The Opioid Dependence Big Picture

First Posted 1/16/2014

Below, internet colleague Paul Dessauer shares his extensive knowledge of opioids in comments about my naltrexone post. His comments were particularly interesting in that they provide evidence that at least someone is aware of the big picture about addiction to heroin and pain pills.

In my post about naltrexone, I described how some people favored the drug over buprenorphine because of its lack of opioid effects. Unlike buprenorphine, naltrexone is an antagonist that has no abuse potential.  But I wondered… at a time when so many young people are dying, shouldn’t the primary issue be whether naltrexone saves lives?  Sure, it is ‘safe’– but does it work?

Paul provided references to answer my question.  While everyone is focused on the fact that naltrexone can block opioid receptors, Paul’s data shows that when naltrexone is used in the real world, people die.  I’m excited that someone, somewhere, has the courage to investigate the one thing that is never addressed in discussions about addiction, whether related to residential treatment, counseling, or medication: Does it work?

Paul’s comments:

You wrote;

<<< If ‘success’ consists of moving to naltrexone—a medication that many real-world addicts reject– how long is naltrexone continued, and what happens when it is stopped? Do people go back to heroin again? If not, why not? The cycle of ‘use, treat, cease treatment, use, and repeat’ should be a black box warning on naltrexone >>>

Hot Flashes from Suboxone and Buprenorphine Treatment

First Posted 1/13/2014

A viewer on YouTube commented on my video about hot flashes  from Suboxone, but I don’t know if that is because the symptoms dissipate, or if people learn to deal with the symptoms.  I suspect that both are true.  But for some people, the sweating and heat are no small matter:

Here is what I wrote back, and a few more thoughts:

There seems to be a form of tolerance that develops more slowly than tolerance to the analgesic and euphoric effects of buprenorphine.  At least in the patients I’ve followed, complaints about constipation and hot flashes only go away over a period of months– after the other subjective effects of buprenorphine are long-gone.

Those who struggle with hot flashes may find relief by reducing the daily dose to the lowest amount that keeps blood levels above the ceiling threshold, around 4-8 mg per day. I think that in some case, people make the mistake of blaming withdrawal for the sweats and taking more and more buprenorphine, when the problem is too much opioid effect, not too little.

I recommend that patients carry a damp cloth or folded paper-towel, to use to create a chill when hot flashes start by touch the cloth to the face or neck. Another trick is to find a sink, and run cold water over the backs of the hands.  Anything that creates a chill—a blast of air conditioning to the face in the car, or an ice-cube touching the neck– will turn hot flashes off before they get started.

Broken Bones on Suboxone; Need Pain Relief

Originally Posted 1/11/2014

I received the following email from a Suboxone patient (from another practice) after he experienced a painful injury.  He shared what happened at the hospital when he was trying to get relief from pain, while taking Suboxone (the active component is buprenorphine).

Hey there.  Just to let you know, i was on 24 mg of Suboxone when I jumped off a fence and crushed bones in both feet.  The injury was among the most painful things I have gone through in my life.  At the hospital they did not understand Suboxone even though I tried to explain to them how it worked.  They couldn’t get a painkiller to break through and I was nearly passing out from the pain.  They finally used Ketamine and it worked immediately.  However, they only used it 3 times and its effect don’t last more than about 20 minutes in my case.  Then they switched to IV Fentanyl….I’m not sure of the dose but I know it was high and after a few injections they hooked me up to a drip bag.  Just wanted to share this info in case anyone finds themselves in a situation like mine where I was ready to strangle a doctor because they tried all of the regular oxycodone, hydromorphone, morphine, etc. all the while I was almost (or maybe even) in a state of shock from the pain.

Questions and Answers about Opioid Dependence and Buprenorphine