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A reader’s question:
I have been on Suboxone for 2 years. My addiction was Oxycontin. I had knee replacement surgery and was successfully able to take pain meds and then get off them and go back to Suboxone. My medical Doc and I noticed that when I restart the Suboxone, I get 2-3 plus pitting edema in my legs, severe enough to require diuretics– and they don’t even work very wel. When I have stopped Suboxone in preparation for surgery, I immediately lose 15 lbs and the edema goes away. My Suboxone Doc says that there are no side efffects. I am 53 and have heart disease, and I know that this extra fluid is not good for my heart. My kidneys are normal. Have you heard other comments of this nature? Is it dose related? This is a serious situation for me.
Reply:
I have had two or three patients with similar complaints. To put things into perspective, though, over 5 years I have treated over 400 people with Suboxone or buprenorphine. One person in particular had very bad edema, that caused a great deal of pain in his legs– so much that he stopped the Suboxone and went back on opioid agonists. In his case, though, the edema did not lessen on agonists and he still struggles with edema a couple years later. I don’t know if he had edema before I met him and started Suboxone; he claimed that the edema was a new development, but I have learned that people sometimes notice things related to their health status that differs from the perspective of an independent observer. This is why, by the way, I don’t fully jump into agreeing with people who report tooth decay ‘that starts after starting Suboxone.’ I had a patient with that complaint, and to look into things we got a copy of his dental records; they showed that the decay was well underway years before he took Suboxone, at least according to dental notes and x-rays. But in his mind, it all started after the Suboxone. The mind sometimes plays tricks on us.
When I worked as a psychiatrist in the WI prison system, women in the maximum security prison reported leg edema from many different medications. I never knew what to make of it, to be honest. Most of the time the medications complained about were easy to replace; if someone felt that the Seroquel caused edema, we could change it to Risperdal. If someone complained about Risperdal causing leg edema, we could change it to Seroquel. It reminded me of the old Dr Seuss story about the Star-Bellied Sneetches. I strongly recommend the story for those who haven’t read it…
I like to think in terms of mechanisms, and I don’t have a good theoretical mechanism for leg edema from buprenorphine or from naloxone. The collection of edema in the legs usually comes from an imbalance of the natural forces that should be in equilibrium; gravity or ‘hydrostatic pressure’ causes fluid to leak out of blood vessels into the interstitial spaces, salts in the plasma and interstitium create ‘osmotic pressure’ that becomes balanced, with a neutral overall effect on fluid movement; and proteins in the plasma cause ‘oncotic pressure’ that draws fluid back into the blood vessels. Veins in the legs are emptied by the effects of muscles that squeeze them during walking or exercise; one-way valves prevent the blood from moving backward or standing in place during this activity. Taking all of this into account, edema is favored during immobility, when the legs are ‘dependent’ (not elevated), when protein levels are low from malnutrition or liver failure, or when the valves in leg veins have become damaged by standing too much in life.
Preventing edema involves keeping legs elevated as much as possible, reducing salt intake, wearing support stockings, and sometimes taking diuretics or ‘water pills’ to eliminate extra fluid at the kidneys. Opioids do have effects on a number of hormones; there are large protein molecules that are cut into smaller pieces that include endorphin and enkephalins, the brain’s ‘natural opioids’. Other parts of those same large molecules have effects on fluid balance, among other things– the inter-relationships are complex and not entirely predictable.
I am posting this in case others have noticed similar effects, or in case a good endocrinologist or nephrologist has a pet theory. Anyone?
Hi all! Sorry for the lapse in posting… I have been gearing up to blog for Psych Central, an opportunity that I am very excited about, and I have a hard time writing one blog and being excited about a second blog at the same time! Please be sure to visit my blog at psychcentral.com, called ‘An epidemic of addiction.’ The first few posts will be mostly introducing myself with information that people here already know, so come visit in a couple weeks when I am up to speed.
A question/answer post for tonight:
As you know, generic Subutex is cheaper than Suboxone. I want my doctor to switch me to Subutex, but I am so afraid to ask him. Even though my doc is nice to me, what if he is one of those doctors….gets mad at me, and discharges me as a patient? I can’t do something that could possibily send me back on that old course of life that seems more and more distant every day.
Can my doctor legally prescribe me Subutex rather than Suboxone? What good reason could he have for not agreeing to, once I show him how much money it will save me? Also, do doctors make extra money by writing a prescription that is filled at a certain pharmacy?
My reply:
Thanks for your question. Isn’t it sad that people are afraid that their doctors will cut them off of life-saving treatment? The writer is not paranoid; there are practices where patients are treated as ‘guilty’ just for asking questions that make the doc uncomfortable. Such a situation does NOT foster the open communication that keeps addiction out in the open, where it can be treated properly and effectively. And such a situation is a far cry from treating addiction as the disease that it is, rather than a character deficiency.
Any doctor who can prescribe Suboxone can also prescribe Subutex. There is no difference in the actions of the two medications when they are taken properly; Suboxone contains naloxone, that supposedly reduces IV use of Suboxone. But studies show that most ‘diversion’ of buprenorphine is for ‘self-treatment’ of opioid dependence– not for the sake of getting an opiate high. I suspect– but have no proof– that the RB reps encourage docs to think that if they prescribe generic Subutex, their patients will be shooting up in their lobbies. This keeps docs prescribing brand-name Suboxone– at least until the Teva generic becomes available.
The main reason a doc won’t prescribe the generic then is fear of diversion, which in my opinion is overblown– not because there is no diversion, but because both Suboxone and Subutex are diverted at an equal rate and used for the same thing– for illicit self-treatment. Some docs probably avoid the generic to avoid a common problem– if the pharmacy doesn’t have the generic they will substitute the very-expensive, name brand Subutex– often resulting in calls to the doctor for prior authorizations or replacement scripts. It is currently easier for the doctor to simply write for Suboxone. Docs should realize, though, that the cost difference is quite significant; in my part of Wisconsin, generic Subutex is lesss than $3.00 per tab, and Suboxone is over twice as costly.
I have heard of places in Florida (sorry Florida– maybe it happens elsewhere too, but you folks have a reputation for this) where docs provide scripts for pain pills with the condition that people use specific pharmacies. I am surprised that such an arrangement would be legal; it is clearly unethical to have such a conflict of interest. That arrangement would violate Medicare law, but if they avoid Medicare patients, perhaps they can get away with it… But to answer the question, I have never seen such a situation in my part of the country. Docs– post anonymously if you are willing– has anyone heard of profiting by prescribing certain medications?
To the writer, I would like to just say ‘ask your doc if he/she will prescribe the generic.’ I can tell you that I would certainly not be ‘offended’ in any way, or think poorly of you. Of course there is always some value in being polite; no doctor likes being told what he/she ‘has to prescribe!’ But you know your doc and I don’t. If your gut says tread cautiously, then tread cautiously. You could always ask your pharmacist if doctor so and so ever prescribes the generic– although pharmacists tend to treat addicts even more poorly than doctors do!
For the docs out there, maybe it would be appropriate to ask yourselves, ‘is this MY patient writing to the blog? And if it is, why is he afraid to talk to me?’
