An Article by Mike Berens and Ken Armstrong, Seattle Times, discusses some of the problems with using methadone as a first-line treatment for pain:

When it comes to battling pain, Washington health officials have encouraged doctors to reach for methadone, a powerful and inexpensive prescription drug. For the past decade, the state has declared methadone to be as safe and effective as any other narcotic painkiller.

Methadone

But in a striking reversal that has gained momentum this week, doctors are receiving stark warnings that methadone is riskier and more dangerous — a drug of last resort — because it’s unpredictable and poses a heightened risk of accidental death.

“It’s a dangerous drug because it accumulates in the body and people die in their sleep,” Dr. Jane Ballantyne, a pain specialist at the University of Washington, said Friday. “It’s very tricky and difficult to use safely.”

Ballantyne and the university are helping spearhead a series of state-sponsored training programs to educate physicians, pharmacists and advanced nurse practitioners about the risks of pain drugs.

Earlier this week, while delivering a continuing medical education course for dozens of physicians and other medical professionals at the university, Ballantyne presented a slideshow in which she cautioned that methadone “should be considered a last option opioid, never a first line opioid.”

The state’s effort is a response to a Seattle Times series, “Methadone and the Politics of Pain.” The investigation, published in December, detailed that at least 2,173 people in Washington have died from accidental overdoses of the drug since 2003.

The Times found that year after year, a committee of state-appointed medical experts sanctioned methadone, empowering the state to designate it a “preferred drug” and steer people with state-subsidized health care — most notably, Medicaid patients — to the drug in order to save money.

The state has included only two drugs, methadone and morphine, on its preferred list of long-acting pain drugs.

During the committee’s meetings, officials from state agencies that have a financial stake in methadone’s selection consistently deflected concerns about the drug.

Methadone’s death toll has hit the hardest among low-income patients. Medicaid recipients account for about 8 percent of Washington’s adult population but 48 percent of methadone fatalities.

After the series, the state sent out an emergency public-health advisory that singled out the unique risks of methadone.

Medicaid officials faxed a health advisory to more than 1,000 pharmacists and drugstores about methadone, as well as about oxycodone, fentanyl and morphine. The state Department of Health mailed advisories to about 17,000 licensed health-care professionals.

The health advisory confirmed that Washington ranks among states with the highest rates of opioid-related deaths, exceeding the number of deaths each year involving motor vehicles.

Most painkillers, such as oxycodone, dissipate from the body within hours. Methadone can linger for days, pool into a toxic reservoir and depress breathing. With little warning, patients fall asleep and don’t wake up. Doctors call it the silent death.

Ballantyne noted that methadone is an indispensable drug and plays an important role in the treatment of many patients. However, due to the heightened risks, methadone should be prescribed only by those with extensive training and experience — and only after every other option has been exhausted.

Dr. Jeff Thompson, chief medical officer of the state’s Medicaid program, now readily agrees that methadone use carries unique risks and that it should not be the first choice if other drugs are equally suitable.

He said physicians are stepping up efforts to unravel the long-term impact on the body from prolonged use of prescription drugs now that Washington’s new pain-management law has gone into full force beginning this month.

The groundbreaking law requires practitioners to follow new standards for treatment and record-keeping. It also requires prescribers to consult with state-certified pain experts when narcotic dosages reach higher thresholds.

While the law’s goal is to lower doses and, if possible, wean patients from narcotic pain drugs, doctors are finding the task more difficult than hoped, Thompson said.

For instance, methadone patients can suffer prolonged withdrawal symptoms, like nausea and depression. With most pain drugs, withdrawal subsides within a week. Methadone’s grip can last for months, even years, he said.

State officials will review methadone’s role on the state’s preferred drug list during a meeting next month.

“I think we’re going back and relearning how to treat pain,” Thompson said.

Wow. I just read an email about a story that I was vaguely aware of– about a doctor in Kansas and his wife, who were together linked to scores of overdose deaths. But that is just the beginning. The doctor was supported, during his trial, by Siobhan Reynolds, founder of a nonprofit advocacy group called ‘Pain Relief Network.’  She started the group back in 2003, when her ex-husband was suffering from severe pain from a congenital connective tissue disorder.

He (the ex-husband) found relief in combinations of high-dose opioids and benzodiazepines, at least until his doctor, Virginia pain specialist William Hurwitz, was convicted on 16 counts of drug trafficking.  The ex died, by the way, in 2006.  Are you still with me?

The trial of the Kansas doctor, Stephen Schneider, went on for years.  During the trial, Ms. Reynolds apparently helped support what she considered to be a ‘dream team’ of attorneys.  She used the case as an opportunity to increase her visibility, encouraging the Schneiders to aggressively fight the charges against them on the basis of ‘patient rights.’  Ms. Reynolds, through the Schneiders, argued that suffering patients are being denied appropriate care because of a war, waged by overly-aggressive prosecutors, against doctors who prescribe pain medication.

Ms. Reynolds even paid for a billboard adjacent to the road to the courthouse, so that jurors could see, en route, the statement “Dr. Schneider Never Killed Anyone.”  Some might see the billboard as ‘free speech’, but the judge presiding over the case was not amused.  At the eventual sentencing, the judge gave both Dr. Schneider and his wife over 30 years in prison, hoping that the sentences would “curtail or stop the activities of the Bozo the Clown outfit known as the Pain [Relief] Network, a ship of fools if there ever was one.”

We already have enough drama for a made for TV movie.  Actually there already is one, made by Ms. Reynolds, about her ex’s struggle over finding appropriate pain treatment.  The hour-long film is called ‘The Chilling Effect,’ and can be found here– along with a number of vignettes about the efforts of the Pain Relief Network.

Make that the former Pain Relief Network.  Ms. Reynolds was investigated by a Grand Jury, led by the same prosecutor who led the efforts against Dr. Schneider.  After years of what she considered to be ‘vindictive efforts,’ she closed down Pain Relief Network, saying that the organization’s finances ‘were in shambles.’

Within weeks of closing PRN, Ms. Reynolds lost her life in a plane crash.  Piloting the plane, and also killed, was Kevin Byers– Ms. Reynold’s romantic partner and also– get this– attorney for the wife of Dr. Schneider.

Our story ends in typical, made for TV fashion, with all of the loose ends tied up.  The Pain Relief Network is gone, tragically missed by some, and considered ‘good riddance’ by others.  Ms. Reynolds, tireless advocate or misguided fanatic, has left this world for the next.  Left behind are the story-tellers;  I will provide links to both sides, so that readers can have a true, balanced perspective.  From the PRN side, simply go to their former web site, and you will find links to the archives.  The archives contain links to stories in a number of publications, including Slate and the NYT– places where David and Goliath stories are repeated without much challenge, particularly for the Davids.

On the other side is a woman named Marianne Skolek, writer for the Salem News online site, who has little positive to say about Ms. Reynolds and PRN.  For years she has chronicled the epidemic of deaths from Oxycontin, and she has also written a number of articles about the Schneiders, Reynolds, and PRN.  One of the most chilling points in a story by M. Skolek is a a list of the patients who saw Dr. Schneider and who died shortly afterward.  The pattern is clear; people in sudden possession of large numbers of pain pills, who took amounts sufficient to end their lives:

The story is not quite over.  The Schneiders are now appealing their convictions, claiming insufficient counsel– namely that the romantic involvement of one of their attorneys with Ms. Reynolds created a conflict that led to poor counsel.  In other words, they may have asked for mercy, had Ms. Reynolds not been cheering them and their attorney to place everything on the line.

As I’ve written many times, the use of opioids for chronic pain is a complicated issue, with no clear ‘good’ or ‘bad’ side. As in most of life’s challenges, the extremes of each position appear…. extreme.  Ms. Reynolds believed that the Controlled Substances Act should be repealed;  I find it difficult to understand how any educated person would adopt such an approach.  But the extreme opposite side leads to enough fear, in physicians, to stifle the use of narcotic pain relievers in people who truly need such relief.  As for me, I keep trying to straddle the wide middle.

Below is an e-mail that I changed just enough to hide the person’s identity.  Every week, I receive messages that describe similar situations.

My husband has struggled GREATLY with substance abuse since in his 20′s; he is now in his mid-40′s. He is the kindest sweetest man and he is the BEST husband and father. When he is using he becomes someone he is not. We have run the gamut from jail to overdose.  Six years ago a friend introduced him to Suboxone and it LITERALLY gave him his life back. He bought it off the friend for years, where it was very expensive. Finally I brought him to a doctor a bit over a year ago. She is pretty adamant about weaning him off of Suboxone.

From experience, I know that 2-3 months after he stops Suboxone he will relapse. I strongly believe it IS a MIRACLE drug! I agree in the sense that if a diabetic needs insulin to save his life, you give it for a lifetime. My husband over the last 6 years has been the man of my dreams, the man I always knew he was. I have extreme anxiety because I know this doctor is just doing her job and trying to follow guidelines however my husband’s LIFE is at stake!  It’s not like if he stops this med he could ‘just’ have depression;  he could end up in jail, or worse. He has his life back. He is enjoying his family life as he should.

If this is what it takes for him to live a normal life then why not?  When we ask his doctor about staying on Suboxone, she says her concern is that we don’t know the long-term effects. She doesn’t want to keep anyone on any med without knowing what it could do. She says it hasn’t been on the market long enough. 

My husband had a SEVERE opioid addiction. He was taking 10-15 Oxycontin 80mgs a day and then ended up switching to 400mgs of methadone before he switched to Suboxone. He has found that he is comfortable with 4 of the 8mg pills per day. I believe it is because he was used to taking such high doses of opioids. He has tried really hard to decrease Suboxone for his doctor but I see the anxiety build in him. She says no one in her practice is on that dose. To be honest he was taking more when he was buying them from a friend but brought himself to a stable 4 pills per day when he started with the doctor. He and I both REALLY like her and would like to continue treatment with her. I wish I had a DVD of little clips of our life from before and after Suboxone. I am positive she would be floored. I am positive she would understand my concern. In my eyes my husband is back. He is such a beautiful soul and I hate to see that taken away from him yet again.

Doctor I read up at the top of this blog that you agree with a lifetime use. He currently has no noted side effects. Do you have any suggestions that I may present to his doctor? I dream of the day that she says it is alright for him to continue on this until maybe he chooses to wean if he so chooses to do so. That would alleviate SO MUCH stress on both of us. Please let me know what you think.

Anyone who reads this blog knows that I agree with most of the opinions expressed in the email.  I know how horrible things are for active opioid addicts—and for the families of active opioid addicts.
More and more physicians pay lip service to ‘addiction as a disease,’ but most do not yet treat addiction as a disease.  The comments about diabetes are ‘right on.’ One could substitute a number of diseases to demonstrate the same point.  We physicians have few illnesses that we cure; rather we manage illness over a person’s lifetime— and opioid dependence is clearly a life-long illness.

To address a couple points in the message:  the active ingredient in Suboxone, buprenorphine, has been in clinical use for over three decades, and has established a clean safety profile.  Buprenorphine has not been used at the high doses employed for treating opioid dependence for quite as long, but even that track record is significant, i.e. 8 years in this country, and longer in Europe.  Most physicians would not consider an 8-yr-old medication to be a ‘new drug!’

The situation described in the message is, in my opinion, the result of several factors.   First and foremost, the reluctance to prescribe buprenorphine is a consequence of stigma.  Doctors prescribe new antidepressants, pain relievers, blood pressure treatments, and cholesterol-lowering agents with much less concern over ‘safety.’     I wonder, frankly, if safety is the concern—or whether there is an unconscious sense that patients addicted to opioids, or to other substances, don’t deserve an ‘easy way out’ of their problem; that sitting through a miserable detox is  a more fitting ‘treatment’ than a pill that makes things better.

I come to this cynical conclusion only because the alternative—that buprenorphine is ‘dangerous’—doesn’t make sense.  The risk of any medication must be compared against the risk of not using that medication.  As the message states, we know the risk of ‘not treating’ the woman’s husband!  Similar comparisons are used to justify the use of chemotherapeutic agents that have severe toxic effects, including the risk of killing the patient.  As I’ve written in prior posts, the fatality rate from untreated opioid dependence is as high as for many cancers.  So does it make any sense to withhold buprenorphine out of safety concerns?!

There are other reasons for doctors’ reluctance to prescribe buprenorphine. Many fear they will do something wrong, and run afoul of the DEA during an audit—a process that all buprenorphine-certified prescribers are subject to.   Some doctors feel pressure from friends and family members of patients, who often blame the doctor for keeping the patient ‘stuck on Suboxone.’  Some doctors want to maintain high patient turnover in order to keep money  coming in, since practices are ‘capped’ at 100 patients per certified physician.

Finally, I think many doctors see ongoing treatment as less satisfying than a ‘cure.’  They consider residential treatment the gold standard, and buprenorphine as a less-intensive alternative.  They buy into the idea that the addict can be returned to ‘normal’—whatever that is—if he/she works at recovery hard enough.  I understand the thought, as that is the type of treatment experience that I went through.  But on the other hand, the relapse rate for opioid dependence, after residential treatment, is very high. I myself relapsed after seven years of recovery, losing my career, and almost my life.  During my years as medical director of a large residential treatment center, patients discharged as ‘successfully treated’ often became repeat customers, at least until they lost their job and health insurance.  Some of them– too many of them–died.

I won’t get into the specifics of treatment;  I’ll leave that to her husband’s doctor to work out.  But I do hope that the doctor will give some thought to whether stopping this life-saving treatment is truly in the patient’s best interest.

To the patient’s wife– I encourage you to continue as an advocate, and I hope your doctor will understand your perspective.

I was stunned to see this story about the town of Brattleboro, a town in Vermont with a name famous for the rats that grew up there.

As an aside, my PhD thesis involved working with vasopressin receptors in the brain, and that is why I’m familiar with Brattleboro rats– a species of rat that spontaneously mutated and lost the ability to make vasopressin.

One would think that inhabitants of a town made famous over a rat would be on their best behavior.  But they behaved worse than their namesakes at a meeting intended to get the OK for a clinic to treat people using Suboxone.  I’ll let you read the article, while I get back to what I was doing when I stumbled across the article.  What a bunch of…

Ah, forget it.

A recent experience with a patient helped me realize some of the dramatic differences in the treatment of opioid dependence, in an era of buprenorphine.

I drug-test patients who are treated with buprenorphine or Suboxone.  The point of testing is not to catch someone messing up, but rather to determine when a person is in trouble.  It would be great if we could simply rely on the word of our patients, but once a person is using opioids, his/her own ability to know what is true falls apart. All of us who treat addiction have heard patients rationalize relapse as something they ‘had to do’ for one reason or another, for example.  The effects of active using on insight are why I like the use of ‘DENIAL’ as a mnemonic for ‘Don’t Even Notice I Am Lying.’

The effects of relapse on telling the truth are part of the profound impact of using on a person’s insight.  Insight disappears very quickly during active using, as the mind abandons the broad view and becomes focused on one goal. Before buprenorphine, drug testing was in some ways more, and other ways less important.  It was more important because after relapse, the person was immediately thrown back into the world of desperate scrambling, where risks for consequences are high.  On the other hand, testing was less important—or maybe necessary– because experienced addictionologists (and spouses) could see the effects of using, including the loss of insight, in the active addict’s eyes.

I was one of those people who experienced that rapid loss of insight after my relapse, back in 2000. For years I had attended AA and NA; hundreds if not thousands of meetings over seven years.  I remember comforting myself that ‘if I ever get off track, at least I now know where the door is to get back.’  I didn’t realize that at the instant one relapses, that door becomes nowhere to be found.

In retrospect, I don’t know if the door actually disappeared. I suspect that with the right attitude, that same door would have opened for me.  But the honesty and humility that I needed, in order to ask for help in finding and passing through the door, were suddenly replaced by the need for secrets—secrets about everything.  As soon as I relapsed, nobody could be trusted. Nobody would understand me.  I was on my own.

Contrast that with the experiences of patients on buprenorphine who relapse with opioid agonists. As I compare their experiences to mine, I realize that I am using the experiences of a couple people to make broad generalizations.  But I have seen a number of examples that support these generalizations, that have consistently followed the paths that I’m about to describe.

One patient—call him ‘Paul’—told me about his relapse before I even mentioned that I would be asking for a urine test.  In fact, he was eager to tell me about his experience, as if he looked forward to getting it off his conscience.  “I have to tell you that I really screwed up last week,” he said. When I asked him what happened, he said that a friend who he hadn’t seen for several months came through town and stopped by his house.  With little warning, his friend pulled out a bag of heroin and a couple clean needles, tossed them on the table, and said ‘let’s fire up.’

After shooting the heroin, Paul immediately felt disappointed in himself.  Unlike in the old days, he felt nothing from the heroin.  While his old friend nodded off next to him, Paul wondered what the heck happened—and immediately wanted to talk to me about the situation.

His desire to talk is an amazing thing—and worth noting.  Without buprenorphine, a person who relapses is not generally eager to speak to his/her sponsor, let alone counselor or physician.  In those cases, the mind reels from an avalanche of shame, and the need to keep secrets—even from one’s own awareness—becomes paramount.

There are many buprenorphine programs that would discharge a person for one relapse—and in such cases, I would not expect the same type of honesty from patients.  I don’t get the logic of those programs, and I become angry when I think about them.  As I’ve said before, if a person relapses, that person NEEDS help—not abandonment!  I believe that the proper approach to treating addiction can be found in almost all cases simply by considering opioid dependence to be another chronic illness.  And if someone with heart disease overexerts himself and comes in with chest pain, we don’t boot him from treatment!

Paul made an appointment to talk about his experience.  He explained how he felt when his old buddy contacted him, and we discussed ways to avoid meeting up with ‘old friends’ in the future.  He discussed the urge to escape when he saw the paraphernalia—to escape from life’s responsibilities—and we talked about how difficult it can be to simply tolerate life sometimes, and the powerful effects of triggers and cues.  Most interesting to me, as a psychodynamic psychiatrist, he talked about a complicated set of thoughts and feelings that came up when he saw the drugs—questions about who he was, about shame, about the heavy load that comes with doing the right thing, and about the pressure of not letting people down.  Those are all big issues, I said as I agreed with him.  How much easier, at least for a few moments, to just be ‘nothing’—to have no expectations about one’s self!

We talked about the challenge of being ‘someone’– of being proud of one’s self.  It feels good to do the right thing– but it may also feel bad.  Am I letting my old friends down, if I do better? I suggested that he might watch the old movie, Ordinary People, where a younger brother struggles after surviving an accident that claimed the life of his brother.

Before buprenorphine, people struggled with opioid dependence largely on their own.  Yes, we had twelve step groups—and still do—but twelve step groups place the responsibility to get one’s act together squarely on the back of the using addict.  Many people in AA or NA will say that “AA is a selfish program.”  It has to be.  When one relapses, one is left with his own distorted insight, accumulating consequences until, hopefully, he finds his way back to the pathway established by the simple program of the steps.

On buprenorphine, relapse doesn’t necessarily cause instant loss of insight.  I don’t mean to minimize relapse, as bad things can always happen.  For example, I have had patients stuck in a pattern of chronic relapse that was difficult to straighten out, even though there was little or no psychic effect from the drug being abused.  But from an optimistic standpoint, relapse on buprenorphine stimulates a deeper investigation into what is missing from the person’s life, and a renewed effort to gain what is missing.

This assumes, of course, that the person is not simply tossed from treatment for the relapse.  In that case, other people are left trying to figure out what happened—when the obituary appears a few months later.

There are ongoing efforts to eliminate the cap on treating people for opioid dependence with buprenorphine or Suboxone.  I don’t know what the odds of success are, but the efforts would benefit from public demand.  If you have had difficulty finding a doctor with room under the cap, write a letter or email that explains just how important the issue is to you, and send it to the address(es) below.

The change requires an Act of Congress, or perhaps an executive order from someone high-placed in the Dept of Health and Human Services.  Consider sending a ‘cc’ to your elected representatives in the Senate or House of Representatives.  I am not excited about using NAABT.org, since they tend to be patsies for Reckitt-Benckiser (I’ve asked to have a link to this blog, or to our 6000-member forum on their web page, but they won’t– but they link to an R-B – supported forum instead– draw your own conclusions).  But this issue is too important even for my own righteous anger to get in the way!

Send comments to the following e-mail or mailing address:

NAABT, Inc.
P.O. Box 333
Farmington, CT 06034

Email address:
MakeContact@naabt.org

A Reader Writes:

Message:

The State of XXXXXX prescription price list noted Target Pharmacy as the cheapest for Suboxone at $6.99/Suboxone pill, 8mg-2mg, qty. 30. So I started getting my prescriptions filled at Target.

Well, needless to say they raised their prices twice since then and I am now paying $8.158333/Suboxone pill, 8mg-2mg, qty. 30, Nov. 12, 2011.

My question: How can they be alowed to jack their prices up so fast and so high in a short period of time? What can I do? It’s like they pulled a bait and switch on me.

Please write back Dr. Junig

My Reply:

I sympathize with you.  The best thing you can do is have an educated and educatable doctor– someone who has enough humility to recognize when he/she is wrong, and adjust accordingly.  Somebody who recognizes that as physicians, we are constantly sorting through new data, responding clinically to phenomena according to science.  Most importantly, someone who recognizes that in medicine, as in all fields, people make assumptions about things with partial data, and sometimes later learn that their assumptions were wrong.

I realize that is difficult in the current era when people with addictions are considered ‘manipulative’ for simply raising appropriate questions.  The truth is also competing with the marketing and persuasion tactics by Reckitt-Benckiser– a company that has found a way to influence policy-makers in government and addiction societies.  I am generally a fan of corporate greed, as I believe that the marketplace is the best stage for ideas to rise or fall (mixing several metaphors, I know!)  But I am appalled by the extent of involvement of Reckitt-Benckiser, the British corporation that makes Suboxone, with physician societies– the groups that are supposed to be advocating for policies that save lives that are being lost to addiction.

The generic tablet of orally-dissolving  buprenorphine, 8 mg, is FDA-indicated for treating opioid dependence.  In Wisconsin, some pharmacies have it for as
low as $2.35 per tab;  the more expensive places sell it for $3.00.  It is CLINICALLY IDENTICAL to Suboxone;  the naloxone in Suboxone is not absorbed sublingually (actually, 3%-5% is absorbed, but does nothing clinically), and after being swallowed the naloxone is completely destroyed at the liver by first pass metabolism.

Suboxone is supposedly safer then generic buprenorphine because naloxone supposedly causes withdrawal if injected.  This is the only justification (initially put forth by the folks at Reckitt-Benckiser) for the need for Suboxone.  The justification is flimsy, since many people who would benefit from the lower price of buprenorphine have very little risk of injecting the medication.  But worse, the flimsy justification is a lie. People who have injected Suboxone intravenously (I have met and heard from many of them) report NO withdrawal from naloxone-containing Suboxone.  What’s more, people who wrote to me who have injected both buprenorphine and Suboxone, at different times based based on availability, have all reported the same thing– that the subjective experience from injecting either substance is identical.

I must point out here that there are MANY reasons to avoid injecting any substance– but particularly a substance made to be taken orally.  These compounds contain fillers that destroy the capillary beds of the lungs, where oxygen is absorbed– potentially leading to severe lung damage.  And infection is always a huge risk, when placing poorly-sterilized material directly into the bloodstream.  Please– don’t do it.

Back to taking buprenorphine properly… the high cost of Suboxone is an unfair burden for patients without insurance coverage, when a much cheaper, idential alternative is available.

I am going to remove your name and location, and put up your question on my blog;  you are then welcome to bring a copy of the post to your doctor. You can also tell him/her to read prior posts, where I explain all of this in greater detail.

For Doctors and Insurance Formulary Committees:

I implore you to look into the facts of this situation with an open mind.  I have a PhD in Neurochem, besides 10 years of experience as an anesthesiologist and training and experience in psychiatry.  Some insurers cover buprenorphine;  they are, of course, the smart ones.  Your company can save a great deal of money by simply allowing the generic equivalent to be covered.  States that mandate the use of Suboxone or Suboxone Film could save large sums of money for their taxpayers.  And doctors–  your cash-paying customers could really use the break, especially in this economy.  If you are concerned that a patient is injecting medication, I understand your hesitancy— even though, frankly, it is misplaced, given that BOTH Suboxone and buprenorphine can be injected.  If your patient pays cash, and never injected medication, do you REALLY think that person is going to start injecting buprenorphine– since doing so would not create any effects?  The ‘ceiling effect’ is in place for ANY route of administration, so a patient taking sublingual Suboxone, who injects buprenorphine, will feel… NOTHING.

Give your patient the gift of affordable treatment as a Christmas present.  You may be saving someone’s life.

JJ

A recent message from a reader:

What would be the ideal care-plan for the pt taking 24mg/dayof Subutex who is going in for c section? I would like to show the response tomy OB, so if there is any way, please be specific as to any tapering or substituting of another low-dose narcotic before surgery, the best med for pain control in recovery and while still in hospital, up to discharge and the best PO med course for home. I would be so appreciative and you’d really help ease my fears.

Thank you

My Answer:

I receive this question often, and I am confident in my ability to provide education about the issue.  I have to point out that I can’t act as your doctor and give medical advice — but I’ll share my experienceafter having a number of patients on buprenorphine (i.e. Suboxone) go through a wide range of surgeries.

You can share with your doctor that I’m Board Certified in Anesthesiology, and I worked in Ors and pain clinics for ten years before leaving the field for psychiatry residency.  Your doctor is more likely to believe me, knowing I have experience in that area.

I will send you a couple references about this topic, and I’ll also send my ‘Users Guide to Suboxone’. The articles provide support for the treatment I’m about to describe.

Did I mention that anyone reading this MUST use the information only to spark a discussion with his/her own doctor? Do NOT use this information on your own; doing so would be quite dangerous—not to mention illegal.

A couple basics first…  The anesthetic for the surgery (in this case, a C-section) should be conducted the same as with any other patient.  Spinals and epidurals work fine.  Local anesthetics are not affected by Suboxone, and the spinal narcotics sometimes used play only a small role in analgesia during surgery, being more important for post-op pain.
Likewise, a general anesthetic in your case would not be affected by buprenorphine, since a narcotic-based anesthetic is not appropriate for a c-section.  So we are really talking about post-op pain in this discussion.

There are two major issues when dealing with post-op or other acute pain in people on Suboxone or buprenorphine (the two medications are clinically identical;  in each case, buprenorphine is the only issue, since naloxone is NOT active orally or sublingually).

The first issue is that buprenorphine is a partial agonist that acts as an antagonist at opioid receptors after surgery in the presence of narcotic pain medication.  Buprenorphine is a
high-affinity, long-acting medication that is VERY effective at blocking the mu opioid receptor. To deal with this first issue, you need to get your blood level of buprenorphine lower.  The buprenorphine half-life is over 3 days, so it takes a week or more to make significant reductions in the blood level of buprenorphine in preparation for surgery.  It is possible to treat your pain on, say, 16 mg of buprenorphine per day– but difficult, requiring very high doses of oxycodone to out-compete the buprenorphine. I have never tried treating pain in a person on 24 mg per day, but I would expect it to be even more difficult than at 16 mg per day.

I tell patients having planned surgery to taper down their dose of buprenorphine a couple weeks in advance.   For someone having a C-section there is a second reason, beyond pain control, to lower the dose of buprenorphine, as doing so will also lessen the chance that the baby will have withdrawal (although I encourage people to avoid getting worked up over that
issue.  Studies show that ‘neonatal abstinence syndrome’ from buprenorphine is much less severe than from other opioids like heroin or methadone).

I have patients taper down to 8 mg per day or less by the time of the surgery–ideally by a week before the surgery.  In my experience, most people don’t notice significant discomfort if they reduce by a quarter tab every week or two (when people stop buprenorphine, most of the withdrawal occurs when tapering off the final 2-4 mg per day).  The goal is to get to 8 mg per day (or less) so that mu opioid receptors can be activated by opioid agonists like oxycodone or fentanyl.

****  It would be a mistake to try to treat your pain using ‘just buprenorphine’.  Some docs apparently do that, as I occasionally receive messages from angry patients who were told they would be fine, who then go through horrendous experiences and write to me, asking me to help them sue their doctors.  People on Suboxone or similar doses of buprenorphine are
FULLY TOLERANT to the effects of buprenorphine, and because of the ceiling effect, higher doses of buprenorphine will provide NO significant pain relief.

As for the second issue, even if we could magically remove all of the buprenorphine in a patient’s system on the day of surgery (we can’t), the person would still have a high opioid tolerance—and so would require high doses of opioids to treat pain.  There is debate over the exact tolerance, but in my experience people on buprenorphine have a tolerance similar to someone taking 60 mg of oxycodone per day, or 40 mg of methadone per day.  That means that even if we could remove all of the buprenorphine, it takes 60 mg of oxycodone (or equivalent) just to break even, before providing pain relief.  Since buprenorphine will be in the system, it takes more than 60 mg– but 60 mg is the starting point.

With that in mind, I generally try to give people the equivalent of 60 mg of oxycodone per day, and provide more oxycodone ‘as needed’.  One way is to give Oxycontin, 20 mg three times per day, and then use oxycodone 15 mg every 4 hours as needed.  Another way is to avoid the Oxycontin, and give oxycodone, 15-30 mg every 4 hours as needed.

**** Oxycodone is a 4 hour medication.  Some doctors make the mistake of thinking that since they are giving higher doses, they can give it less often. Again, their patients write to me afterward to complain.  Oxycodone is metabolized at the same, fast rate in people on buprenorphine as in everybody else, and has little effect beyond 4 hours.

**** Some docs fear respiratory depression from using high doses of opioids, and would rather just let the person suffer than carefully think through the issue.  I’ve even heard about docs telling patients ‘there is nothing that can be done for your pain’.  That is nonsense; pain relief CAN be provided, but it takes high doses of narcotic to do so, and THAT requires some extra planning.  If they need to put you in the ICU to feel comfortable, so be it– you deserve pain relief.

For doctors:  because of the long half-life of buprenorphine, ‘renarcotization’ is not an issue.  (that situation can occur with short-acting antagonists like naloxone, when a patient receives long-acting pain medication… and then the blocker wears off, leaving the patient vulnerable to respiratory depression).   Buprenorphine easily outlasts any agonist, so a patient is not going to suddenly overdose.  In fact, people on buprenorphine are protected to some extent from overdose; deaths on Suboxone occur when a person with a low or no opioid tolerance takes Suboxone, usually combined with a second respiratory depressant like alprazolam.  People on buprenorphine usually report getting pain relief from 15-30 mg of oxycodone,
but not ‘feeling’ the drug in any other way.  They feel no euphoria or sedation– but they get pain relief. I’ve written about the benefits of the combination for treating severe chronic pain but that’s another issue….

Typically, XXXXXXX, I tell my patients to taper to one tab of buprenorphine or Suboxone per day by a week before surgery.  Starting the day before surgery, I have them take a half tab of buprenorphine or Suboxone per day– and continue that on the day of surgery, and throughout the post-op period.  Why continue it?  Because with the long half-life, it will be there anyway– and I feel better having some idea how MUCH is there.  There are benefits to continuing it as well, such as preventing euphoria from opioid agonists, and making it easier to restart the full dose of buprenorphine later– without the need to go through 24 hours of withdrawal to avoid precipitated withdrawal.

I would have the surgeons do the surgery as they always do, using general, spinal, or epidural.  For post-op, I usually recommend using PCA (patient controlled analgesia) with fentanyl; there are some anecdotal reports that fentanyl competes more effectively with buprenorphine than morphine (which would make sense, since fentanyl has much higher affinity).  I suggest that they forget numbers, and set the PCA for at least twice what they normally would use, pay close attention to your respiratory rate, pulse-ox, and PAIN, and increase the dose QUICKLY if necessary.

As soon as you are taking oral meds, things become much easier.  I usually recommend the medications listed above– i.e. 15-30 mg of oxycodone every 4 hours.  I sometimes use a ‘basal narcotic’ like oxycodone, and dose on top of that as mentioned above.

When you no longer need opioid pain relief, stop taking oxycodone for at least a few hours, and then resume your full dose of buprenorphine.  NOTE– I have not had a patient get precipitated withdrawal, provided they continue at least 4 mg of buprenorphine every day throughout the post-op period.  But I cannot guarantee that it won’t happen.
The safest thing is to stop the oxycodone for longer than 4 hours– for as long as possible, until you actually feel withdrawal– and THEN restart buprenorphine.

I have to stop at this point– I will send those articles when I’m at work tomorrow.  Good luck with your new baby!

JJ

FYI:  E-mail me for a free copy of my ‘User’s Guide to Suboxone’ and for the reference described above.

I owe it to readers to make it clear that I do not endorse any product sold for the expressed purpose of reducing opioid withdrawal. I have PPC ads on the site, but I have no control over the ads that run in them. I am not saying that the products that often appear in ads do NOT work– only that I have not prescribed or advised people to use them, and know of no peer-reviewed studies showing them to be effective or ineffective.

As always, caveat emptor.

As I give my last post more thought….  I wonder if there is ANY clinical difference between $uboxone at $7 per dose, vs. generic buprenorphine at $2.33 per dose?  Researchers out there– can anyone send me a reference?

Read my last post for details– but the essence is that naloxone is destroyed when Suboxone is taken properly (orally, sublingually), and has no action whatsoever– on that issue there is scientifc agreement (although there is a great deal of ignorance among prescribers about this fact).  The ONLY think naloxone does, is to supposedly serve as a deterrent to IV injection of buprenorphine.

Sounds good, but…  we know that people divert Suboxone intravenously, naloxone and all.  Buprenorphine binds opioid receptors very tightly- so tightly that the naloxone doesn’t effectively compete with buprenorphine.

The State of WI requires Medicaid patients to take expensive Suboxone Film, whereas in other cases they require prescribing the generic.  What is the argument for requiring the film?  RB would argue (now that the tablet has lost the luster of being on-patent) that the film is harder to ‘divert’– i.e. to inject.  But frankly, the intravenous diversion of buprenorphine is a tiny issue compared to things like heroin addiction and a budget crisis.  Most of the diversion of buprenorphine, either Suboxone or generic, is not injected, but rather taken orally to ward off withdrawal– and the film makes no difference in that case.

Insurers, likewise, are wasting millions of dollars (literally) by paying for Suboxone— sometimes exclusively(!)  Have the bean counters fallen asleep on this issue?

I have nothing personal against Reckitt-Benckiser, beyond the fact that they refuse to engage in conversation with me.  If the good Brits at RB have discovered a way to suck millions of dollars from the weakest members of society, more power to them.  But I am a big fan of intellectual honesty, particularly in regard to the science behind medical practice.  So if someone has evidence that $uboxone is clinically different than generic buprenorphine, whether used properly or injected, please send it my way.