Real Questions About Addiction, Dependence, and Treatment
Ask me Anything
Ask an addiction medicine expert, Dr. Brian Clear, M.D. FASAM. I get fantastic questions from patients and others I work with all the time, and here is a collection of my favorites.
Of course, this information is for general educational purposes only and is not intended to diagnose or treat any medical condition.
“I want to start Suboxone, and I want to keep my dose low so I can stop it in the future.
What’s a normal dose of Suboxone, and what’s the lowest dose that usually works for people?”
A: The right dose for any one person is always determined by how you feel, and surprisingly, trying to keep your dose low will work against you, especially when starting out. Here’s why:
First, some quick context: talking about averages, when stopping heroin or 7-OH, 16mg daily is a typical Suboxone dose; from fentanyl, 24mg is more common; from short acting prescription pain medication or kratom extracts (mitragynine), 8-12mg.
Now to determine, “What’s the lowest dose that works for people,” we use a unique process to find the answer every time we start buprenorphine. We start with a small initial dose (2-4mg, sometimes 8mg), then we add an additional dose each hour until we find the lowest dose that completely relieves withdrawal. Then over the next 2-3 days, we may make additional adjustments until relief lasts a full 24 hours.
We want to be very careful not to under-dose because healing the brain pathways that generate cravings requires breaking the cycle of using opioids for relief (reward). If we’re allowing withdrawal to persist or to creep back up between doses, even a little, then we’re not completely eliminating the reward sensation from opioid use. Completely eliminating that reward sensation, then giving the brain enough time to remodel, is critical for permitting healing to reduce long-term relapse risk.
We also want to avoid giving too high of a dose because that increases tolerance unnecessarily. This isn’t dangerous, but for patients who would like to decrease their dose eventually, it becomes a longer process.
I always recommend that patients focus on how they feel, not on the number of mg. Once you’ve stabilized and we’ve broken the cycle of withdrawal → relief, then you can begin to decrease your dose slowly as tolerated, if you like.
- Dr. Clear
Now, the question behind the question is “will having a drink while on naltrexone lead to loss of control?”
It could, but it’s less likely compared to drinking without naltrexone. Because naltrexone reduces the reward signal from the first drink, it weakens the trigger that would otherwise lead one drink to become several. Patients on naltrexone often observe that if they drink more than intended it just feels bad, and they don’t want to do it again.
Current evidence supports that no amount of alcohol has clear health benefits, and completely stopping drinking is a good default recommendation. It’s also possible for many people with a history of Alcohol Use Disorder or Binge Drinking to return to occasional controlled alcohol consumption with treatment. The choice always depends on individual circumstances, values, and goals. I’m able to support either goal in my practice.
- Dr. Clear
“Can I still have a drink sometimes while taking Vivitrol? Will it make me sick?”
Yes, you can have a drink while taking naltrexone (Vivitrol), and it won’t make you sick. It’s interesting to understand what happens when you do.
Naltrexone (Vivitrol) works by reducing the “buzz” or pleasure response that comes from drinking alcohol. This buzz is produced through stimulation of the brain’s natural opioid reward system, and naltrexone suppresses that system. Naltrexone won’t suppress the sedating effects or loss of coordination, but because it reduces the “buzz,” it also reduces reinforcement of the dopamine reward response that drives cravings.
Naltrexone doesn’t eliminate the pleasure response; think of it as putting a cap, or a limiter on part of the brain’s pleasure response. It does not impair your ability to enjoy normal pleasures of life: food, friends, fun, and so on. It does limit the abnormal super-response that drives addiction to alcohol and opioids.
Submitting a question does not establish a patient-physician relationship.