Suboxone Talk Zone: A Suboxone Blog http://suboxonetalkzone.com Questions and Answers about Opioid Dependence and Buprenorphine Fri, 19 Dec 2014 11:08:35 +0000 en-US hourly 1 The Opioid Dependence Big Picture http://suboxonetalkzone.com/the-opioid-dependence-big-picture/ http://suboxonetalkzone.com/the-opioid-dependence-big-picture/#comments Thu, 18 Dec 2014 03:16:04 +0000 http://suboxonetalkzone.com/?p=8591 Continue reading 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 >>>

The other “black box” issue is dropped tolerance overdose when someone exits naltrexone treatment and relapses to illicit opioid use.

You asked; <<< How many people will die in their quest—or their doctor’s quest—for ‘abstinent recovery’ with or without naltrexone? >>>

This study used Australian coronial records to compare mortality rates amongst patients in methadone treatment, buprenorphine treatment, and naltrexone treatment. The authors make it clear that they believe the mortality rates for naltrexone calculated here are significant underestimates, as coronial data does not record such deaths consistently, and they found the majority of known naltrexone-related deaths did not appear in this data.

<<< When expressed as deaths per number of treatment episodes, it was estimated that naltrexone had a mortality rate of 10.1 per 1000 treatment episodes. If the mean treatment retention in naltrexone treatment was estimated at 3 months (rather than two months, as assumed in the above estimate), the mortality rate for naltrexone treatment increased to 15.2 deaths per 1000 treatment episodes.

Naltrexone was associated with a mortality rate of 22.1 per 100 person years during the period of high risk (2 weeks post-treatment), and 1 per 100 person years during the period of low risk (during treatment)…. >>>

<<< …The estimated mortality rate was 0.02 per 1000 treatment episodes for buprenorphine and 2.7 per 1000 episodes for methadone.

The mortality rate for naltrexone was four times higher than for methadone when calculated as deaths per number of episodes of treatment, and substantially higher than for buprenorphine.

When considering deaths per periods of high and low risk, the mortality related to naltrexone was approximately seven times that of methadone during the period of high risk and three times the rate during the period of low risk. Naltrexone treatment was associated with a mortality rate of 22.1 per 100 person years during the period of high risk (two weeks following treatment cessation) and 1 per 100 person years during the period of low risk (during treatment). Buprenorphine mortality rates were not expressed in terms of periods of high and low risk due to the low number of deaths detected with this search method. >>>

<<< In comparing mortality rates associated with these pharmacotherapies, it is important to draw the reader’s attention to the rates of mortality for active heroin users. It has been estimated that mortality rates for heroin-dependent persons not in treatment are in the vicinity of 0.9 per 100 person years of risk, very similar to the mortality rate of a person in naltrexone treatment (during the period of low risk) calculated in this study. >>>

Actually, this is slightly less than the risk of naltrexone-associated death calculated in the study, which is believed to be an underestimate.

And the risk of naltrexone-related death calculated for the “high risk” period (the two weeks immediately following cessation of naltrexone) is more than TWENTY TWO TIMES higher than the risk of death estimated for someone using street heroin who is not in any form of treatment at all.

<<< While maintained in methadone or buprenorphine treatment after the initial induction stages, opioid-dependent people are at lower risk of dying. Clearly, an important aspect of methadone and buprenorphine treatment for opioid dependence is the improvement of treatment retention rates.

The mortality risks associated with oral naltrexone treatment, particularly following treatment cessation, warrant serious attention. This is especially the case considering that the majority of unselected opioid-dependent persons will return to opioid use soon after leaving naltrexone treatment. It is recommended that future trials of all treatments for opioid dependence include monitoring of post-treatment mortality risk >>>

Gibson, A. and Degenhardt, L. (2005) Mortality related to naltrexone in the treatment of opioid dependence: A comparative analysis, Sydney: National Drug and Alcohol Research Centre

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Hot Flashes from Suboxone and Buprenorphine Treatment http://suboxonetalkzone.com/hot-flashes-from-suboxone-and-buprenorphine-treatment/ http://suboxonetalkzone.com/hot-flashes-from-suboxone-and-buprenorphine-treatment/#comments Tue, 16 Dec 2014 22:00:28 +0000 http://suboxonetalkzone.com/?p=8238 Continue reading 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.

Nerves release acetylcholine to activate sweat glands in the skin, so medications that block acetylcholine reduce sweating.  But acetylcholine is also the neurotransmitter for salivary glands, so medications that block sweating will cause dryness of the mouth.  Many medications with unrelated primary functions have blocking effects at the acetylcholine receptor, causing ‘anticholinergic side effects.’   Anticholinergic effects are so common that medical students use a mnemonic as a reminder to keep the side effects in mind, when patients present with a certain pattern of symptoms:  dry as a bone, red as a beet, blind as a bat, hot as a hare, and mad as a hatter.  The symptoms are particularly common in the elderly, but can occur in younger patients taking high doses of anticholinergic medications.

The goal is to take an amount of an anticholinergic medication that reduces the worst of the sweating, without causing other anticholinergic effects.  Oxybutynin and glycopyrrolate are two medications used off label to reduce perspiration.  Sweating serves a valuable function by cooling the body, particularly in warm atmospheres.  Anticholinergic medications have the potential to cause hyperthermia, and even death.  Anticholinergic medications can also cause memory problems, particularly in older people.

Most of my patients have found that hot flashes, like constipation, become less severe over time.

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Broken Bones on Suboxone; Need Pain Relief http://suboxonetalkzone.com/broken-bones-on-suboxone-need-pain-relief/ http://suboxonetalkzone.com/broken-bones-on-suboxone-need-pain-relief/#comments Mon, 15 Dec 2014 01:43:37 +0000 http://suboxonetalkzone.com/?p=7623 Continue reading 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.

Hope this can help someone out in the future.

I wrote back the following message, with a few minor changes:

Thank you for sharing your story.  As you may know, I was an anesthesiologist for ten years before developing my own addiction to pain medications.  I have been in the position, many times, of treating pain in patients after surgeries or accidental injuries.  Pain relief is possible in every case, if a competent doctor takes the time and effort to control the pain.  There are arguments within the field of medicine over the use of narcotics for chronic pain, but those arguments do not extend to acute pain.  There are no reasons a person should be allowed to suffer from pain in a US hospital—beyond incompetence or failure of the system.

Buprenorphine complicates pain treatment in two ways; by blocking mu receptors and by contributing to a higher opioid tolerance. Opioid agonists (pain medications) compete with buprenorphine for binding at mu opioid receptors.  Larger doses of buprenorphine cause greater blockade of mu receptors, requiring larger amounts of agonist to treat pain.  When I read your description of the different things tried, my impression was that your pain control was delayed by your doctors trying too many things, instead of sticking with one thing until it worked.

Some opioids (notably morphine) trigger histamine release, which causes hives, lowers blood pressure, and limits the dose that can be given in a short amount of time.  Large doses of high-potency opioids like fentanyl or sufentanil cause muscles to tighten, and in rare cases cause rigidity of the chest that interferes with breathing.  But that side effect is rare, and not a major concern in modern acute care facilities.

For the most part, oxycodone (oral) or hydromorphone or fentanyl (IV) could be given in almost infinite amounts, and at some dose either medication will provide pain relief.  Doctors should remember their training from medical school, when they learned to focus on the patient rather than the numbers.  In your case, nasal oxygen and pulse oximetry should have been applied, and attention directed to your respiratory rate. Oxycodone (oral) or hydromorphone (IV) should have been titrated upward until your respiratory rate was 12-14 breaths per minute.  At that point you would have been relatively comfortable.

Anesthesiologists regularly use respiratory rate to determine whether additional narcotics are indicated in patients near the end of surgery.  The dose of hydromorphone (Dilaudid) necessary in your case may have been high, but respiratory rate decreases gradually as opioid effect increases and pain is relieved, allowing for safe use of virtually any amount of narcotic. The term for this type of care is ‘titrating to effect.’ With appropriate monitoring (present in every ER, OR, recovery room, or ICU), titrating in this way is very effective.  Some hospitals place limits on intravenous opioid doses on general med/surg units, but there are no such limits in units with 1:1 nursing, oxygen, and pulse-oximetry.

There were other ways to provide pain relief, depending on whether you were the hospital CEO, a major donor, or a guy labelled a ‘drug addict.’  They could have placed an epidural and run local anesthetic at a dose low-enough to allow you to walk with assistance while greatly reducing your pain.  Or they could have used a higher dose of anesthetic that provided complete pain relief.  Higher doses of anesthetic cause temporary muscle weakness that may have kept you from walking, but you probably weren’t walking anyway, given the injuries you described.

Readers are invited to use the ‘share’ button to create a print-friendly version, and to place a copy in your wallet—in case you ever find yourself in a buprenorphine knowledge-free zone!

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Short Term Suboxone http://suboxonetalkzone.com/short-term-suboxone/ http://suboxonetalkzone.com/short-term-suboxone/#comments Sat, 13 Dec 2014 15:33:33 +0000 http://suboxonetalkzone.com/?p=7319 Continue reading Short Term Suboxone ]]> Firsted Posted 1/8/2014

I received an email today containing an angry comment about Suboxone/buprenorphine that I’ve read a number of times before on forums about addiction.  The essence of the comment was that Suboxone has caused tons of problems, including diversion, people stuck on the medication, and buprenorphine abuse. He wrote that the reason for all these problems was because Suboxone was ‘never intended for long-term use’, but rather was originally intended for detox only.

I could address the nonsense of his email by pointing out that the ‘problems’ he listed are infinitely better than the death that results from untreated addiction, but I’ve made that point already in a number of posts. Instead I’ll address his claim that the addiction community has hijacked a medication intended for short-term use and used it, incorrectly, for long-term treatment.

Let’s first presume, for the sake of the argument, that buprenorphine WAS originally intended for detox and not for maintenance, back in the year 2000 when the FDA considered approval of the drug.  That was not the case—but so what if it was? Over the past ten years we’ve gained knowledge about addiction that we didn’t have back then.  Studies that have shown, quite clearly, that use of buprenorphine for a year or less does little to ‘cure’ addiction.  We’ve also gained clinical experience with buprenorphine.  This gain in knowledge is not unique to buprenorphine, or to addiction.  All fields of medicine progress in a non-linear manner, as medications or procedures are honed to perfection over years of trial and error

.

I remember taking care of people going through autologous bone marrow transplants in the mid-1980’s when I was an intern in medicine.  Back then, bone marrow transplant patients were the sickest patients in the hospital, and many of them died.  I remember one young man in particular who had metastatic testicular cancer. We talked at the same time each night, when I was summoned to inject medications that helped him tolerate the side effects of platelet transfusions. I was moved by what he was doing, subjecting himself to horrible pain and nausea in order to get through a procedure that at the time was rarely successful. He died from a fungal infection during the stage of treatment when his own bone marrow had been destroyed by chemo, but before the transplanted bone marrow grew back to defend against the many organisms in our environment that can kill people who are immunocompromised.

Autologous bone marrow transplants have changed in many ways over the years, including how the marrow is harvested, how the marrow is cleaned of malignant cells, how the marrow is stored and re-introduced, the timing of each step in the process, the meds and techniques used to prevent fatal fungal infections, and the types of cancer appropriate for such treatment.  The current procedure bears little resemblance to the original—which is a good thing.

The same can be said of every aspect of medicine, from liver transplants to laparoscopic surgeries to running ACLS ‘code blues’.   In the latter case, we added calcium.  When we learned that brain damage was made worse by calcium, and we removed calcium.  We added bicarb, and took away bicarb.  It’s interesting to look back over 30 years at the number of things ‘we knew were right’ that proved to be wrong.  That’s how medicine worked—and still works today.

In the same way, if buprenorphine WAS ‘intended for detox’, so what?  We now know that short-term detox yields long-term sobriety in less than 5% of patients.  Even in the residential treatment centers that use buprenorphine only temporarily, to aid detox, success rates are poor.  Like meetings, buprenorphine works when you work it.  Like meetings, its value ends when you stop taking it.

In reality, buprenorphine was never ‘just a detox agent.’  I became certified about three years into the use of Suboxone in the US, and for a short time served as a ‘treatment advocate’, teaching other doctors how to treat patients with Suboxone.   We didn’t set time limits on treatment.  I suppose there were people who had a mystical view of how medication works, who hoped that buprenorphine somehow erased all of the psychopathology that accumulates during active addiction… but there were no official recommendations to use Suboxone only in that way.  Short-term detox was not the ‘intended use’ for Suboxone.

I’m left wondering: Where do these statements come from, that “Suboxone was never intended as a maintenance agent”, or that “it gets in your bones”, or “it is the worst opioid to come off”, or “it made me gain weight”, “it rotted my teeth”, “it is dangerous long-term”, etc.? Is it like the old ‘telephone game’, where stories take gain details as they are passed from person to person?  For that matter, why do some people spend their time trash-talking buprenorphine on sites intended to help people understand buprenorphine?  The forum is often visited by trolls who are obsessed with other people taking buprenorphine. Do people go on forums for illnesses other than addiction, and taunt patients with bogus information?

As I wrote to the angry person earlier today—if you don’t want or need the medication, move on already.  To some, this is serious business.  Surely you must have something better to do.

Addendum: Since this post, attitudes toward buprenorphine seem to have changed to some extent. We have far-fewer people coming to the forum just to attack buprenorphine. I’m hoping the difference is because of a better understanding of the medication, and not because of less use of the medication.

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Does Suboxone Stop Working Over Time? http://suboxonetalkzone.com/does-suboxone-stop-working-over-time/ http://suboxonetalkzone.com/does-suboxone-stop-working-over-time/#comments Thu, 11 Dec 2014 23:11:16 +0000 http://suboxonetalkzone.com/?p=6914 Continue reading Does Suboxone Stop Working Over Time? ]]> First Posted 12/31/2013

Buprenorphine is relatively unique among opioids in having a ‘ceiling’ to mu opioid effects.  There are other known molecules that act as partial agonists at mu opioid receptors, but buprenorphine is the most useful, at this point, because of other traits of the molecule– such as having few side effects from actions at non-mu receptors.

As most opioid users soon realize, opioid agonists increase tolerance over time to what appears to be an infinite degree.  The mechanisms of tolerance are complicated. I often describe tolerance as a process where receptors become less and less sensitive to opioids with stimulation, to the point where native opioids (endorphins and enkephalins) no longer activate opioid pathways.  Some of the change in sensitivity is caused by the binding of phosphate molecules to the intracellular portion of receptors, causing changes in conformation. Tolerance development is likely far more complicated, though, and includes other changes in synaptic transmission through different mechanisms.

Opioid Effect vs. Dose of Drug
Opioid Effect vs. Dose of Drug

The best model to understand the effects of buprenorphine, in my opinion, is to plot the curve with ‘mu effects’ on the y axis and ‘blood drug level’ or ‘dose’ on the x axis.  Opioid agonists yield a straight line with a slope that correlates with drug potency.  Buprenorphine yields a straight, sloped line in microgram doses and low blood levels, but a horizontal line in high doses.  At a sufficient blood level, buprenorphine essentially sets the tolerance at the degree of opioid effect predicted by that horizontal line.

We could also graph the development of tolerance over time, to high doses of opioids.  Agonists would yield a sloped line that eventually flattens, providing the dose of drug is held constant.  In increase in dose of agonist would cause the line to slope upward for more time, and flatten at a higher level.  With buprenorphine, on the other hand, the slope would flatten at a level that remains constant, even if dose of buprenorphine was increased.

This second graph answers the question of whether buprenorphine or Suboxone stop working at some point in time. From a theoretical standpoint– which is mirrored by clinical experience– tolerance from high-dose buprenorphine does not change beyond the increase in tolerance over the first few weeks of use—- or beyond the decrease in tolerance that was caused by higher amounts of an opioid agonist.  If we graphed the development of tolerance to high dose buprenorphine (say 16 mg per day) vs. time, the graph would be different for opioid-naive persons than for people taking high doses of agonists.  In the former group, the line would slope upward and flatten in days to weeks.  In people taking high doses of opioid agonists, the line would slope steeply downward over the course of minutes, and flatten at the same level as for the first group of patients.  The steep, downward-sloping line would represent the forced-lowering of tolerance by buprenorphine, which is experienced as precipitated withdrawal.  In precipitated withdrawal, buprenorphine is ‘yanking’ tolerance down suddenly.  The graph would be similar for the mu antagonists naltrexone or naloxone, but the point of leveling off would be lower– theoretically at the level of zero, if enough antagonist is used.

I realize that it is difficult to develop mental images from another person’s written descriptions… but I encourage people who want a better understanding of buprenorphine to give the mental images a try.  Once a person can picture the flattening of opioid effect with increased dose or blood level of buprenorphine, the mechanism of action of buprenorphine is easily understood.  As long as the blood level remains above the point where the line becomes horizontal, the opioid effect does not decrease– and so from the brain’s perspective nothing wears off, and nothing ‘comes on’.  Tolerance develops to that level of opioid effect within days to weeks, removing any subjective opioid effect.

After the initial days to weeks on buprenorphine, the tolerance level remains constant– even if the dose of buprenorphine is raised or lowered, as long as the dose remains above the critical level that yields the ceiling effect of the drug.

For those who want ‘just the facts’, the response of opioid receptors to high-dose buprenorphine does not change over time.  Buprenorphine and Suboxone therefore do NOT stop working over time, and there is no need for the dose to change over time.  If anything, my patients tend to move to a lower dose with time, as they find the minimum dose necessary to produce the ceiling effect of buprenorphine throughout the entire dosing interval.

The graphs also explain why there is no truth to the common internet comment that ‘the longer you take buprenorphine, the harder it is to stop’.  Tolerance remains constant, so from a physical standpoint the journey off buprenorphine is the same in three months or three years.  My own clinical experience suggests that people find it progressively easier to stop buprenorphine the longer they take the medication. I have no proof for if or why that occurs, but I suspect that a number of psychological factors are responsible—including the transformation to a new, non-using identity that allows withdrawal symptoms to act aversively and remind people of their desire to stop opioids.

In other words, I suspect that being on buprenorphine for a long time reduces the cravings during withdrawal, instead causing cravings

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The Overdose Report http://suboxonetalkzone.com/the-overdose-report/ http://suboxonetalkzone.com/the-overdose-report/#comments Wed, 10 Dec 2014 05:16:10 +0000 http://suboxonetalkzone.com/?p=6700 Continue reading The Overdose Report ]]> I set up a new site today that collects newsfeeds related to the epidemic of opioid dependence and posts links to the articles.  Some of the news stories strike a sensational tone, as opposed to the somber nature of the content— and my intention was not to create a website fashioned after an episode of ‘Cops’.   But there is an epidemic going on, and many of the articles refer to efforts to stem the tide through legislation at the state level throughout the country.  Feel free to check it out…  and I hope it doesn’t come across as insensitive because of the title.

Overdose Report

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