Buprenorphine, one of the three Food and Drug Administration-approved medications for opioid use disorder (MOUD) does not mix well with fentanyl. You don’t want both of them in your system at the same time—unless one of them is just a very small amount. So when people talk about microdosing buprenorphine, it’s usually in the context of switching over from fentanyl. I microdose buprenorphine while continuing to use at least six bags of fentanyl a day.
Some background: Opioids like fentanyl, heroin and methadone are full agonists. Basically this means they have a strong effect. On the other end of the spectrum, you have opioid antagonists, such as naloxone—these kick the aforementioned full-agonist opioids off your receptors, which is why naloxone is great for reversing overdose.
Opioid overdose causes respiratory depression, and the right dose of an antagonist clears out just enough of the full agonist to let someone start breathing on their own again. But an excessive dose—one that doesn’t leave enough of the full agonist behind—puts the person into withdrawal. But all at once, rather than over the course of hours, and trying to make the symptoms go away is difficult and dangerous. This state is called precipitated withdrawal. It sucks.
Buprenorphine, AKA Suboxone or just “bupe,” is a partial opioid agonist. This means it’s a very effective MOUD for some people, while for others it’s just not enough. But it also means that bupe can precipitate withdrawal, too, if someone takes it while they still have too much of a full-agonist opioid in their system.
Over my many years of using many different opioids, I’ve adapted the Bernese method to my daily life.
The traditional way of getting on bupe is that you have to wait until you’re way into regular withdrawal before you start taking it, to avoid precipitating withdrawal. And if you get desperate and take it too soon, or a doctor misgauges how long you should wait, you end up precipitating withdrawal anyway.
There are a small number of alternative methods that are much more humane, the best known being microdosing through the Bernese method. This basically involves starting with tiny doses of bupe that you gradually increase while you continue using your usual opioids, and doesn’t require you to be in a miserable state to get started. It’s a short-term thing, just for the period of transitioning away from the full agonist. But over my many years of using many different opioids, I’ve adapted the microdosing protocol to my daily life.
This works for me for two reasons. First, I’m semi-regularly in situations where I need to switch over fully to bupe for a few days—family gatherings, that type of thing. Second, my tolerance is pretty high. If it weren’t for those two things, I wouldn’t be doing this. Nothing in this article is medical advice, just in case that wasn’t obvious.
Let’s say I’m using a bundle—10 bags—of fentanyl per day. (Or rather, fentanyl plus whatever else ends up in there these days.) And let’s say in 10 days I’m going to get on a plane to visit family, and I’ll need to get by on just the bupe until I’m back home.
I can’t just switch over from fentanyl all at once. So at T-minus 10 days I’d get one of my 8-mg Suboxone strips and take just a tiny piece—about one-tenth of the strip. And I’ll take that on top of my 10 bags. At T-minus nine days, I take two of those pieces, and drop my street supply intake down to nine bags. At T-minus eight days, three-tenths of the Suboxone strip and eight bags of dope, and so on and so forth.
Once a day, about three days a week, I take 1 mg of Suboxone.
This is not a perfect system. Of the dozens of times I’ve done this, only one single time did I manage to pull it off flawlessly; if you graphed it, with bupe going up and the fent going down, it would have made a perfect X. Bernese himself would have given me a kiss. The Bernese method is actually named after Bern, Switzerland, but that’s not the point.
So even though I’ve been doing this over a decade, I still almost always end up with some withdrawal symptoms here and there. What I’ve found makes the process smoother is to keep a low level of bupe in my system at all times, not just special occasions.
Once a day, about three days a week, I take 1 mg of Suboxone. I’m just eyeballing one-eighth of a strip as I tear it off, so each piece is probably between 0.75 mg and 1.25 mg.
Despite the concern about using bupe too soon after using a full agonist like fentanyl, it’s never made that much difference whether I take the bupe before or after I start using fentanyl for the day—but this is because I use a lot of fentanyl. For someone using smaller quantities, or a less-potent opioid, 1 mg of Suboxone could easily throw them into vicious precipitated withdrawal if they take it too soon.
Usually I do my two-bag wakeup dose of fentanyl first thing in the morning, and then see how I’m feeling. If I’m feeling good, and it’s one of the three-ish days a week I’m microdosing, I’ll take the little piece of bupe right then and get it out of the way—because while I appreciate bupe as a useful tool, and know what a literal lifesaver it is for so many people, personally I kinda hate it. I don’t get any effect from it, and it often dulls the fentanyl. So I have to keep an eye on whether my fentanyl use goes up as a result of the microdosing, and sometimes it does. But overall this has been manageable, and the constant microdosing seems to help acclimate my brain to the partial agonist—both physically and mentally.
Image via New Mexico State Legislature
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