Buprenorphine Overdose After Naltrexone Treatment

Naltrexone induces mu-receptor hypersensitivity.  Buprenorphine’s protective ‘ceiling effect’ may not prevent overdose in patients with this ‘reverse tolerance’.

A new patient described his recent history of respiratory failure several days into buprenorphine treatment.  He was told by his doctors that he experienced an allergic reaction to Suboxone. The rarity of buprenorphine or naloxone allergy led me to look deeper into his history, and my conclusion differs from what he was told by his last treatment team.

The patient, a man in his mid-50s, has a history of significant opioid use over the past 20 years.  He used a variety of opioid agonists over the past year, mostly prescription opioids, with an average daily dose greater than 200 mg of oxycodone per day.

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Avoiding Precipitated Withdrawal

I received the following question earlier today:

Hello Dr. Junig, I am opiate dependent or rather an opiate addict. I want to seek treatment because I can’t continue this life style. I have questions about treatment. Do I have to be in full withdrawals when I go to see a doctor? Is it true that most doctors probably won’t see me because they have too many patients already? I know Suboxone works for my withdrawals. I’ve stuck in this rollercoaster for at least four years and now I know it’s time for me to seek help.

My thoughts:

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Tough Choice

I have been struggling with part II, primarily because there are no easy answers to the situation. I realize that I could easily criticize whichever path a doctor suggests for our imaginary patient.

As an aside, I believe that a major reason for the lack of sufficient prescribers of buprenorphine in some parts of the country is the ‘damned if I do, or damned if I don’t’ scenario. All docs are aware of the current epidemic of opioid overdose deaths, and I think most doctors assume that tighter regulations on opioids are appropriate, and are just around the corner. Some addiction physicians and some pain physicians, particularly those who prescribe opioids, fear being grouped by the media, DEA, or a licensing board as part of the problem, rather than as part of the solution. I recently read of a doctor charged with manslaughter for being one of several prescribers for a person who died from opioid overdose. He prescribed meperidine—and outdated and toxic medication—which likely contributed to the charges… but the story creates a chilling atmosphere, regardless. Suboxone and buprenorphine are much safer medications, but when the target population consists of people with addictions to opioids, there will always be some people who use the medication inappropriately— some with disastrous results.

For those late to the party, we are discussing the best treatment approach for someone who cannot control using opioids, but who for now, at least, has a low opioid tolerance. Starting buprenorphine in such a patient will cause opioid side effects, as described in an email that I received from a woman who was addicted to hydrocodone for four years, who stopped taking hydrocodone for 7 days before induction with buprenorphine.

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Do You Prescribe Buprenorphine?

I’m not sure about the make-up of readers of this blog.  I know that there are about 20,000 page views each month, but I don’t know how many are by people addicted to opioids, people taking buprenorphine, family members of addicts, or physicians who prescribe buprenorphine.  If you fall into that latter category– i.e. if you prescribe buprenorphine, or if you prescribe other medications to treat opioid dependence such as Vivitrol or methadone– consider joining the group at linkedin.com called ‘Buprenorphine and other medication-assisted treatment of opiate dependence.’  If you already belong to LinkedIn, you can simply follow this link to join: http://www.linkedin.com/groupRegistration?gid=2710529

I have always resisted separating those who prescribe buprenorphine from those who are prescribed the medication.  I have avoided, for example, placing a ‘doctors’ section’ at SuboxForum, as I don’t want there to be two separate discussions.  Clearly, each group would benefit from the wisdom of the other.  But there are some physicians who want to discuss prescribing habits, techniques, and science with other docs, who are not comfortable discussing some topics in the ‘presence’ of their patients.

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Sick from naloxone, maybe?

A person wrote about feeling ill after taking Suboxone, thinking that naloxone is to blame and frustrated that her physician would not prescribe Subutex:

I first read your blog last week as I was going through the despair and misery of withdrawal from Percocet, and considered suicide. I didn’t want to die, or create anymore suffering for my family; I just didn’t see any options or hope. Your well written words (I thank you deeply) about the hell of withdrawal got my attention & brought me to tears. I continued to read, found out about Suboxone, which led me to message boards from others like me. For the first time I felt hopeful. I found a doctor and made an appt, and after the initial, office administered dose I found myself feeling the best I had in years– no withdrawal and no physical pain – wow! At the 2hr follow-up I told (the doctor) that my pain was completely gone, which she disputed, saying it’s not prescribed for pain. What I know now is that she had given me Subutex in the office, and a Suboxone prescription to take home!!I filled the prescription, took the ½ pill dose, and within minutes my stomach hurt/gnawed, and I developed a very strange headache and mild to moderate chest pain. By the evening I’d vomited and the headache worsened. By next morning I had the worst headache ever and started vomiting large amounts of bile, all of which continued throughout the day. My doc insisted I show up for the follow up appt. that day, even though I was too sick to hold my head up. She insisted I was sick from withdrawal.

 

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