Amazon
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Taking a Few New Suboxone Patients
I am opening my Suboxone practice to about eight or ten patients. I am looking for people who are truly sick and tired of opiate addiction; those are the people who do great on Suboxone. Details about me philosophy of treatment can be found at my web site, wisconsinopiates.com. If you are interested please contact me within the next few weeks.
Wisconsin Opiate Management Center
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New Hosting Account, Ads, Donations
I'm sure that you have noticed the frequent changes in design and more recently hosting for my blog. I have made the changes for several reasons; I am happy to say that readership is increasing, and so I wanted to be at a place where I have a bit of control over the site. I am generally not a fan of lists of things that I cannot do; I am learning all of this 'internet stuff' on the fly, and it is hard enough to figure things out without extra rules on top of all the other things.
That said, I DO NOT like the fact that the ads from Google on the side of the page often are filled with places to buy OPIATES of all things. I am trying to figure out how to control those ads and block certain advertisers, but for now try to ignore them. They must pay every time someone clicks on their ads, as you all know... so... so...
Anyway, I have also heard comments regarding the rather vivid picture of a shooting junkie. Yes, it is a bit graphic. I do NOT intend to glamorize drugs, and if that is the perception I will rethink things. I want people to remember the ugliness of using. I also want people to make the connection between snorting and oxy; there is nothing that separates the oxy snorter from the scene in the picture except for time. I went from swallowing to shooting, missing snorting altogether. But it always progresses, particularly after periods of sobriety, when during relapses people find themselves doing things they never used to imagine doing before.
Finally, please notice the Amazon donation bucket. It is now 1:00 am and I have patients at 8:30 tomorrow morning and then my radio show at 10, then I am in court all afternoon testifying for a person who has been charged pretty highly with felony counts— a young kid with a future ahead of him who got addicted... but has been working hard to turn things around. And that is what it is all about, my friends— look at your mistakes and have the courage to take them on, and to change them, and then move on. I have great respect for people who keep trying to move forward. Take a hit, get up, and keep moving. That's how it's done, and Kudos to those of you who are moving forward. And as for those who thought you would never make it— come back in five years and show them your nice new suit.
Man, I wander when it is late! THE AMAZON HONORS PROGRAM! I spend a lot of time here and because the readers are mostly not local, I do not get referral or advertising from the site... so if you find the information here valuable, or entertaining, or even just ?nice diversion, any donations are appreciated. I am considering offering some paid content... nothing major so don't worry. Something like a video file that is a primer on opiate addiction, that describes all of the treatment options out there. I will contrast the pros and cons of each type of approach. Stay tuned, as I think it will be interesting. How much is an hour long worth, that has a psychiatrist who specialized in addiction discussing all of the options? I'm thinking 30 bucks. It sounds high, but it is less than one 80 mg oxy tablet. The 80 will be up the nose and gone, and this will stick around forever.
If you are willing and If you find me helpful, please chip in for a few bucks. Thank you very much for visiting.,
And Visit My Forum Suboxone Forum, where you can register under an alias and post all you want.
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Suboxone and Pain
A Question:
I see my urologist, the prescribing doctor on Monday, August 18th and am planning on asking him to write a prescription for Subutex for my pain. This weekend I am trying to collect some useful information to bring to him in support of my request. As I have previously stated it was my physicians’ idea to try this medication. I believe he feels uncomfortable prescribing it as in this country it is being very actively promoted/publicized for addiction. Like may doctors he may be under the impression that he needs a special UIN number to prescribe it.
See:
http://www.helpmegetoffdrugs.com/wst_page9.html
http://www.naabt.org/links/DEA_Bup_for_pain_letter.pdf
As can readily be identified in the above DEA letter he does not need any special qualifications.
Besides showing him the letter I need to find credible medical information to show him as to the equivalent dose Subutex/Suboxone to the “Avinza” 90mg he currently has me on?
As stated I see no downside to my trying Subutex/Suboxone for pain management, do you?
“long half-life results in a very stable subjective experience” I see this as a benefit.
“Tolerance occurs very rapidly…I would expect tolerance also to the analgesic effects. So theoretically it should not be a good pain drug because the rapid tolerance would eliminate the analgesic effect after a few days.” Should this occur than I would of course not be able to sustain.
“In reality, though, patients will claim relief from suboxone for an indefinite period of time in many cases. I have no explanation…”
“Suboxone certainly has advantages over other opiates, if it is found to be effective. The tolerance with buprenorphine is limited, whereas the tolerance to a pure agonist has not limit—so there is a lower amount of withdrawal if/when the drug is eventually discontinued. The stable blood level prevents the temporary ‘highs’, the miserable lows, and the cravings that can accompany the use of agonists. The patient feels much more clear headed on suboxone compared to opiate agonists. And suboxone can be dosed once per day, which has a couple effects—first, it just is less trouble to take, but more importantly the absence of ‘as needed’ dosing all day long will help prevent the patient from focusing as much on the pain.”
Again I see no down side to trying it, not focusing on my pain or if and when I might start having break through pain, not having my mood go up and down as a medication blood level changes (very important to me is leveling out my mood), possible cravings (I have not had yet),. I would be much relieved to be more clear headed. I have been having cognitive problems for several years now and have had neurological testing for it. Having a clear head and a level mood(good or bad) could potentially provide me with some relief from some of the problems and might provide some answers as to why they are occurring which might enable me to address the cognitive deficits more effectively.
“…many people have told me that suboxone seems to work as a ‘mood stabilizer’…”
As I suffer form treatment resistant depression and have read several accounts where buprenorphine has helped depression I am interested in trying it as for me it has a potential dual purpose.
“Chronic pain is a very difficult issue…I encourage you to avoid opiates as much as possible—there is generally little future in opiate treatment of pain, since tolerance always chips away at the effects of the opiate over time…”
I have a limited understanding here but as buprenorphine is a partial agonist, having this ceiling effect I was thinking it might be helpful to me in the long run as far as building up tolerance to opiate medications? For instance if I am able to obtain adequate pain management with buprenorphine over several years would I not benefit from this over taking morphine or oxycontin, full agonists over the same period of time? My tolerance for the full agonists could potentially increase during this time and if I need to continue with opiate pain management the tolerance will minimize the ability for pain management with full agonist medications if I need to go on them at some later point.
It is not clear to me whether my tolerance for buprenorphine will increase quickly or not. You stated that in theory tolerance occurs rapidly but in practice this is not always the case.
“Suboxone certainly has advantages over other opiates…”
You have in the above statement impressed upon me several advantages to using buprenorphine for pain management if it can be accomplished.
I would appreciate any input or advise you might have for me on this issue. I would also appreciate it if you could provide any relevant links to credible medical information about buprenorphine and pain management and/or suggested equivalent starting doses.
I believe my email is in my profile but to b sure you have it:
XXXXXXXXXXX
Thank you for your consideration,
“tiggy”
My Reply:
I agree with everything you wrote– although I recognize that most of the quotes are from things that I have written, so how could I not agree?! I’m joking– I suppose I should write LOL to clarify that…
As for the question about starting dose– because of the ceiling effect, the Suboxone dose is always going to be in the same general area, regardless of the opiate requirement for pain or the opiate tolerance of the patient on maintenance addiction treatment. I have disagreed with a couple earlier posts that suggested different Suboxone doses (or using methadone instead of Suboxone) for people who have high opiate tolerance; I have helped patients go on Suboxone from HUGE doses of methadone or oxycodone, and I do not think that a high tolerance argues for methadone over Suboxone or vice-versa. I see tolerance as dynamic; in any one person, tolerance is a function of two things, time and opiate dose, with the latter being most important. My own addiction to intravenous fentanyl (anesthesiologists have access to very powerful medications!) resulted in an extremely high tolerance, despite being ‘active’ for only a few months, because I kept pushing the dose higher and higher.
I have come to see withdrawal as the subjective symptoms of lowering one’s tolerance level. Suboxone has an opiate agonist potency equal to about 30 mg of methadone per day. Taking Suboxone will make one’s tolerance ‘reset’ at that level, and stay there for as long as the person is on Suboxone. A person who starts Suboxone from a lower tolerance level will get ‘high’ for a couple days, until his tolerance stabilizes at the higher level; a person who starts Suboxone from a higher tolerance level will have ‘precipitated withdrawal’ as his tolerance is ‘yanked down’ to the lower level. That is why we usually ask an addict to stop using for 24 hours or so; that way his tolerance will come down a bit (and he will experience withdrawal), and starting the Suboxone will not cause an instant surge of withdrawal symptoms. People sometimes ask why Suboxone causes withdrawal when one stops taking it; the reason is because there is no free lunch– Suboxone protected the person from needing to go through all of the withdrawal necessary to get tolerance down to zero, and when one stops Suboxone there is still work to be done to bring the tolerance down.
I tend to wander a bit… but as for specifics, the starting dose of Suboxone would be about 4-8 mg. The usual ‘final’ dose is about 16 mg. Some pain patients claim more pain relief from higher doses, but I am skeptical of anything more than a placebo effect, as we know that buprenorphine’s effects at mu opiate receptors are subject to the ‘ceiling’ that I have been referring to. Similarly, dosing once per day will result in complete, constant binding of all of your mu opiate receptors– dosing twice or three times per day will cost more and be more trouble but probably has no benefit beyond the placebo effects.
You are correct about the requirements for Suboxone prescribing; any doc can use it for pain. It may be helpful to write ‘for pain treatment’ on the script; that way the pharmacist may be less likely to question it. BUT… that does not mean thats a doctor will prescribe it or that a pharmacist will fill it. There is a great deal of ignorance about Suboxone, and many docs just don’t want to mess with something that they are not familiar with. Moreover I have noticed that many pharmacists have become more active in controlling prescriptions; many times I have run up against pharmacists who simply refuse to fill something for reasons that are highly suspect, including ‘I don’t like the looks of the guy’ (I honestly have heard that!). Sorry Walgreens, but when I have had problems it almost always has been from one of your pharmacists. Surprisingly, I have had problems with many different Walgreens locations! I don’t think this is true, but I sometimes wonder if Walgreens trains their pharmacists to be jerks– patients have told me that they were told ‘your doc is breaking the law’ or ‘your dose should be lower’… Then I had the Walgreens pharmacist call after cutting all of the controlled-release pills for a patient in half because he didn’t have the lower dose in stock, and asking for me to write a script instructing him to do what he had already done (which, by the way, results in the dangerous, instant release of 12 hours of medication)…
I had better stop before I get carried away. But I don’t like that particular pharmacy chain.
Anyway, as I was saying, your doc or pharmacist may not go along with you, and there is nothing you can do about that. I do not recommend that you threaten your doc; he is not required to prescribe what you want him to. And frankly, it is always a bit dangerous for a doc to prescribe meds that he/she is not familiar with.
You asked if there was any ‘downside’; understand that you must not take Suboxone when you have opiate agonists in your system or else you will get VERY sick. I took naltrexone once in a misguided attempt to get clean back in my using days; I never want to be that sick again! The other rules of Suboxone apply as well, the primary issue being to avoid taking benzos or other CNS depressants until you are tolerant to the Suboxone. The other downside is that while you are on Suboxone, no other opiate agonists will work. If you need emergency surgery you can be put to sleep OK but it can be difficult or impossible to get good pain control for a day or two afterward. It takes AT LEAST several days to get the Suboxone out of your system.
I do not have references for use of buprenorphine for pain– I am actually out of town this week and don’t have access to everything I usually have access to. The references are out there– as are references for use of buprenorphine for depression or other mood problems. Understand that opiates are not ‘indicated’ for treatment of mood, and it is possible that a doc could get into trouble by using opiates for such an indication. Given the issues of tolerance and addiction, I consider use of opiates as mood stabilizers or antidepressants to be extremely risky at best. Yes, they do have the mood ’side effects’, but that is a completely different issue than using an opiate primarily for mood effects. I would not be surprised if there were state laws against using opiates for such purposes.
You are accurate with the ‘tolerance’ comments. Suboxone causes tolerance that will reduce efficacy for pain treatment, but so do all other opiates.
I have to run– good luck with your doc. Let us know what happens.
SuboxDoc
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A typical addiction story
I am posting this message from the ‘comments’ section for a couple reasons; first because it highlights a couple things that go on with addiction, but second because it is from a person who is clearly hurting and in trouble– and is in a place where many of us have been before.
The message:
I have been an opiate addict for about 5 years now. I started off on prescription pain pills like Vicodin, Percocet, Lorocet, etc.. Then when that wasn’t good enough, I moved onto Oxycontin. I have an extremely high tolerance to pain pills. Last summer I checked myself into a 7 day in-patient detox hospital, and they put me on Suboxone. Starting at 8mg/day and tapering down to 4mg/day. I stayed on the 4mg/day for quite awhile. I then tapered off the Suboxone by myself. It took me about 2 weeks to really start feeling ok. About 3 months after I was clean of everything, I relapsed on Heroin. I did Heroin for about 5 or so months. I was doing about 10 bags/day at $20/bag. When I realized I couldn’t go cold turkey off the Heroin, I reached out for help again. I went back to my Suboxone Dr. and he put me on 16mgs/day to start. I tapered down eventually to 4 mgs/day. I stayed on the 4 mgs for about 5 months and about 4 days ago, I came off of the Suboxone totally again. I tapered of course. Well, when I came off of the Suboxone, I just so happened to run out of my Xanax at the same time. So I was going through Opiate and Benzo withdrawal at the same time. It was pure hell. I thought I was going to lose my mind. I was going to go to the hospital, but thank God my Dr. wrote me a script for 150 0.5 Xanax’s with me taking up to 5 per day. The Xanax is really helping me a lot with the Suboxone withdrawal. But I know it’s just another Narcotic drug, and just another crutch. I seem to be in a vicious cycle here. Should I stay on the Xanax for the time being while I’m coming off the Suboxone? So far, I’ve been taking Xanax for about 4 months. And before when I was a very active drug user, I took benzos whenever I could get them. So I have an extremely high tolerance for them as well. Am I making this worse on myself by continuing to take the Xanax, or is it ok until my Suboxone withdrawal is all gone. I know I can’t come off the Suboxone cold turkey. I’ll have to taper for sure. Any feedback from anyone is greatly appreciated. Thank you.
My reply:
First, understand that many of us have been where you are; there are several ’solutions’ that range from temporary fixes (not a great term in this setting!) to life changes that have the potential to help you find a much better life. I want to point out a couple things for you and for other readers before getting into treatment issues.
You have been using for ‘about five years’. There is an opiate addict ‘inside’ of you; your use has been fueled by a combination of genetics, psychodynamic personality factors, conditioning, fear of withdrawal… what makes you think that Suboxone will make any of these things go away? You go on Suboxone– it treats your cravings and prevents withdrawal, and things stabilize… but when you go off if it you are right back to where you started. Nothing has changed, and in such cases opiate use always returns. Why wouldn’t it?
I think that the way you have used Suboxone (perhaps the fault lies in your doctor) invites disaster; We know that people who take a break from using and then return often pick up at a higher level of use– such as going from oxy to heroin, or going from snorting to needles. Subxone does nothing by itself to ‘fix’ the underlying factors that result in addiction. So my first suggestion is to get back on Suboxone and stay there until significant changes have occurred in your life– including getting off the Xanax. You have things backward in stopping the Suboxone and then stopping Xanax; you should stay on Suboxone until the other things are changed– which may not happen for a long, long time.
Xanax has been addressed in other notes. It is a bad med for many reasons (as are all of the benzos); the tolerance results in ever-increasing dosages; the withdrawal consists of severe anxiety, which patients mistake for an anxiety disorder; it is very hard to get off of; benzos interfere with cognition in people who often have ADD; benzos ‘fire up’ the addictive pathways in the brain, and finally, opiate addicts tend to focus too much on how their bodies ‘feel’, and it is important that they learn to direct their attention ‘outward’… but benzos reinforce paying attention to physical feelings. People on benzos long-term tend to get worse and worse, as they become more and more tolerant to benzos: after each dosing cycle the anxiety returns, fueled by benzo withdrawal… the anxiety becomes more and more the center of their attention… benzos cause their sleep to fall apart… and eventually you have a big mess.
I do recommend getting off benzos, but benzo withdrawal can be fatal– so consider getting assistance from your doc. It is often easier to go on a longer-acting benzo like clonazepam and then taper that down.
The doc that gave you 150 Xanax tablets is a fool. You wrote that you were greatful, but that is the type of practice that kills people– either quickly or slowly.
Suboxone will keep things stable and treat addiction just as medications treat hypertension. Addiction and hypertension are both chronic disorders; they both respond to medication, and many times they both can be treated by other things. For hypertension we recommend diet changes and exercise. For addiction the only proven treatment is ’step-based’. In our modern culture people like the quick solutions that come in pill form; for both hypertension and addiction the best answers lie in taking the longer path. I have mentioned AA and NA before; I strongly encourage you to look into them. If you can ‘get it’ through meetings– find the ability to let go and change– then you can think about stopping Suboxone.
The alternative is to stay off Suboxone and get to a meeting TODAY… I recommend getting to one soon, before another relapse, as each relapse tends to be a bit worse.
In a rush today– maybe more later…
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Wat’s dis?
Sometimes I get comments that seem a bit ‘out there’– Maybe you all can help me out. Does this message seem ‘legit’ to you? Yes, of course I know people talk this way… but do people write this way as well? Y’all chek dis shit OUT!
whats up man, i have been taking sub’s 4 about 6 months now….the reson that i have been on thim for so long is cuz i was really off bad when i was useing…it was like 3-4 o.c. 80s a day …so my doc told me i really need to stay on the sub’s for like a year or so ,and i really love being off the shit … but….i really need xanax not to get fucked up. just to calm me down (idc if u know what i’m talking about but i fill on edge all the time ,and cant sleep) i was going to ask my doc. for mybe like a 1mg dose 2 times a day. but i’m shour u know how docters fill about mixing thim ..but its not like that wit me “i mean shit i know people that get 2mg bars and o.c. 40s” its B.S. enyways…..what do you think i sould say to him to get the xanax? cuz i really need it~
OK man– I dont spose U R bein str8 wit me… but… no, U R thru wit the Xanax. Done. (sorry– I have to go back to my boring talking). It is time to ‘live life on life’s terms’– If U keep doing xanax you will only end up where you started, back with the oxys. The danger is in mixing them, although that can be dangerous if you aren’t used to at least one of them… but the real danger is in continuing to think that a substance is needed to deal with life. I ask you (and others), if your grandmother and grandfather could face life without Xanax, why can’t you? If all the straight people you see getting up every day, going to work, busting their butts to pay the bills… if they can do it without xanax you can to.
And yes, by the way, I have been there too. I remember detoxing in a locked psych ward, no shoelaces (so I wouldn’t hang myself), legs kicking every which-way uncontrollably, puking, running to the bathroom with diarrhea… after a couple weeks I had lost 20 lbs and was so weak I could hardly walk, but I still couldn’t sleep at all. That was the worst part– being awake all night long while the rest of the house was asleep– my career gone, my family gone, depressed, sick, lonely, ashamed… I remember looking at the clock after what seemed like hours, and seeing that 10 minutes had passed. Yuck. I remember my first NA meeting and how self-righteous I felt– all just cover for my shame. But I also remember about six months later, when I finally had a good night’s sleep– I remember going outside, the sun hitting my face, and thinking about how my body was free of all that crap.
I am not a bit ‘12-stepper’ but for someone having a hard time with a bunch of feelings there is nothing better, and like they say– ‘it works if you work it’. Skip the Xanax and instead check out a meeting.
Good luck man–
SD
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Suboxone vs Subutex
I noticed that in the stats area I can see the search terms used by those who found my blog; I think I will answer some of the ‘questions’ in the search terms now and then. One person searched for ‘do suboxone and subutex feel the same’? The answer is that yes, they feel the same for most people. Some specifics:
The active ingredient in both Suboxone and Subutex is buprenorphine. Buprenorphine is a ‘partial agonist’ that has a self-limiting effect on opiate receptors. There is a common misperception that the naloxone in Suboxone is responsible for the ceiling effect or for precipitating withdrawal during inductions; neither is true. The naloxone is in there supposedly to prevent injection of dissolved Suboxone, as the naloxone is inactive orally (for the most part) but is active if injected. I say ‘for the most part’ because there are some situations where the naloxone may make a difference. I don’t have any data to support what I am about to say– and I don’t know if any data exists. But I think that my ideas are sound, using some basic knowledge of how the body works. Some background: Naloxone is not absorbed well through mucous membranes and buprenorphine IS absorbed well; the naloxone therefore is swallowed, and some is absorbed by the small intestine. From there it enters the portal vein and goes to the liver. Some medications are efficiently destroyed by the liver; this is called ‘first pass metabolism’.
Times when I change patients to Subutex:
-During pregnancy. Even though little naloxone gets into the circulation, and even less crosses the placenta, and even less survives going through the fetal liver, there is a general principle to expose the fetus to as few drugs as possible. Suboxone has two, Subutex has one, so Subutex wins.
-After gastric bypass. In some gastric bypass procedures the distal small intestine is pulled up and attached to the stomach; I would assume in such cases that the naloxone would then pass from the stomach to the ileum instead of the duodenum, and it would get absorbed by capillaries that do not empty into the portal system. The result would be that the naloxone would bypass the liver and bypass ‘first pass metabolism’, potentially causing a touch of withdrawal. So I give the patient Subutex.
-Some people get headaches after taking Suboxone and not after taking Subutex. Are the headaches from the naloxone? I don’t know. Subutex costs considerably more, and some insurers therefore will not cover it… so it may depend on how bad the headaches are as far as making the switch.
-Same thing for the taste– Subutex supposedly doesn’t have the ‘fruity’ flavoring, and some people like it better. It costs 50% more– is it 50% better tasting?
Keeping it short tonight… Son back from college and so I want to talk to him a bit. Hey– I have a radio show about psychiatry… if you want to check it out you can click on it from the Fond du Lac Psychiatry web site. Thanks for checking it out.
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Taking opiates for pain… on Suboxone.
Question:
hi doc,
i am a 35 year old man with a very active career and full life with 10 years recovery from alcoholism.
i struggled with ongoing pain issues including migraines since age 10 and a diagnosis of fibromyalgia.
i have AA sponsees, a very good spiritual life, and in general love my life, with the exception for being knocked down hard from three day headaches. i eat very well, am in great shape physically and otherwise have a good mental outlook. i see an acupuncturist regularly as well as a massage therapist bi-weekly.
in any case, i found myself abusing my pain medication last year and am now on 16 mg suboxone 2x a day. i had a knock down drag out month emotionally and then another injury that put me over the edge. i had strong narcotics at my displosal and then began abusing them to numb myself from physical and emotional pain. fortunately i came clean to my friends and family after only one month of abuse and decided to do treatment. i have way too much to lose in my life.
for the most part, suboxone has been incredibly helpful. i am in an out-patient program and am on half time disability. this past week i was hit with one of my monster migraines, completely debilitated and wanting to put my head through the wall, except that i couldn’t move because of the nerve pain in my face from inflammation.
my addiction doc and my pain doc both said to go to the ER, where it would be ok to use the dilaudid shot that always works for me. i had already taken torodol at home, which was doing nothing.
my question is this, can i intermittantly treat these monsters with narcotics and remain on suboxone?
suboxone has actually been very very helpful for the muscle pain and daily headaches. i feel truly stuck. the pain issues are real, no matter how much mind of matter, prayer and juggling other medications that i have done for the past ten years, i get one of these 72 hour monsters anywhere from no times in a month to once a week. it depends on what is going on in the air with the weather and pollen.
any thoughts?
i have friends who can hold medication for me, i just hate the ER ordeal as it is a waste of time for me and the physicians who probably would rather be treating more critical patients (even though the pain in my head has me wanting to die)
thanks so much,
XXXXX
Answer:
Hi XXXX,
Ouch! The combination of chronic pain and opiate dependence puts a person in a tough spot, as you have learned all too well. There is no great solution, and unfortunately you will quickly find that doctors are uncomfortable when they are at a loss, and they take that discomfort out in ways that sometimes makes patients feel as if they are doing something wrong. So my first comment would be that if you start to feel a bit paranoid and misunderstood, the reason is because your doctors won’t want to really understand what is going on– instead they will try to ‘pigeon-hole’ you into certain categories, particularly into the ‘addict’ category. If you get angry about that, it will only reinforce that opinion. So try to understand ‘how things are’, and do your best to work with the medical system with all of its flaws.
My best answer will probably leave you unsatisfied– but opiates are just a dead end for chronic pain. There are many reasons that I have come to that conclusion over the years… tolerance always takes away the vast majority of the analgesia from opiates; addiction always becomes a problem eventually (despite the oft-heard statement that people taking opiates for real pain will not become addicted); and the emotional and physical withdrawal from opiates makes life a constant struggle. There are other reasons that are just as important but more difficult to understand and accept; when pain patients are using opiates, their pain complaints eventually become very intertwined with psychological factors that are not really pure addiction, but that have addictive components. For example, a patient who is trying to avoid opiates will start thinking about how ‘maybe the pain is so bad that an opiate is justified’… that idea will grow like a weed until the patient is convinced that the opiate is absolutely necessary. I have watched that ‘weed’ grow in people over and over, sometimes over a week, other times over an afternoon– I will get a series of e-mails where one can see it clearly, and watch as it grows– watch as the patient loses more and more insight and perspective, until they have entirely lost sight of the original position they were in. I have considered that perhaps the pain is increasing and that is what causes the insight to disappear, but after enough times I know that there is a different reason– that the ‘addict inside’ gets a foothold and takes over, actually changing the person’s personality. It is a scary and fascinating thing for an intelligent person to be susceptible to something akin to a ’split personality’… and the only way to avoid it completely is to avoid opiates completely.
But… you probably already know that, and have decided that there is just no way to make it without opiates. I don’t know if that is completely valid because of your degree of pain, or if the ‘addict inside’ is doing the talking. So I will just appeal to the ‘true you’ to really give it some thought– in light of the fact that active opiate addiction will eventually rob a person of everything he/she holds dear. I do think that a person on a sufficient dose of Suboxone, by having the cravings suppressed, is more likely to be ‘running the show’ as far as the ’split personality’ thing goes… but not in all cases. I also admit that in spite of tolerance some chronic pain patients seem to get a long-term benefit from a small, constant level of a potent opiate. I have no idea why that is the case.
You are talking about something a bit different in that intermittent dosing would avoid some of the tolerance, although just being on Suboxone is going to keep your tolerance constant at a raised level. If you wanted to get pain relief from an opiate it would take a significant dose, even if you waited for the suboxone to leave your system (and that takes a long time). To be more specific, I sometimes need to provide pain relief for a Suboxone patient who is having surgery (I have had three patients deliver babies over the past three months– two by C-section. The moms and babies are fine, by the way). If a person took 8 mg of Suboxone in the morning (I usually maintain people on 16 mg once per day) it is very, very difficult to relieve postoperative pain– it requires going to an ICU and taking 20-50 mg of morphine every 2-3 hours. Stopping Suboxone for three days helps a bit, but still results in the need of large doses of opiates to relieve pain– I have prescribed oxycodone, 30 mg every 4-6 hours with some success at that point. So to answer your question from a practical standpoint, it is a very difficult thing to do– to use opiates for intermittent analgesia while on Suboxone. You mentioned that the headaches can last 72 hours– I suppose in those cases you could stop taking Suboxone and start taking oxycodone at doses of 30 mg or so… and after a day or two they may start working. Not a good solution.
People do not generally get sick from being on Suboxone and adding an opiate agonist. They precipitated withdrawal occurs in the other direction– when a person on opiates goes back to Suboxone. A person with an intermittent need for opiate agonists is not a great candidate for Suboxone– although the key word is ‘need’. Given the destructive power of opiates, how genuine is the ‘need’? Only you can answer that question. I do not want to imply that you are ‘faking’ anything– I have no idea what your pain feels like. But if there is any way for you to tolerate it using relaxation, etc, that is called for here. Finally, a Suboxone patient who may need opiates should probably be on a lower maintenance dose. Suboxone relieves withdrawal at very low doses– down as low as 2 mg per day. Higher doses are usually required to stop cravings. But finding a compromise of 4-8 mg per day may help to get some relief from opiates on rare occasions.
I re-read your message and note that you say you take 16 mg Suboxone per day times 2? If that is right, that is quite a high dose– about double what is used on average and above ‘indicated’ dose. I recommend talking to your doc about at least getting down to 16 mg, and maybe lower, as there will be no hope for opiates to act with that much blockade going on. You may even be getting headaches from the high amount of naloxone in such a big dose of Suboxone; Buprenorphine itself can even have an antagonist effect of its own at high doses. In my experience, patients get little out of doses above 16 mg (presuming they are taking it correctly). Patients can, however, get into a misguided dosing schedule where they think they need to dose more than once per day– in those cases the symptoms they feel late in the day (sweats, etc) are ALWAYS a product of the mind, and not true withdrawal. One can easily prove that to one’s self because if the person doesn’t happen to have Suboxone to treat the ’symptoms’, or the person gets distracted, the symptoms are gone 15 minutes later– not the case with real withdrawal. This is a tangent, but I strongly encourage patients to dose ONCE per day, in the morning. Use discipline in regard to those late-day feelings, ignore them, and they will go away completely in a few days. If you feed them by dosing, THEY WILL GROW.
A couple random thoughts…
Some patients with chronic pain will claim that taking an opiate relieves their pain, even while they are on Suboxone. I don’t have an explanation for why that happens– I tend to ascribe it all to a placebo effect that is perhaps ‘jazzed up’ a bit by addiction. But when I discuss it with the affected patients they do not buy a placebo effect– they insist that it is ‘genuine’ pain relief. The thing is… the placebo effect is just as ‘genuine’– patients getting pain relief have the same subjective drop in pain sensation as do patients getting ‘real’ pain relief.
Opiates often cause headaches, and some patients get in a cycle of post-analgesic headaches causing the person to take more opiates, etc…
Some people find that tramadol (Ultram) is helpful. Don’t confuse it with toradol– which is an NSAID– tramadol has several actions including increasing central serotonin and also activating non-mu opiate receptors (which are not blocked by buprenorphine). Two side effects are important– tramadol can cause seizures, and the combination of tramadol and antidepressants can cause ’serotonin syndrome’, which I will let people look up.
Many times people confuse migraines with sinus headaches– which are treatable using local application of a strong decongestant and a med to break up mucous like guaifenesin. I mention this because of your mention of ‘pollen’ and other ‘air things’. If you are having visual scotomata then you are likely indeed having migraines. Have you tried all of the suppressive therapy– including the newer one, Topiramate (Topomax)? Have you tried the different abortive treatments for migraine? I hate ERs also, and would do anything to avoid them… but if you are there, ask if they have anything else that they use in such situations– I have heard of ERs using nitrous oxide, oxygen, IV toradol…
You mentioned ‘nerve inflammation’ in your face- I wasn’t sure if you were referring to the migraines or to something else. For ‘neuropathic’ pain, anticonvulsants sometimes help (like Neurontin, carbemazepine, etc).
I know I am grasping at straws here, and I wish there were better options.
Take care,
JJ
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How long should I stay on Suboxone?
I have posted a poll on Subox Forum with the question, how long do you plan to take Suboxone? My stance is that since opiate addiction is a life-long disorder, treatment must be life-long as well; once addicted to opiates a person has several options: take a buprenorphine product, take methadone, go to meetings regularly for life, or… prison or death. I have met many opiate addicts and have not yet met one who did not take one of these paths.
Regarding Suboxone, I am curious about the experiences out there. What has your doc told you to do? What do you plan to do? In your part of the world is buprenorphine used for short-term, for long-term, or do you have a choice in the matter?
I invite people to reply to the poll, and to post if you have other thoughts on the topic– or about any other topic related to opiates or Suboxone. You must register, but feel free to use an alias, and of course it is free.
Thanks– I will be in touch with the results!
JJ
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Methadone, Suboxone, Sweden.
What follows is an edited message from a reader in Sweden, and my response. The original message can be found as a comment to my ‘methadone revisited’ post. I removed a bit of the writer’s sarcasm and corrected a couple typos; as always nothing was added.
Comment: Yes, methadone is a ‘pure’ agonist, but to claim no difference between it and morphine and other short acting agonists is really naive. The sole reason methadone is used is because of it’s different pharmacological profile. You claim that tolerance is as much an issue with methadone as with morphine/heroin, how is it then that patients stay on the same dose for decades?
Response: There are several reasons that methadone is used for maintenance, not one sole reason. First, it is easy to manufacture and so is dirt cheap. Methadone clinics typically mark it up to $10-$15 per day, but when prescribed for pain treatment it is pennies per dose. It does have some unique properties, and yes, those unique properties make it a good maintenance drug; for example it binds extensively to proteins and so has a long half-life when used for long-term maintenance treatment of addiction. Interestingly though, when used for pain treatment it has a shorter ‘effective half-life’ and generally must be given every six hours or so. In other words the half-life of the drug changes with chronic administration. This somewhat unique property is one reason that SOME patients can be maintained on a stable dose for long periods of time. A short exercise will help to understand this point: Google ‘opiate conversion calculator’ and use it to find the dose of oxycodone that is equi-potent to 40 mg of methadone. A good conversion program will ask you to differentiate between acute and chronic methadone. You will see that with chronic use, methadone becomes more potent by a factor of 10 or more. I see this as the main reason for the APPEARANCE of stability of dose with methadone maintenance. Yes, some patients stay on the same dose for years. But that same dose changes potency over time in ways unique to methadone, so that the patient is actually getting a constantly-increasing opiate potency at the receptor level—even as the oral dosage stays the same. This does not occur with other agonists, and certainly does not occur with buprenorphine.
Comment: To claim that a methadone patient is still an active, using addict but someone on Suboxone is in recovery, that’s the biggest load of BS that I’ve seen in a long time. Sure, buprenorphine is only a partial agonist, but there’s still stimulation of opiate receptors going on. People without tolerance get just as high on buprenorphine as they do methadone, and tolerant users don’t get high with neither buprenorphine nor methadone.
Response: People without tolerance are not the issue here, but for the record you are wrong—patients cannot get ‘just as high’ on buprenorphine as with methadone. As an anesthesiologist I used buprenorphine for just that reason—for example, on the labor floor buprenorphine is a safer narcotic because medications given to the mother can cross the placenta and accumulate in the fetus, causing respiratory depression (and arrest) after the birth—a partial agonist like buprenorphine has a maximum effect that preserves respiration, at least as long as no other CNS depressants are present. Similarly a patient without tolerance will not be able to kill himself using only buprenorphine, as the effect will ‘max out’. With methadone, on the other hand, it is quite easy to OD and die, simply from taking a few too many tablets. In fact, a teenager experimenting with methadone for the first time can die from just two or three 10 mg tablets.
As far as whether methadone users are ‘in recovery’ or are in ‘active addiction’, that is a matter of opinion. I see a clear difference between taking methadone, a drug that causes progressive tolerance, and buprenorphine, a drug which allows tolerance to remain static. The ‘shift of tolerance’ is at the heart of addiction—as it shifts upward the addict is high, and as it shifts downward the addict is in withdrawal. Buprenorphine allows tolerance to increase to a level that eliminates the high, sedation, and other drug effects, but then the tolerance becomes fixed. And for reasons not understood, doses higher than the ‘ceiling dose’ eliminate subjective cravings. For people who consider being on methadone to be ‘in recovery’ I would just ask… why? What is the difference between being on methadone and being on oxycodone, other than the dosing frequency? I didn’t intend to take on the entire methadone system, but there are some very intrusive methadone ‘advocates’ out there—they pop into buprenorphine forums and spout opinions, using pseudo-scientific arguments and misquoting articles, causing nothing but confusion and ill will. I suggest they get a blog of their own—maybe then they would feel less need to flame others.
Comment: Having been on both substances myself, I can testify that the only difference I find between the two is that methadone has (for me) the ability to take away my cravings completely whereas buprenorphine didn’t quite do so.
Response: Medication is only part of any recovery program. In my opinion 16 mg of buprenorphine suppresses cravings sufficiently to allow any patient to remain clean. Until a few years ago every single opiate addict in recovery (and not on methadone) was doing it without the help of a medication. The real situation is that a person who uses from ‘cravings while on Suboxone’ is not ready to quit, and (sorry) in my opinion is looking for an excuse to use. Nothing is perfect in life—people with opiate addiction must realize they have a fatal illness, for Pete’s sake!! Cancer patients have to put up with the pain of surgery, severe nausea, hair loss, severe fatigue… if an addict whines over a few ‘cravings’, I suggest they get real and take a good look at where they are at in life, and start being grateful for being alive.
In my prison work I frequently come across patients who are intent on fine-tuning their subjective experience using every med they can get. They think that medication should make them happy, relaxed, content, and filled with self esteem… but in reality medication will do none of those things. Their expectations are completely out of line. I get the same impression from patients who always need a bit more of this or that for cravings. The whole process of that type of ‘treatment’—the focus on symptoms, the need to medicate one’s self, the self-centered demand to feel perfect– is more consistent with addiction than with recovery!
Comment: I got annoyed when you’ve written stuff that is twisting the truth, if not lying, about the treatment that has quite literally saved my life. And calling methadone patients active, using addicts (also something many many doctors would disagree with you on).
Response: There are the ‘many doctors’ again… but seriously, if it works for you, that’s great.
Comment: Why can’t you accept that our treatments are very similar to each other? I know that you in the US can perceive them to be oh so different, since one can be prescribed in an office-setting and the other can’t. I can see that it can lead to a them-and-us-thing, where suboxone can appear “better” or “more refined” or “less dirty” or whatever.
Response: The treatments have similarities and differences. I don’t think one is ‘less dirty’ or ‘more refined’. But the molecular actions of the drugs differ from each other, and so the subjective effects differ. Sorry—that is just a fact.
Comment: I live in Sweden and here we don’t have ‘clinics’ per se, here both buprenorphine and methadone is prescribed in the hospital, and we have to go there to get our meds daily, for the first 6 months and then we get take homes at certain intervals (if we’re clean that is).
Response: That stinks. You are missing out on one of the biggest advantages of Suboxone.
Comment: Here buprenorphine and methadone alike is looked upon with judgment by many many people, since the treatments are so misunderstood. Here buprenorphine (and methadone) patients are called addicts by people who don’t know better.
Response: They ARE addicts– myself included– And will always be addicts. Opiate addiction is not ‘curable’—it can only be managed. I am an addict. But I am not ashamed of that—although I am ashamed of some of my actions during active addiction. It bothers me that the whole concept of ‘recovery’ is absent from methadone programs. A methadone ‘advocate’ made silly remarks a few days ago that showed a complete absence of knowledge of 12 step groups— something that has been an incredible movement throughout the entire world, for almost 100 years!
Comment: You seem to have a little of the mentality that if I can do it, so can you. And I find that a bit strange since then you could easily have become sober without medication at all, since other people have been able to do so. Do you see what I mean? I’m just saying that while suboxone works for a lot of people, it doesn’t work for all, and it’s just naive to think so.
Response: You know what? A common thing said at NA meetings is that ‘if I can do it, so can you’. Yes, I do have ‘that mentality’ as you put it… and I don’t get your objection to that mentality. I don’t understand the rest of that paragraph either—I think we come from totally different perspectives. I believe that EVERYBODY is capable of getting clean without the use of medication. Unfortunately, many addicts will not choose to give up their addictions until they have lost everything. I had to lose a career and a great deal of money before I ‘got it’. I didn’t ‘get it’ with Suboxone; I went away to residential treatment for over three months. I didn’t want to do that, but my back was against the wall and finally there was no other place to hide. Suboxone was not available at that time—at least not in my area, and I had never heard of it (this was in 2001). I had the ‘typical miracle’ of AA, NA, etc… I realized I was powerless, and the urge to use went away. It really is that simple. Unfortunately, addicts will not usually recognize their powerlessness until they have lost everything—buprenorphine allows people to find some peace without having to go that far. But I do worry that their ‘recovery’ does not run as ‘deep’—see my articles on the topic here: http://subox.info/index_files/recovery.htm .
The issue isn’t over who is ‘better’; the issue is whether the recovery will last, and whether the person ends up having a rewarding life. Opiate addiction is a horrible, fatal illness—I have lost friends and patients to it and so the bottom line is that any way that a person keeps clean is OK with me. And so I usually present the options to the patient and let him/her decide which path they will take. Yes I have opinions about methadone—just as others have opinions about Suboxone. From my perspective, it seems that there are ‘methadone people’ who can’t tolerate the opinions of others. And I wonder… is that a ‘recovery’ issue? Part of recovery is learning to accept things we cannot change… like the opinions held by others. Part of recovery is acceptance—the idea of ‘living life on life’s terms’— including the fact that people are going to disagree on some issues. And part of recovery is learning to know one’s self, and to know that one is OK regardless of how other people think… like not getting all flustered if some stranger in another state– who doesn’t even know the person– holds the opinion that his choice of medication isn’t the best. These parts of recovery are what make many people grateful for being an addict. If things are as I suspect, and methadone maintenance patients are not taught how to find these things… that would be a shame.
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More Xanax
A Question:
I have been taken xanax for over half my life. initially for anxiety and insomnia. then like most was unable to function or handle the withdraw and remained on it. later because of an injury i was introduced to oxycontin. i became addicted and could not step off. one because of “real back pain” the other because of the withdrawl. i would have to go to rehab and or miss work. which is impossible for me because i am the sole provider for my children and i. also my family is very uneducated with these things and have a “zero” tolerance and would be disowned for sure. i no longer want to take opiates but i do feel i need xanax. will taking suboxone while taking xanax be fatal. or is it possible to combine the 2 until i am opiate free?
My Answer:
Thank you for writing; I feel for you, and have been there. It sounds like you recognize where things stand, which is miles ahead of many patients on Xanax who misinterpret the withdrawal as their own ‘anxiety disorder’. I would first suggest that you never give up the courage to get off of the Xanax. While it is a difficult thing to do, most people will eventually have less anxiety, less insomnia, less fatigue, and less depression if they can get away from benzos. You CANNOT simply stop the Xanax, as you probably know, as the withdrawal from that class of medication can be fatal, and includes seizures that can just occur suddenly out of nowhere… while you are driving down a highway for example.
I must be cautious to avoid giving medical advice that has the potential to be dangerous; anyone reading my posts MUST make any treatment decisions along with their own physician. But for the sake of education, yes, people have died from the combination of Suboxone and Xanax (alprazolam) and other benzos (like lorazepam, diazepam, clonazepam, etc.). But two points deserve mention. First, the deaths occur from respiratory depression when opiates and benzos are combined– the respiratory depression is ‘multiplied’, not just added together. The danger is primarily restricted to people who are not tolerant to the medications. If a person is used to both medications, the risk of having trouble is not all that significant. So in your case, I would start the Suboxone and if you feel ‘buzzed’ from it I would have you take only half of your Xanax dose until you are tolerant to the Suboxone. You could probably resume your regular Xanax dose after a couple days.
The second point is that the danger from Suboxone is much less significant than the danger of combining a full opiate agonist (like methadone, oxycodone, or hydrocodone) with a benzo. The antagonist action of buprenorphine provides a significant measure of safety that is not present with opiate agonists.
One final comment– the best way to get off the Xanax is to change to a very long acting benzo– clonazepam is usually the best choice– and then go on a slow taper. If a person is motivated to get clean, and if the taper is done very slowly (over a period of 6 months) the withdrawal is minimal and can be tolerated without the need for inpatient detox.
Take care,
SuboxDoc
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Striking a nerve with Methadone revisited
I received several replies from methadone advocates; I am going to highlight portions of their comments and respond to them. But first I would like to make a personal comment to the writer who spoke of her pain treatment with methadone– and I would like to thank her for her heart-felt letter, and say that I agree taht opiates must be available for adequate analgesia in the case of cancer and other serious illnesses. I think that the over-use of opiates for chronic back pain and other inappropriate uses are part of the reason why opiate use is ultimately limited in legitimate indications. And that is a shame for everyone– for the cancer patient with pain, for the doc who is investigated for prescribing appropriately, and also for the patient with low back pain who is destroyed by narcotics, all the while thinking they are necessary and helpful.
But in this case I am referring to methadone for addiction ‘maintenance therapy’, and the ‘methadone advocates’ that wrote to complain that I had ‘dissed’ methadone. In an earlier post I noted the mention of ‘countless experts’ who supported methadone use, and I asked, which experts? Their replies contained references that I will eventually list in case anyone wants to look them up and read them in their entirety—as I did. I have the benefit of access to the online library and search functions of a major medical school—every time I use it I think about working on my thesis in 1986, reading science citation index each morning, writing down references, and then going up and down the back stairs in the ‘stacks’ of the medical library as I searched for the articles, sometimes needing to dig through bins of unshelved books and journals to find the right one… I can now do something at home in 30 minutes that used to take 4 hours at the med center. These efficiencies from the internet hopefully partially make up for the hours wasted on the internet by society… leaving me with some hope for the future of the human race. But I digress…
It is important to look up entire articles and read them from beginning to end; many times a sentence will be quoted by someone to make a point, but taken out of context in a way that completely changes the meaning of the sentence. Sometimes comments will get handed down from article to article like that old ‘telephone operator’ game, where a comment is passed from person to person around a large circle. Again, comments are changed a bit in each ‘generation’ of article until a whole new comment is generated. I would encourage ‘Arm-me’ to do this exercise with the comments that he/she provided; or just read on… I will get to the articles after responding to the more personal comments.
There was an accusation of a ‘financial motive to prescribe bupe’— I have been at the 100-patient max and closed to new patients for months; I recently re-opened for a few more but unfortunately there is no shortage of supply of addicts in my part of the country (although apparently not enough addicts to keep the methadone clinics open, as several have closed). As for ‘researching methadone for the benefit of my patients’, I explained in ridiculous detail in a prior post how my life has ended up devoted to opiate addiction— as both an addict and as a doc treating addicts—and I know methadone pretty well.
As for the scientific articles, here is a portion of one comment, out of several comments made by the methadone advocates: Here is one of the more extensive reviews of 24 clinical studies re: methadone vs. buprenorphine. In fact when they first started prescribing suboxone they told patients on methadone if they didn’t do well on 60-80mg of methadone they “most likely” weren’t going to do well on Suboxone.
I don’t know who Arm-me is referring to by ‘they’. He provided this reference: Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. - Mattick RP - Cochrane Database Syst Rev - 01-JAN-2008(2): CD002207. This references a ‘meta-analysis’; a meta-analysis is done by taking a number of separate studies which often have no significant findings, and adding them all together in order to create something statistically ‘significant’. This type of study is sometimes useful to summarize the findings of other studies, but one has to look at the nature of the collected studies—24 in this case—before drawing conclusions. This meta-analysis, for example, includes studies that predate DATA 2000 (the Act of Congress that legalized the Suboxone program), before which bupe was available only as a chemical dissolved in a liquid— and the use of the drug was very dissimilar to modern use of Suboxone. In the meta-analysis the author referred to ‘low, moderate, and high-dose’ buprenorphine; the ‘low-dose’ studies are irrelevant to current practice, as we now know that it takes 8-16 mg of bupe to suppress cravings. I know I am starting to bore all of you… The other reference was: Am Fam Physician 2006;73:1573–8, 1580: Managing Opioid Addiction with Buprenorphine—it was not a study at all, but rather a review article that is filled with the ‘telephone operator game’ quotes I mentioned earlier. Arm-me listed quotes from this review article, which the review article itself copied from other articles, which had also copied them… I tracked them back and found that they originated from two articles: one in 1997 (before Suboxone was patented) and the other in 2001—which was another garbage meta-analysis. Bottom line—there is nothing in those references that shows that methadone is preferential to bupe in any circumstance—UNLESS you compare methadone to a subclinical dose of bupe, which is where the quotes came from. Yes, it is true that in 1997, methadone in high doses was better than 2 mg of bupe. But no kidding—that is why nobody who knows what they are doing limits bupe to 2 mg. Another of the quotes referred to a study that measured ‘success’ as staying in the study—at a time when Subox was not available and the dosing had to be done at the study center using a liquid form of buprenorphine. Talk about apples and oranges… there is a big difference between going to a med center and waiting to have bupe squirted in your mouth vs dosing with Suboxone at home.
There are some other things about the latter reference supplied by Arm-me-the-methadone-guy that make me wonder about the bias of the article. The article has a table with a cost-comparison of methadone vs Suboxone; in the comparison the author lists the price of Suboxone as ‘$100 for a 15-day supply of 2 mg’, and methadone as ‘$30 for a 30 day supply not including counseling’. Suboxone is sold by Wal-Mart for a little over $5 for 8 mg; at the full daily dosage of 16 mg the cost is $300/month. Why does the author use a 2 mg dose (that nobody uses for maintenance), which implies a much higher cost per mg? And then the methadone price of $30 for 30 days– how many people out there have a clinic that charges one dollar per day? In Wisconsin the charge ranges from $10- $15/day! Either the author is being deceptive, or he doesn’t understand how things are– either case making his opinion a bit suspect a best.
I have to wrap this up… but there were a couple more things written that worked me up a bit. Arm-me took issue with my comments about AA and NA, suggesting that there is not data to support the efficacy of that approach— but there are plenty of studies supporting the 12-step approach and so I am not sure where such an impression came from. I’ll provide one of the most recent ones and he can use the references in it to track back to others: Witbrodt J. Bond J. Kaskutas LA. Weisner C. Jaeger G. Pating D. Moore C. Day hospital and residential addiction treatment: randomized and nonrandomized managed care clients. Journal of Consulting & Clinical Psychology. 75(6):947-59, 2007.
Ironically my exchange with Arm-me only reinforced my opinion of methadone programs. He ended his message with this bizarre comment in reference to AA and NA: ‘if you can show me studies that prove that utilizing these support groups make your chances of sobriety better than hoping for a spontaneous remission, than I will gladly add the research to my “bookmarks” on mdconsult’. This a comment from a person who presents himself as knowledgeable about addiction—and as a ‘methadone advocate’. In contrast, the training for docs who want to prescribe Suboxone recognizes, teaches, and requires an understanding that medication is only a small part of recovery.
I have seen so many miracles in those who ‘get it’— those who ‘cling to AA as a drowning man seizes a life preserver’ (or something like that—taken from an AA reading)— as have other fortunate people who have been forced to make the tough changes that AA and NA require. That Arm-me would call them ‘support groups’, and then compare their value to ‘hoping for spontaneous remission’, tells me that he knows nothing of ‘recovery’ at all. And now I understand the whole problem here—the source of the tension. In talking to a person on methadone, I am talking to an active, using addict. Maybe the need for dope is temporarily filled—maybe he has even learned to repress the cravings into the unconscious. But the addict BS and loss of insight is still there. But of course, why wouldn’t it still be there?
After all, methadone is just another opiate agonist.
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Suboxone and other medications; Xanax?
Q/A with a person from suboxforum.com:
I have a question regarding suboxone and i cant figure out how to post comments so i figured i would email to see if i can get my questions answered that way.
1) I know that suboxone has some kind of ceiling effect to where if you take too much it is either pointless or does the opposite, Is this true?
2) I am prescribed to xanax and zoloft as well.Will my anxiety medicine or my depression medicine (xanax/zoloft) not work with me being on suboxone? Does it block out benzos like xanax and valium and soma? Or does it just block opiates?
3) My boyfriend is on suboxone as well but I worry that he is abusing it? Can he get high off taking more than his prescribed amount or is it absolutely impossible to get high off suboxone alone?
My Response:
Hi–
I encourage you to keep fiddling with the site, using the username and password below– you can change the password on the site if you like. That way you can participate in the discussions. But for now…
Yes, Suboxone has a ‘ceiling’ at a dose of about 4 mg, assuming it is being taken correctly (it has to be absorbed through the mouth; whatever is swallowed is destroyed and inactive). Above about 4 mg there is no more opiate effect; at very high doses (above 40 mg) it starts to ‘block itself’ and have even less effect, so a person can cause withdrawal by taking a real large amount.
The active ingredient in Suboxone is buprenorphine; buprenorphine selectively activates and blocks the mu opiate receptor and will not interfere with xanax or other benzos, and will not interact with soma. BUT… buprenorphine will cause respiratory depression in people who do not have a high opiate tolerance, at least until the person gets used to Suboxone (after a few days). Benzos also depress respiration and there have been deaths from the combination of Suboxone and benzos in people who are naive to one or both of the drugs. Also, Xanax and other benzos cause tolerance even faster than opiates do; the first-line treatment for anxiety is serotonin (an SSRI) and benzos are best avoided by people with addictions. Benzos will reduce anxiety, at least for a few weeks, but they are very addictive in their own way, and the withdrawal from them can be fatal. The early withdrawal consists of severe anxiety, which patients often misinterpret as their own ‘anxiety disorder’, for which they think they need more benzos… and the cycle continues. All of us opiate addicts are too focused on how we ‘feel’, and benzos only reinforce turning our attention inward, when what we really should be doing is trying to ignore how we feel and instead focus on things ‘outside’ of us. You can tell, I’m sure, that I don’t like benzos. But patients sure love their benzos– patients get more attached to their benzos than to any other med in my experience, and it is very hard to get a person to give them up.
As for your boyfriend, a person can get high off suboxone if he/she takes it only intermittently and never becomes tolerant to it. That would be very difficult for most addicts to do, as the person would have to take it and then come down, wait a few days, and take it again. Most opiate addicts would not be able to ‘come down’– they would just keep taking it. I cannot imagine how a person could get a high with regular use, as tolerance would prevent it. BUT… I have had Suboxone patients who (unfortunately) took oxycodone or another agonist while taking Suboxone; they had no effect from the agonist but they still could not stop taking it. It appears silly on the surface, taking something so expensive like oxy and getting no effect, yet not being able to stop. But opiate addiction is complex– it is more than just taking something because it feels good. In fact most addicts will admit that they have not had a ‘high’ in years, but they still have to keep using. Using ’serves many masters’, and each person may have a different master. For example, a person who is actively using becomes completely absorbed in the drug– finding it, playing with it, using it, worrying about finding it again… Some people after starting Suboxone have a great deal of anxiety– the way I see it is that suddenly they don’t have the obsession with opiates occupying their minds, so they are free to worry about the other things in their lives. One reason for their use, then, is to reduce anxiety… and perhaps that is what is going on with the people I know who are on suboxone but are still using. By the way, I do not keep people in such a state– I may give the person who uses one more chance, maybe with a higher dose of Suboxone, but if he/she can’t stay clean (and after crossing that line, most do not stay clean) then methadone or residential treatment is their only hope.
I am going to answer your question ‘publicly’ but I will take away your e-mail info. Please continue to visit the site, and post when you get it figured out–
SuboxDoc
http://suboxforum.com
http://suboxonetalkzone.com
And again, check out this site about Warmal Globing!
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Striking a nerve with Methadone
Wow. I have heard others talk about methadone zealots ‘out there’ who get very emotional about the drug– I figured the people that described them as a bit crazy were exaggerating… I went ahead and approved a couple of the replies to my last post so that people can judge for themselves. They are 100% free of editing– nothing added, nothing removed.
I don’t want to whip out resumes and see who’s is larger, but I do want to establish my credentials and experiences. The posts make many references to ‘experts in the field of addiction’, and as that is exactly what I am, I am not sure who they are referring to. I assume they refer to people like Dr. Michael Miller, President of ASAP, the American Society of Addiction Medicine– down the highway from the city where I live, in Madison Wisconsin. Or the medical researchers who did the work that led to the approval of Suboxone. I would think those people are ‘expert’ enough. I know the work and the stated opinions of those experts– I have personally met and spoken with some of them, and have read editorial opinions and research papers written by others. I can honestly say that I have read pretty much every major study about opiate addiction over the past 8 years– certainly all of the ones that were in the peer-reviewed literature.
As for my own credentials, I am a Board Certified Psychiatrist; I am on the faculty of a major medical school where I teach mainly about addiction and addiction treatment; I am a trained Suboxone Treatment Advocate—I have been to meetings with the people who did the original (and later) research in Suboxone; I have met many, many opiate addicts over the years in my own recovery activities, as Medical Director of a 50-bed residential treatment center, through my own work treating over 150 patients with Suboxone, and through my work in the state prison system where I treat women and men who are incarcerated. I have worked in a methadone clinic, and have spoken with the VP of Med Services of the large company that has purchased many of the methadone clinics across the country– one of their ‘people’ few out to take me to dinner, to recruit me for a regional position as medical director of several individual methadone clinics.
The comments refer to the molecular actions of methadone; I completed my PhD in neurochemistry in 1986 before I went to med school, and my thesis involved work with brain receptors– characterizing how they bind to their ligands, localizing specific receptors, etc. While my thesis was not on opiate receptors (rather it was on receptors for vasopressin), several of the other scientists in the Center for Brain Research down the hall from my lab were doing the early work with opiate receptors, substance P, and ’second messenger systems’. It was an exciting time, as that was when our knowledge base really expanded in those areas. Anyway, I have a pretty good understanding of the molecular issues.
Whew. I won’t repeat all of the things that got them so angry, as you can go back to my original post. I will comment on a couple specific things though. First, whenever you come across someone who is so worked up, you have to ask yourself, Why? What fuels the anger? Sometimes a person has their own issue with the topic that they are trying to avoid thinking about– you may have heard the phrase ‘thou doth protest too much’ from some Shakespearien source, in reference to a person who is denying something in an exaggerated manner. Maybe a person has a financial interest at stake; or maybe the person is afraid of losing access to something he/she needs… I don’t know. Maybe since I have a blog they see me as an ‘authority figure’ and that riles them up. Although it is pretty easy to have a blog these days.
Similarly, I am always a bit suspicious about a person who talks about ‘the experts’ without naming specifics. Zenith mentions a study about IV heroin users doing better with methadone– If I get the reference I will look it up and check it out. I have helped many IV heroin addicts with suboxone without any problem at all, so I am curious. If I don’t write about it, it will be because I was never given the reference and couldn’t find it in my own lit search (which I will do after this post).
There is no debate over the molecular actions of buprenorphine and methadone– anyone can find a Merck manual and read for themselves. Methadone is an opiate agonist, just like oxycodone, hydrocodone, hydromorphone, fentanyl, sufentanil, alfentanil, meperidine, morphine sulfate… In all cases the primary effect is at the mu class of opiate receptors (some drugs activate other classes of opiate receptors, like ketamine for example). Buprenorphine is a partial agonist, which gives it unique properties compared to agonists. Tolerance is universal and unavoidable with agonists. There were trials of ‘morphidex’ a couple years ago that gave hope for a way to limit tolerance… but it didn’t work in humans.
Methadone potency increases linearly with dose; buprenorphine levels off and becomes flat (I have read reports of antagonist actions in high doses, actually causing a ‘bell-shaped’ curve). Methadone is just another agonist– as any opiate addict knows. Buprenorphine is different. That is why a person who is using can take methadone to avoid withdrawal or to get a ‘buzz’, but taking buprenorphine will cause withdrawal if the person hasn’t abstained long enough to reduce the activity of agonists at the receptor– the bupe will displace the heroin, methadone, or oxycodone and block the opiate receptor.
Some of the other stuff gets a bit off-topic… yes, I realize that nothing is for ‘everybody’. If a person fails buprenorphine, they may have to go to methadone– including making the drive each morning to the nearest clinic and standing in line for their dose, knowing that if they miss it, it will be a long, long day. Fear of having to do THAT helps keep people taking their Suboxone! I also mentioned the problems with Suboxone and the need for surgery or intermittent narcotic pain treatment.
As far as my comments about the evils of opiates… thanks for reminding me that molecules aren’t people! (is it unprofessional to say ‘duh!’?). I was an anesthesiologist for 10 years– I loved the power of being able to instantly remove pain, in surgery, on the OB floor…. and in myself! Every opiate addict will likely have the need for narcotics at some point in life– but those who have learned to stay clean know that those times are very dangerous, and that pain medication must be feared. Anybody who wants to go the route of total sobriety from all substances– including methadone and buprenorphine– must learn to fear opiates if they are to stay clean. That is ‘recovery 101′– also the ‘first step’ of a 12 step approach. Powerlessness. And since we addicts are powerless over opiates, and since opiates will always destroy every good thing about us during active addiction, we had better fear them. I will talk about the twelve step approach sometime– it is the only approach that has ever worked to maintain total sobriety, and has certainly stood the test of time. Other things have come and gone over the years (google ‘moderation management’ and Audrey Kishline) as people try to find an ‘easier softer way’, but there is none…
As for my hatred of opiates, I lost a career and much more to opiates, and I have known a number of people who are now dead from opiates. So pardon me, but we are talking about ADDICTION here. And in that context, I HATE opiates– I hate them for the friends that they have killed, and for what they have done to my life and to the lives of those who I care about. That is what works for me– I am not into ‘euphoric recall’– talking about the good old days– or even thinking that ‘y’know, opiates THEMSELVES aren’t all that bad’. I will use them if I ever absolutely need to, but I will do my best to hate them the entire time.
Too much writing for a Sunday. I haven’t even taken a shower yet! Methadone users: chill out!