patients to move forward in life without substances.  People do best if besides Suboxone, they focus on other principles of recovery, determined with their physician or with a counselor.  The point of Suboxone, in my opinion, is to learn to tolerate ‘life on life’s terms.’  That includes dosing at most twice per day, and learning to say ‘no’ to the minor cravings that most people have, even on Suboxone.

I’m glad you are looking for help– and I wish you the best!

Avoiding Precipitated Withdrawal

I received the following question earlier today:

Hello Dr. Junig, I am opiate dependent or rather an opiate addict. I want to seek treatment because I can’t continue this life style. I have questions about treatment. Do I have to be in full withdrawals when I go to see a doctor? Is it true that most doctors probably won’t see me because they have too many patients already? I know Suboxone works for my withdrawals. I’ve stuck in this rollercoaster for at least four years and now I know it’s time for me to seek help.

My thoughts:

My comments, as always, are intended to increase general knowledge about buprenorphine and to promote discussion between patients and their doctors.  They are not intended to take the place of a relationship with a ‘real’ doctor!

The appropriate waiting period before starting Suboxone– ‘induction’– depends on the person’s opioid tolerance, and on the specific opioid that the person has been taking.  An opioid-free delay before induction reduces the amount of opioid agonist bound to the receptor, and lowers tolerance to some extent.  Starting Suboxone or buprenorphine is likely to cause precipitated withdrawal when either 1. There is agonist binding at the mu receptor, or 2. There is very high opioid tolerance.

It is hard to give exact guidelines, as every person reacts a bit differently.  But in general, people match up well for Suboxone induction if they are taking about 60-80 mg of oxycodone equivalents per day.  Someone on that amount of agonist, who waits over 12 hours, will generally do well at induction, unless the person has been taking methadone.  In that case, a longer waiting period is beneficial.  How long?  As long as possible, and at least a few days.  Even so, the transition from methadone to buprenorphine is difficult, often causing headaches or minor withdrawal symptoms for several days.  The best response to precipitated withdrawal is to take the prescribed dose of Suboxone/buprenorphine each day, without trying to overcome the symptoms by taking more of an agonist or extra Suboxone.  Doing so only lengthens the period of withdrawal, and considerably increases the risk of death.

If a person is taking a very low dose of an agonist, or taking a weak agonist like hydrocodone, the problem at induction isn’t withdrawal, but rather opioid intoxication, causing respiratory depression and nausea.  Nausea during induction is much more likely to signify relative overdose, NOT withdrawal.  Patients who have nausea and vomiting from buprenorphine or Suboxone should NEVER take a second respiratory depressant or sedative!  When in doubt differentiating between withdrawal and opioid intoxication, the pupils are a good guide.  Withdrawal comes with LARGE pupils.

If a person is taking a very high dose of agonist each day– over 150 mg of oxycodone or methadone, for example— that dose should be tapered down over time, to the equivalent of 40 mg of methadone per day.  Unfortunately, some people cannot carry out or tolerate such a taper.  In those cases, it may be better to have the person in a controlled environment, and wait as long as possible before induction.  Even if tolerance is very high, a person will often do well if off opioids completely for 4-5 days or more.  Of course, that’s easier said than done!

There is a cap on the number of patients that doctors can treat for addiction using buprenorphine.  Doctors can have up to 30 patients at first, and can petition the DEA to increase to 100 patients after a year.  It is frustrating to keep people who are desperate for help on a waiting list— especially when there is no limit on the number of pain patients that a doctor can treat using opioid agonists!

Suboxone relieves withdrawal symptoms when taken properly.  But the main function of buprenorphine/Suboxone is to eliminate the obsession to take opioids, and to allow patients to move forward in life without substances.  People do best if besides Suboxone, they focus on other principles of recovery, determined with their physician or with a counselor.  The point of Suboxone, in my opinion, is to learn to tolerate ‘life on life’s terms.’  That includes dosing at most twice per day, and learning to say ‘no’ to the minor cravings that most people have, even on Suboxone.

I’m glad you are looking for help– and I wish you the best!

Suboxone Withdrawal in Newborns

One of the top search terms for Suboxone relates to pregnancy, and fear that the baby will experience withdrawal; official name ‘neonatal abstinence syndrome.’  I wrote this post a couple years ago, and I think it is worth reposting. Since the first time around, several studies have shown that withdrawal symptoms occur in about half of babies born to mothers on buprenorphine. The symptoms, when they do occur, tend to be milder than the symptoms in babies born to mothers on methadone or other opioid agonists.

Headlines grasp for attention with words like ‘addicted babies.’ Realize that there are many differences between physiological dependence and addiction to substances. For example, people who take Effexor are dependent– and will have significant discontinuation-emergent side effects– but they are not ‘addicted’, which consists of a mental obsession for a substance. The same is true of beta-blockers, in that discontinuation results in rebound hypertension, but there is no craving for propranolol when it is stopped abruptly.

We have no idea of the ‘cravings’ experienced by a newborn, but I cannot imagine a newborn having the cortical connections required to experience anything akin to the ‘cravings’ experienced by opiate addicts, which consist of memories of using and positive reinforcement of behavior—things that are NOT part of the experience ‘in utero’.

It is also important to realize that the withdrawal experienced by addicts consists of little actual ‘pain’ (I’ve been there—I know). Addicts talk about this subject often, as in ‘why do we hate withdrawal so much?’ It is not physical pain, but rather the discomfort of involuntary movements of the limbs, depression, and very severe shame and guilt. The normal newborn already has such involuntary movements as the result of incomplete myelination of spinal nerve tracts and immature basal ganglia and cerebellar function in the brain. And the worst part of withdrawal—the shame and guilt and hopelessness—are not experienced in the same degree in a baby who has no understanding of the stigma of addiction!

Finally, if we look at the ‘misery’ experienced by a newborn, we should compare it to the misery experienced by being a newborn in general. I doubt it feels good to have one’s head squeezed so hard that it changes shape—yet nobody gets real excited about THAT discomfort—at least not from the baby’s perspective! I also doubt it feels good to have one’s head squeezed by a pair of forceps, and then be pulled by the head through the birth canal! Many hospitals still do circumcisions without local, instead just tying down the limbs and cutting. Babies having surgery for pyloric stenosis are often intubated ‘awake’, as the standard of care– which anyone who understands intubation knows is not a pleasant experience. And up until a couple decades ago—i.e. the 1980s (!), babies had surgery on the heart, including splitting open the sternum or breaking ribs, with a paralytic agent only, as the belief was that a baby with a heart defect wouldn’t tolerate narcotics or anesthetic. I don’t like making a baby experience the heightened autonomic activity that can be associated with abstinence syndrome, but compared to other elements of the birth experience, I know which I would choose!

My points are twofold, and are not intended to encourage more births of physiogically-dependent babies. But everyone in the field should be aware of the very clear difference between physiological dependence and addiction, as the difference is a basic principle that is not a matter of opinion—but rather the need to get one’s definitions right. Second, the cycle of addiction and shame has been well established, and there is already plenty of shame inside of most addicted mothers. If there are ten babies screaming loudly, only the whimper from the ‘addict baby’ elicits the ‘tsk tsk’ of the nurses and breast feeding consultants. My first child was born to a healthy mom years before my own opiate dependence, and he never took to breast feeding; he his mother been an addict, his trouble surely would have been blamed on ‘addiction’ or ‘withdrawal’. Unfortunately even medical people see what they want to see—and sometimes that view needs to be checked for bias due to undeserved stigma—for EVERYONE’S good, baby included.

Addendum:  Another of my posts, including a response to a mother’s comments and several references, can be found here.

Short-Timers

Another question from a reader:

The current blog brings up the notion of long term use of Bupe or short term detox.  You say you are a fan of long term use, and that is clearly a good thing when the patient is one headed back to a drug culture of life of crime or is obsessed with the drug.  But-  what about patients like me and I think many others who have zero contact with the drug world, have never taken an illegal drug, and yet have taken Ocy C over the years for pain and find it all but impossible to stop the Ocy C.  

 The Suboxone helps with the W/D and just getting through with that is all we want.  NA meetings and the like are like being on Mars, it makes no sense.  There are no drug cravings at all and the goal is just normal.  Or rather, the goal is to make it through the W/D which is so harsh with Oxy C as to be dangerous for older people, whose only source of drugs indeed is the doctors Rx for them  And now that too is unavailable.  This group does not need Suboxone to become a new problem for them.  They just want the help.  It is not critically  important to determine “who” is being treated.  The certification training materials seem to brush over this so lightly that there is only one induction method allowed.  One that a drug company would love, but not always a patient –  pleading, do no harm.

My Thoughts:

I hear you, and watch for those patients.  Frankly I wish I had more of them, so that I could get some movement through my practice—- instead of being stuck with 100 chronic patients and a long wait list.   The financial motivation for the DOCTOR is to push people through, for that same reason.  Of course the drug company gets paid in either case.

The first question is whether buprenorphine even helps in the case you describe.   It is easier, in many ways, to taper with methadone than with buprenorphine, as you don’t have to divide such tiny pills.  It has been suggested that it is easier to taper off a partial agonist than an agonist—and I believe that to be true, simply because I have seen people do the former and not the latter.  But I don’t know HOW much easier it is—or if psychological aspects of the taper were more responsible than the person’s state of misery.

There were several studies a few years ago that showed relapse rates of 100% in people treated with Suboxone for less than a year;  those findings, it seems to me, put a damper on the idea that buprenorphine could be useful for short-term detox.  But I don’t know where those people would have fallen on the spectrum that you are presenting.  I do know that they were people with a primary diagnosis of ADDICTION— NOT chronic pain– so maybe they are not relevant here.

My caveat would be that I HAVE met many people over the years who are convinced that they fall in the pain camp you describe, but who turn out to be just as ‘addicted’ as anyone else.  They describe the process in different terms;  instead of admitting to ‘relapsing on opioids’, they describe ‘deciding the pain was worse than they expected, and that it was a mistake to go off opioids.’  They will claim to be different…. But an objective observer would see the same growing attachment to opioids, the same gradual dose escalation, the same excitement and activity when opioids are ‘on board’, and the same depression and misery if a day passes without using.

I agree with your thoughts, and get your point.  I just don’t know if very many people are as clearly-defined as you describe. One reason is because there are few conditions that cause pain severe enough to require high-dose opioid agonists for an extended period of time– say, a few months– that then go away.  Most pain conditions have residual symptoms—- from chronic inflammation, or even from the set-up of central pain circuits.  In a sense the pain is remembered, even after the original injury is repaired.  The severity of that residual pain is affected by the person’s emotional state, dependency, motivation, genetics…..  and the residual pain becomes a expressway back to using opioids— an expressway that is used often by many people.

Thanks for your comments!

Mean Streak

I guess I do get irritable sometimes…  but I’m getting better at controlling my anger as I get older.  One cool thing about a blog is that I can go back and see what I wrote years ago.  In this case, I was looking for a post about telling the difference  between opioid toxicity (from taking too much) versus opioid withdrawal. In that post I suggested looking at the size of the pupils.  The name of the post, in case anyone is interested, is called ‘abres los ojos’– the name of an old Penelope Cruz movie and spanish for ‘open your eyes.’ 

Penelope Cruz sounds very cool, by the way, when she whispers ‘abres los ojos…’ as you can hear at the beginning of the movie trailer.  The movie was remade and called ’Vanilla Sky’– again with Penelope Cruz, but this time with her speaking in English.

Am I the only one who cares about this stuff?!

The post BEFORE that one was from a time– 2009– when people often wrote to tell me how misguided I was for recommeding buprenoprhine.  Those comments, at a time when so many young people were dying from overdose, would really get to me.  I’ll share the exchange, for old time’s sake.  For people who enjoyed my older, feisty posts, they are still out there– you just need to keep hitting the ‘earlier posts’ button!

The post:

This guy doesn’t like Suboxone– or the horse it rode in on.  He has been trying to write angry posts under my youtube videos, but I have been blocking them– His feelings about Suboxone popped up on one of the health sites out there this morning, catching my attention through ‘Google alerts’ for Suboxone.  It must be the same guy, because the complaints are the same, the language is the same, and in both cases the screen names are related to frogs(!).  I will go ahead and post his comments, and then my response, so that he can relax– knowing that he has done his part in the epic struggle over Suboxone.

Ive looked all over the internet and still have not found more then 5 people who have quit suboxone like i have. I took it for 12 months tapered down to 2 mg and quit 5 days ago..Basicly i am writing this due to the fact that i am really pissed at the fraud i feel is being commited by the drug maker of suboxone. I was taking 15 10 mg a day of percocet and 10 mg a day of norco a day b4 i got on sub. Anyways the reason i am so pissed is that these last 5 days have been the worse 5 days ive ever had.My Dr says oh youll just feel little tired for a few days is all.. ya right… 5 days of not being able to move,anxiety,depression you name it.. and no i am not crazy i took pills for shoulder injury so i have an idea where these feelings come from and its the good ole subs that all these Drs are making a fortune off. You must remember that out of all My drs patients i am like the only one whos quit totaly and can actually sit here and tell you what its like.. Its terrible and after considerable thought i think people need to know this sub is just another opiate and what gets me is the withdrawls are even worse then reg opiates. I CLOSE WITH ONE LAST COMMENT: ITS ALL ABOUT THE MONEY WHEN IT COMES TO SUBS: Think twice before some slick talking Dr wants you on it.. its far from a magic pill. Just ask the few of us out of 1000000,0000 people who quit the phoney stuff.

There is no magic pill for addiction to pain pills and if you think sub is then think again..One last thing, try and ****** suboxone withdrawls and guess what youll find??? first 50 sites pop up are paid for by the drug maker of sub and you have to dig to find real facts from patients with experience.. Drug maker pays big bucks to keep all the info ” positive” on subs… They are no dam different then the crooks on wal-street !

My Response:

Before my answer, a quick comment–  I do like the ‘crooks on wal-street’ remark;  I haven’t seen that ‘play on trademark words’ before.  I am assuming that he was making a joke–  he had to be, right?

OK, here is my response.  As usual it is a bit ‘snotty’– but you have to remember that I get this garbage all the time, and it gets old:

I am sorry to be the one to break this to you, but you are an opiate addict. Moreover, you will always be an opiate addict; hopefully you will be an addict ‘in remission’. The brain pathways that make up ‘addiction’ are laid down in a manner that involves memory processes; becoming a ‘non-addict’ would be like forgetting how to ride a bike. It cannot happen. Again, you can be in remission, but with opiates, that is very difficult– and unfortunately very uncommon.

Many people write about how they used will power or vitamins or some other silly technique to quit opiates– once they have gone over 5 or 10 years, I am interested in listening to them. It is easy to quit using for a year– it is another thing entirely to quit using for 10 years. I got clean in 1993 and felt pretty proud of myself… I quit through AA and NA, not Suboxone. I worked with opiates the whole time, giving patients IV fentanyl, morphine, demerol, etc in the operating room… but in 2000, thanks to a little market in the Bahamas that sold codeine over the counter, I relapsed. I ended up losing almost everything, including my career, all my money, a vacation cottage, my medical license… ****** ‘mens health’ and ‘the junkie in the OR’ and you will read my story.

There is no ‘fraud’, no ‘slick doctors’. There are doctors trying to help, and some work harder than others to keep people on track. We now know that Suboxone is best thought of as a long-term treatment, just like most other illnesses; we treat diabetes, hypertension, asthma, etc with long-term agents; if you stop your blood pressure meds abruptly you will have ‘rebound hypertension’ that can be very dangerous… Suboxone is similar to any other treatment. The thing is, pharmacy companies never used to care about addiction; the money is in treating other illnesses– just watch the commercials on TV! The money has been in viagra-type drugs! Suboxone is the first generation of opiate-dependence medications; the next wave will have fewer side effects, and so on. That is what happens with every disease. I am glad addiction finally has the attention of pharmaceutical companies. As for ‘slick docs’, there are many easier ways to make a buck in medicine! I am at the ‘cap’ of patients; the money I make treating patients with Suboxone is a tiny fraction of what I made as an anesthesiologist; I could drop the Suboxone practice tomorrow and take one of the 30 jobs in my area frantically looking for psychiatrists and make as much or more money. Yes, there probably are some ‘bad docs’ out there– there are ‘bad everythings’. But a bad doc will make a lot more money treating ‘pain’ using oxycodone than treating addiction with Suboxone! For one thing, there is no cap on pain patients! And when a doc wants to prescribe Suboxone, he/she can have only 30– THIRTY– patients for the first year. Hard to get rich on 30 patients!

Suboxone has the opiate activity of about 30 mg of methadone. When tapering off Suboxone, the vast majority of withdrawal symptoms occurs during the final parts of the taper– the last 2 mg. That is because of the ‘ceiling effect’. But you are not just tapering off Suboxone…

Do you remember when you started Suboxone, how lousy you felt, and how Suboxone eliminated the withdrawal? YOU NEVER FINISHED GETTING OFF THE STUFF YOU WERE ADDICTED TO. There is no ‘free lunch’; Suboxone allowed you to avoid all that withdrawal; if you stop Suboxone, you have to finish the work you never finished before– going through the withdrawal that you ‘postponed’ with Suboxone! Welcome to the real world– you likely abused those pills for years, and if you don’t want treatment with Suboxone, you had better start a recovery program, or you will be right back to using again.

Human nature can be a disappointment at times… When I ‘got clean’ after my relapse 8 years ago, I was just grateful to be ‘free’– even for just a few days of freedom! To get to freedom, I was in a locked ward for a week, no shoelaces (so I wouldn’t hang myself!), surrounded by people who were either withdrawing or being held to keep them from self-harm (it was a psych ward/detox ward combined). After that, I was in treatment for over three months– away from my family all that time, and I couldn’t leave the grounds without an ‘escort’ (no, not that kind of ‘escort’!). Treatment started at 6:30 AM and ended at 10 PM. The rare ‘spare time’ was used to do assignments. After those three months I was in group treatment for 6 years, and also AA and NA meetings several times per week. I still practice and active program 8 years later– I know what happens to people who stop: they eventually relapse, and some of them die. I AM NOT EXAGGERATING ‘FOR EFFECT’ HERE.

I had better stop or I will spend all of 2009 with this post… My final comment: Most of what you are feeling is not ‘Suboxone withdrawal’. I have watched many people stop Suboxone; some have bad withdrawal, some have NONE. When you talk about ‘anxiety’ or other problems facing life on life’s terms, you are experiencing life as an untreated addict. ADDICTS WHO SIMPLY STOP TAKING THEIR DRUG OF CHOICE FEEL MISERABLE!!! That is not withdrawal, and it doesn’t go away! Suboxone held things ‘in remission’ and allowed you to pretend you were not an addict; it is NOT a cure. So now, off Suboxone, you will see what it is like to live life as an opiate addict without treatment– and if you don’t get treatment, you will likely relapse. You will relapse because untreated addicts find life intolerable.

My human nature comment– everyone wants good things, but nobody wants to do the work to get them… (I’m in a bit of a mood today I guess– sorry). Recovery from opiates has always taken work– very hard work. And even then, success was rare– most people had to go back to treatment over and over and over before finally getting it. If people stopped working, as I stopped working in 1997, they eventually got sick again. Enter Suboxone: now you can have instant remission from active addiction! So are people grateful for that fact? That now, instead of years and years of struggle, they can take one pill each morning and hold their addiction in check? NO. Now they complain that ‘I don’t feel good when I stop Suboxone!’. Sorry, but a part of me says ‘poor baby’. You have a fatal illness, and you think you are done with it… you will find going forward that you will either use, or you will take buprenorphine or a new medication along the same line, or you will be attending meetings for life. Those are your three choices– pick one.

If you find a 4th choice, tell me about it in 5 years. I would like to hear how you did it, and yes, I hope you do find it (rather than die using). But I looked for that other path myself for years and never found it, and so did millions of other addicts.

Back to the present…

Phew.  Makes me tired just remembering those days.  Since then the number of deaths have only gone up, but at least there is a better acceptance for treating opioid dependence using effective medications— at least for people ready to accept that help.

Size Matters?

I’ve received several complaints from patients and readers about one of the current buprenorphine formulations.  The primary complaint is that the tablet is ‘not ‘working as well as the other formulations;’ that it seems to wear off earlier, or that people feel compelled to take more than what is prescribed.

buprenorphine formulations

Buprenorphine 8 mg tabs

My understanding, admittedly based only on what people have told me, is that there are three current formulations of buprenorphine.  The brand form, Subutex, comes as a relatively-large, flat-oval tablet, white or off-white in color.  The Roxanne version is a round white tablet, with a diameter of about 0.5 inch.  The tablet people have complained about is from Teva, and is smaller;  about the size of a tic-tac.

In general, I think that generics are as good as brand name medications.  I have never come across a reliable instance, in my practice, of generics being less potent or less active.  I recognize that particularly for psychiatric medications, the placebo effect accounts for significant portions of the actions of medications—so if a person BELIEVES that generic fluoxetine is less likely to work, it IS less likely to work.  But take away the placebo issue, and a molecule of fluoxetine is a molecule of fluoxetine—regardless of where it comes from.

That said, I realize that the delivery of molecules can be affected by the design of capsules and tablets.  I remember a study, years ago, that showed that many of the vitamins sold in the US passed through the intestinal system without even dissolving, let alone getting into the bloodstream. If the active substance is encased inside insoluble resin, there is little to be gained from taking it.

The delivery issue is less of a concern with a medication that is delivered through the oral mucosa, as with buprenorphine.  There are several factors that affect absorption of buprenorphine;  the concentration of buprenorphine in saliva,  the amount of surface area that buprenorphine is allowed to pass through, and the time allowed for that passage to occur.  If the smaller tablet dissolves more slowly, molecules of buprenorphine may have less actual contact-time with oral mucosa, thereby reducing absorption.

On the other hand, I am well aware of the psychological reward that people describe from taking buprenorphine or buprenorphine-naloxone, even in the absence of any subjective sensation.  The fear of withdrawal is relieved by taking buprenorphine—making the dosing experience ‘rewarding.’  It may be that the smaller tablet provides less reward, as the small size engenders less confidence in those unfelt ‘effects.’

In any case, I invite readers to share their experiences, just in case those who have already written are truly onto something.  Please leave comments below—and thanks for sharing!