Buprenorphine Split doses

[Busunsc713]

Does anyone take Buprenorphine every 12 hours instead of a single dose every 24 hours. If so, do you have literature support/ support article link?

[Joolsg]

I take in 2 split doses 4 hours apart in the evening. I started to do this when I got breakthrough RLS at 8pm the evening after I took 0.4mg. By splitting the dose and taking 0.2mg at 9pm and 0.4mg at 12.30/1am- I get 24 hour cover & zero symptoms ever.There is no literature or research/studies to support this..There is only ONE study on Buprenorphine for RLS. That's the study by Dr Berkowski.

We on this forum are effectively the 'study' on Buprenorphine as there seem to be limited numbers in the UK, Australia and USA, Canada taking it.

For anecdotal reports, put Buprenorphine in the search engine.

Some on here take the patch but most seem to be taking the sublingual pill.

[LanaCSR in reply to Joolsg]

I do the same! I take my 2 doses a little further apart...noon (12:00 pm) and 9:00 pm (right before going to bed). I was told to try this by my doctor who prescribes me the sublingual form of buprenorphine, and it works PERFECTLY for me every single time!!

[Jelbea in reply to LanaCSR]

Hi Lana - I also take buprenorphine and I am interested in your timings and also how much do you take daily. I need to take 200 mcg at lunchtime and again 200 mcg around 6.00 pm and 400 mcg at 10.30 pm. I would like to try to take just two doses per day but am afraid to upset things by changing.

Would you mind telling me about your daily dosage. Thank you.

[LanaCSR in reply to Jelbea]

Hey Jelbea! I take the sublingual 2 mg tablet twice a day. Mine only comes in 2 mg and 8 mg. It doesn't come in any different strengths. But the 2 mg twice daily works great for me!!

[ID158 in reply to LanaCSR]

Hi Lana. If I may ask: Did you *start* at 2mg twice a day, or eventually work up to it?

I'm taking the sublingual film, and while it too comes in 2mg does, I'm cutting it up and only taking a quarter of that per night currently.

[LanaCSR in reply to ID158]

I actually started at a higher dose and cut down. I was taking 2 mg three times a day and then went down to 2 mg twice a day.

[Riversong]

Buprenorphine

Hello Busunsc 713,

Started Buprenorphine six weeks ago after being on Pramipexole for 25 years and having a brutal withdrawal period of a few months. The dosage prescribed for me was 200 micrograms taken an hour before symptoms usually begin, increasing the dose by one tablet of 200 micrograms every two to three weeks to a maximum of 1.2 mgs. As the augmentation symptoms started to settle I reverted to only getting RLS symptoms in the evening so took one tablet at 9pm. The result has been life changing and amazing, 8 hours sleep, no RLS. After first two weeks, had some RLS symptoms early evening so added in one tablet around 4pm. Working really well, no side effects. I think this start slow and increase slowly approach is ideal as it reduces side effects. My neurologist in UK was Dr Chris Murphy in Manchester. Only literature I have is pharmacy leaflet. My GP was happy to prescribe this on recommendation of Neurologist. Hope that helps.

[Busunsc713 in reply to Riversong]

Thanks for your reply.

[LotteM]

I did that for several months when it occurred to me that my morning and daytime restlessness might be miniwithdrawals. At the time I took 0.2mg in the evening, don’t remember what time. After the morning dose, the restlessness would return later, in the afternoon. To get full coverage, I would have had to retake buprenorphine tablets about every 6h. In the end, my pharmacist listened, confirmed that it was most likely mini-withdrawal as breakdown rate varies a lot among people who take it, and suggested a 7d patch. It worked like a charm.

I tried to find information in the scientific literature about breakdown rates of bup, but couldn’t. And I do have good acces through my institute ( a university). I only could find an effective half life of 4-6h and “Elimination is bi- or tri-exponential with a terminal half-life of 32-35 hours.” I couldn’t figure out the bi-exponential or tri-exponential part.

There a two good and fairly recent review papers about buprenorphine, but no mention of RLS.

[LanaCSR]

I do the same as Joolsg except that I take my 2 doses a little further apart...noon (12:00 pm) and 9:00 pm (right before going to bed). I was told to try this by my doctor who prescribes me the sublingual form of buprenorphine, and it works PERFECTLY for me every single time!!

[Red_Kelt]

Just as a side note. I work in substance misuse in the UK, and I have severe RLS after taking Pramipexole for a few years. Today I will be administering buprenorphine and methadone to clients. However, that's as close as I get to it. You have to be a misuser of opiates in the UK (or in my neck of the woods) to get buprenorphine. I'm at the end of my tether but good luck with it all.

Who would have thought 0.2mg would be so useful? We sometimes administer 18mg daily, with 16mg daily being the most common dose for opiate substitute treatment.

[Joolsg in reply to Red_Kelt]

If you can see one of the handful of specialists who follow up to date research- you can get a prescription for low dose buprenorphine in the UK.There are areas where it is 'red listed' so only a specialist can prescribe.

Where are you? Dr Chris Murphy in Salford, Prof Guy Leschziner at Guys London, Prof Matthew Walker at UCL London, Dr Robin Fackrell in Bath and D4 Jose Thomas in Wales are all familiar with the miraculous results of low dose buprenorphine for refractory RLS.

You have severe RLS BECAUSE you are on Pramipexole. It has an iatrogenic effect. It feeds the disease- increasing severity.

RLS -UK website has a withdrawal schedule and iron therapy schedule under 'useful resources'.

Show it to your GP.

[Red_Kelt in reply to Joolsg]

Hi, I'm in South Wales, and thank you for the reply. One of the doctors I work with says he has a friend who is well versed in RLS. I wonder if it could be Dr J Thomas.

[Joolsg in reply to Red_Kelt]

Please do your research. You need to get off Pramipexole. It is poison. The AASM new guidance has relegated all dopamine agonists to 'end of life scenarios' because of the inevitable severe drug-induced worsening ( augmentation) and the very high rates of Impulse Control Disorder.Start by reading RLS-UK website and 'useful resources'. Then read the new AASM guidance. .

Just click on my name and search my posts. I've added the AASM guidance.

Read Dr Andy Berkowski website relacs.com.

He did a study on Buprenorphine. Most RLS patients need much lower doses than when opioids are used for pain or for opioid withdrawals.

Dr Winkelman's opioid register at Massachusetts General hospital shows RLS patients do NOT develop tolerance or addiction (unless history of abuse).

Learn all you can because UK doctors aren't taught anything during medical training.

[Busunsc713 in reply to Joolsg]

Buprenorphine worked! I have watched a friend live a horrible existence during 2023 through November 2024. The sleep specialist described his augmentation as the worse he’s ever seen. To make a long story short, Buprenorphine was prescribed. His violent jerking, PLM, RLS are completely controlled 24hrs daily. …. From the first day.

[Joolsg in reply to Busunsc713]

If I had a pound for every doctor who says a patients' augmentation/severe RLS is the Worst they have ever seen, I'd be extremely rich.What they really mean is they had no idea that dopamine agonists could cause such severe RLS.

Anyone experiencing severe augmentation will have violent leg jerking & all over, uncontrolled RLS.

I do hope your friend is reducing the dopamine agonist.

Buprenorphine instantly settles augmentation symptoms BUT some patients then assume all is well and stay on Ropinirole/Pramipexole. And of course, within weeks/months the D1 dopamine receptors start screaming again and break through the Buprenorphine.

Then they have to go through hellusg withdrawal.

So make sure your friend gets off the dopamine agonist.

[Busunsc713 in reply to Joolsg]

Buprenorphine is the only medication he’s on. If you’ve followed my periodic posts, he was weaned off dopamine agonists in latter 2023/ early 2024. Gabapentin did not work. It was horrible. Hydrocodone worked but not completely. There absolutely no movement on Buprenorphine.

[Joolsg in reply to Busunsc713]

Superb. It really is miraculous for so many of us.

[Red_Kelt in reply to Joolsg]

Thank you Jools for the reply. I think I might start my own thread as I appear to be hijacking this one.

[SueJohnson in reply to Red_Kelt]

Welcome to the forum. You will find lots of help, support and understanding here.

I agree with Joolsg.

You are augmenting . The signs of augmentation are when you have to keep increasing your dose to get relief, or when your symptoms occur earlier in the day or there is a shorter period of rest or inactivity before symptoms start or when they move to other parts of your body (arms, trunk or face) or when the intensity of your symptoms worsen.

And this means you need need to get off the pramipexole.

Since you are suffering now I suggest you add half of a .088 [.125] tablet and wait until your symptoms settle. However don't be tempted to stay on it as you will augment quickly again.

First off check if you are on the slow release pramipexole. The slow release ones usually have ER or XL after their name. If so you need to switch to the regular pramipexole because the slow releases ones can't be cut.

To come off pramipexole reduce by half of a .088 [.125] tablet (ask for a prescription of these if needed) every 2 weeks or so. You will have increased symptoms. You may need to reduce more slowly or with a smaller amount or you may be able to reduce more quickly. Wait until the increased symptoms from each reduction has settled before going to the next one. You will suffer and may need a low dose opioid like buprenorphine temporarily to help out with the symptoms especially as you near the end. Some have used kratom or cannabis temporarily to help. But in the long run, you will be glad you came off it.

Ropinirole and pramipexole are no longer the first-line treatment for RLS, gabapentin or pregabalin are. They used to be the first-line treatment which is why so many doctors prescribed them but they are not up-to-date on the current treatment recommendations. Also don't let your doctor switch you to Neupro (rotigotine). S/he may tell you that it is less likely to lead to augmentation but that has been disproved.

The beginning dose is usually 300 mg gabapentin (75 mg pregabalin). Start it 3 weeks before you are off pramipexole although it won't be fully effective until you are off it for several weeks and your symptoms have settled. After you are off pramipexole for several weeks increase it by 100 mg (25 mg pregabalin) every couple of days until you find the dose that works for you.

Take it 1-2 hours before bedtime as the peak plasma level is 2 hours. If you need more than 600 mg take the extra 4 hours before bedtime as it is not as well absorbed above 600 mg. If you need more than 1200 mg, take the extra 6 hours before bedtime. (You don't need to split the doses with pregabalin)

Most of the side effects will disappear after a few weeks and the few that don't will usually lessen. Those that remain are usually worth it for the elimination of the RLS symptoms. If you take magnesium even in a multivitamin or magnesium-rich foods, take it at least 3 hours before or after taking gabapentin (it is OK with pregabalin) as it will interfere with the absorption of gabapentin and if you take calcium don't take it nor calcium-rich foods within 2 hours for the same reason (not sure about pregabalin). According to the Mayo Clinic Updated Algorithm on RLS: "Most RLS patients require 1200 to 1800 mg of gabapentin (200 to 300 mg pregabalin)."

The reason I suggest trying gabapentin or pregabalin first before going to buprenorphine, although you could use it to help the withdrawal, is because buprenorphine can be hard to get because of the opioid crisis and there is the stigma effect for friends and family who may not understand that you won't get addicted taking it for RLS. Also some of the side effects of buprenorphine can be hard to live with although if you find they are OK while withdrawing from pramipexole then stay with it

Have you had your ferritin checked? If so what was it? That is the first thing a doctor should have done. You want your ferritin to be over 100 as improving it to that helps 60% of people with RLS and in some cases completely eliminates their RLS and you want your transferrin saturation to be between 20% and 45%.

If not ask your doctor for a full iron panel. Stop taking any iron supplements including in a multivitamin 48 hours before the test, don't eat a heavy meat meal the night before and fast after midnight. Have your test in the morning before 9 am if possible. When you get the results, ask for your ferritin and transferrin saturation (TSAT) numbers. If your ferritin is less than 100 or your transferrin saturation is less than 20% ask for an iron infusion to quickly bring it up as this will help your withdrawal. If you can't get an infusion, let us know and we can advise you further on the best iron tablets to take and how to take it.

Check out the Mayo Clinic Updated Algorithm on RLS which will tell you everything you want to know including about its treatment and refer your doctor to it if needed as many doctors do not know much about RLS or are not up-to-date on it as yours obviously isn't or s/he would never have prescribed a dopamine agonist at Https://mayoclinicproceedings.org/a...

Some things that can make RLS symptoms worse for some people are alcohol, nicotine, caffeine, sugar, artificial sweeteners, carbs, foods high in sodium, foods that cause inflammation, foods high in glutamate, ice cream, eating late at night, dehydration, electrolyte imbalance, melatonin, Monosodium Glutamate (MSG), collagen supplements, low potassium. eating late at night, stress and vigorous exercise.

Some things that help some people include caffeine, moderate exercise, weighted blankets, compression socks, elastic bandages, masturbation, magnesium glycinate, fennell, low oxalate diet, a low-inflammatory diet, selenium, 5 minute shower alternating 20 seconds cold water with 10 seconds hot water finishing with hot water for another couple of minutes, hot baths, distractions, applying a topical magnesium lotion or spray, doing a magnesium salts soak (epsom salts), vitamins B1, B3, B6, B12, D3, K2, if deficient, and potassium and copper if deficient, massage including using a massage gun, vibration devices like therapulse, using a standing desk, playing and listening to music, creative hobbies, meditation and yoga.

Many medicines and OTC supplements can make RLS worse. If you are taking any I may be able to provide a safe alternative.

[Cookiebum24 in reply to Red_Kelt]

This is what I was told by one of the GPs at my practice despite getting a letter from a neurologist recommending that I take it.

Luckily another GP stepped in and prescribed it for me….as she said she’s only doing what a consultant has advised so she’s not personally recommending it.

Maybe you need to try this route. My GP practice did I initially agree to prescribe it upon recommendation, I just unfortunately got a hesitant GP the first time I asked.

[Skifam]

I take Buprenorphine at 2 mg in the morning and 2 mg in the evening. There is no literature I could find to support split dosing. I am fortunate to have a physician who has quite a bit of expertise in this field and she believes in letting me decide how to handle dosing up to a point of course. This split dose works well for me. Again, it is vital to find a physician who understands your issues and is willing to work with you.

[davchar23]

Dear Busunsc713,

Clearly from all the sensible replies you have had that there are many ways of finding out the best way to apply "bupre". The underlying factor from my perspective is SIDE EFFECTS and how to at least minimise them!

The side effects i am talking about are nausea, dizziness, constipation and insomnia . I discussed bupre half life with Twitcher 707, who has done a lot of research on this topic, and I think that LottoM is correct in her 30hour+ conclusion. However it is difficult to get the right balance except by a lot of individual experimentation

I am of the opinion that "mini withdrawals" are a real problem and I eliminate these by using bupre "weekly" patches (10mcg/hr). I know from my research that i need about 500mcg per 24hours to block RLS and I stop the mini withdrawals by taking small portions (using a tablet cutter) of sublingual tablets (50mcg/portion) throughout the day to give me a total balanced dose of about 450-500mcg in 24 hours

What this means is that the level of bupre in my system never exceeds the concentration which causes nausea (the worst side effect for me). I found that if I took tablets as Joolsg and others do then my nausea is very bad and even cannabis oil does not help this.

Good luck in your way forward to find the modus operandi that suits you.

Davchar23

[Renaul]

I take buprenorphine in divided doses as and when I need it. Some days I have symptoms early afternoon. Mostly it is early evening and late at night.

I am blessed with a GP who has allowed me thr freedom to work with my symptoms.

[707twitcher]

I have tried the patch and sublinguals (Suboxone film). I prefer the latter, mainly because I seemed to experience much more fatigue on the patch than the sublinguals. I haven’t seen anyone else with the same experience, so maybe I’m imagining it. But we all react differently to meds.

When I first started with buprenorphine, it actually was effective for over 30 hours. I could take a dose every other evening and it covered two nights. That didn’t last long, and it has evolved into a 12 - 15 hour effective period for me. I don’t get symptoms between my every evening doses unless I nap in the afternoon. I need some buprenorphine if I want to nap more than 30 minutes. When napping, I usually take half my normal evening dose, and then the other other half that evening. That usually works, but occasionally I get symptoms around 5 or 6 am. I would need a higher dose to make sure I avoid that, but side effects keep me trying to minimize dosage.

For me, I don’t think it’s mini-withdrawals. It’s the 12 - 15 hour effective life that I have to manage.

[Ticki]

I also split my dose up. I have 4 mg in the morning and 4 mg in the evening.