An Addict's Story

I received the following email last week.  I considered trimming it down, but the story is well-written and describes a history that is similar to that of many of my patients.  As usual, I will write a follow-up post in a week or so.
Dear Dr. J,
I have read many of your posts over the past few years. Like many, I started out disagreeing with your comments and insight, while blaming my inability to manage my addiction on the Suboxone treatment. My active addiction to opiate pain medications was brief, about 4 months of hydrocodone/oxycodone use in the end of 2007. In early, 2008), I reached out to my primary care physician who directed me to an inpatient stabilization followed by Suboxone maintenance/addiction therapy. When I entered treatment I maintained the belief that I was not an addict, and my doctor initially supported this attitude. He described my situation as physical dependence stemming from treatment of pain. I was a recent college graduate, I had a wonderful upbringing, a bright future…I believed that “people like me don’t become drug addicts.” So of course I wanted to minimize the seriousness of my illness. I convinced myself that this physical dependence “happened to me,” and I was doing what needed to be done to resolve the issue. So I saw my doctor monthly and went to weekly addiction therapy sessions. I did not use “street drugs,” or any other RX meds, so my UAs were always clear, and eventually I was seeing the doctor for a refill every few months.
At the same time, I was dealing with the onset of some anxiety and panic issues, which I also used to rationalize my initial abuse of the opiates. As college came to an end I began to get very anxious about the future and panic in certain situations. When I was prescribed the Vicodin and Percocet for a knee injury, it was like finding the key that turned off all these negative feelings/physical sensations. My beliefs regarding success and failure fueled my anxiety, and allowed me to rationalize abusing the opiates as self-medication. When I began taking the pain medications I had no understanding of addiction or opioid dependence, and I honestly thought “this is an RX medication, I am prescribed it for pain, it also helps with this anxiety issue, so taking a few extra is fine.” So, as I said, it was very easy to go along with this idea that I was somehow different than all the other addicts.(“terminal uniqueness,” one of my NA friends taught me that term, I have always loved it.)
My starting dose of Suboxone was 16mgs/daily. Between January and August 2008, I tapered down to about 1 mg/daily. However, in July I experienced a major panic attack and was prescribed clonazepam for my anxiety/panic.  In August, I discontinued my Suboxone and was prescribed Bentyl, Tigan, and Clonidine for acute WD symptoms. The withdrawal was really not bad. It lasted about a week; the worst of it was my anxiety, stomach, and exhaustion, which continued beyond the week. I tried to push on through it, however, it was as though I had traveled back in time to the day I had gone into treatment.
The reality was that I had done nothing during those 8 months to understand or manage my addiction or anxiety (beyond medication).  At the time, of course, I didn’t understand this– and was immediately looking to place blame with the Suboxone. “Why the hell did I take the drug if I was going to end out feeling the way I did right when I started…I wasted 8 months delaying this inevitable hell”…the usual retorts from an addict in denial. I tried a number of different SSRIs/SNRIs, as well as amphetamines, to help with my exhaustion and focus. Nothing helped; I lost 35 lbs. by late November 2008.
From the very first follow up after stopping the Suboxone, my doctor suggested starting again. I had never relapsed during my treatment with Suboxone, and I had not used since stopping, so starting Suboxone did not make sense to me at the time. However, I knew that it would make my discomfort go away, and decided to start the Suboxone again in early December 2008. We determined that my decrease from 8 mg to 1 mg over two weeks prior to discontinuing was too fast. I still wasn’t willing to deal with the reality of my anxiety and addiction, and continued to minimize.
I went back on the Suboxone. Over the next year, I stayed on the Suboxone consistently, and just focused on living life. I did not do any NA/AA, addiction therapy, etc. In early 2010, I began relapsing. I would run out of my prescription early and substitute with other pain medication. Still rationalizing that the Suboxone was a pain, and I was just doing what was needed to make it work. It was during this period that my addiction became fully active, and the use became less about self-medicating and more about the feeling/escape.
In late 2010, I checked into a treatment center to detox from all opioid medications. Again, the immediate WD symptoms were very mild and the isolation of the center helped with my anxiety. I was able to isolate and almost hide from the anxiety by being in the center and cut off from the world. I left the center 4 days later, prescribed Gabapentin and clonazepam for anxiety. The day I left, I relapsed on the ride home from the center.
It is amazing, but it still had not clicked for me. The anxiety was in the forefront, and I still thought that the addiction was a symptom or result of those issues. Needless to say, I ended up sleeping all day, exhausted, depressed, with the same stomach issues. I was finishing up business school, and trudging through. I would rationalize taking the pain medications again on days when I had school. And I walked down the same road again. The entire time I cursed Suboxone as the cause of all my issues. “If only I would have gone cold turkey from the pain killers back in 2008….I wasn’t an addict until I was prescribed Suboxone”…again the usual BS.
As you can probably guess I hit the wall again, and ended out back in treatment. However, this time something clicked in me, and I was fortunate to have a team of caretakers who could see through my BS. I realized that I had crossed so many lines that I thought I never would, and could not control myself. Instead of just doing a short-term stabilization, I spent 3 weeks in intensive out-patient treatment following my inpatient stay. I was stabilized back on Suboxone, and then for 3 weeks, 8 hours a day, I was focused on my addiction, and the team at the center was not letting me half-a@@ anything. I started that program in mid June 2011. I learned about my addiction, and got honest with myself, my family, and my friends (I had hidden my addiction and treatment from everyone in my life except for my mother and father up until last summer).
I was humbled in a major way, and finally got real with myself. I had always thought that saying “I have an addiction” was a cop out. Coming to terms with my lack of control was and continues to be very hard. I feel a great deal of guilt and disappointment towards myself. And there is part of me that still wants to believe that I can control all of this and with enough will-power fix all my issues. Ironically, in a way, I am striving to maintain control and fix these issues every day, as I stay clean and focused on my sobriety. I was always afraid of being defined by my addiction. However, when I got honest, I realized that the more I tried to ignore reality, the more my addiction consumed my life.
Ultimately, I wanted to write this email as a thank you to you and share my story with those who visit your site. It took me 5 years, 3 times off and back on Suboxone, and 2 stays in treatment to realize that I am an addict. In hindsight, I think much of my downfall was classic addict behavior; placing blame, terminal uniqueness, etc. I expected Suboxone to resolve all my issues, without doing any actual work.
Looking back on all of my experiences, I thought this is where I would end out. However, working through my addiction has helped my anxiety immensely. And I am beginning to feel it is time to appropriately taper and discontinue my Suboxone. With all the support I have now, and the skills I have gained I feel very optimistic (cautiously).
Dr. Junig – I would be interested in your advice regarding tapering or insight on my story in general.
Thank you to the writer;  I’ll be adding my thoughts soon!
 

The Downside of Methadone

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.

Suboxone, Pregnancy, C-Section, and Surgery

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.

Upcoming Changes in Pain Medication Regulations

This is a repost from my blog on PsychCentral:
There are changes afoot in the use of opioid agonists for chronic pain treatment. This blog has described the epidemic of opioid dependence that has killed tens of thousands of people across the country over the past few years, and the changes are directed toward reducing the harm caused by this epidemic.
A number of interventions have been proposed. Vicodin, the number one-selling medication in the country, contains the opioid hydrocodone combined with acetaminophen, the agent in Tylenol. Hydrocodone and Vicodin are currently ‘Schedule III’ medications, and will likely move to Schedule II, where oxycodone, Oxycontin, and Percocet are currently assigned. The change will have significant impact on the use of Vicodin and hydrocodone, since medications classified as Schedule II must be ordered on written prescriptions—i.e. they cannot be called in to the pharmacy. There are a number of other limitations on Schedule II medications; the prescriptions cannot have refills for example, and a maximum of 90 days of medication can be ordered at any one time. The laws that govern diversion of Schedule II medications are more strict as well, meaning that trading or selling Vicodin or hydrocodone to a friend or relative will carry significant risk of prosecution—and incarceration.
There are proposals for additional certification and training for doctors who prescribe pain medications, beyond the current DEA licenses that typically allow registrants to prescribe all of the controlled substances, without distinguishing between classes or uses of medications. These proposals anger the ‘pain treatment lobby,’ whose members claim that additional certification requirements will lessen the availability of pain medications. And they are correct—that is, after all, the whole point of the proposed changes.
There are a couple issues that merit discussion that have no clear right or wrong answer—at least in my opinion. First, in the debate over additional certification, there is little argument that such changes would reduce the number of doctors who prescribe opioids. Many doctors will decide that it is not worth the hassle and cost to obtain the special certification. Some others will see the requirement as a golden opportunity to leave the pain med prescribing to others, as they will be able to tell their patients ‘I’m sorry—I’m not allowed to prescribe them’—an easy way to avoid confrontation with patients asking for pain pills who doctors consider to have borderline indications for them.
We don’t know, though, whether other doctors will see the changes as business opportunities—growth in a new specialty of ‘pain pill prescribing’ for example—and fill the void left by less-frequent prescribers. And if there is a reduction in pain medication prescribing, will the reduction affect the people who don’t really NEED pain medications—i.e. the patients with mild lumbar strain, who would do much better using a heating pad and ibuprofen, and perhaps learn to lift without bending at the waist? Or will people with severe pain that truly warrants opioid medication find it impossible to have their pain adequately treated?
People should be aware that there are very significant differences in opinion over the proper use of opioid pain medications between physicians. For years, doctors were taught that people with ‘real pain’ rarely become addicted to pain medications. I was stunned when I read a study a couple years ago that claimed that less than 10% of patient who are prescribed pain medications develop opioid dependence. My clinical experience, after working for ten years in pain treatment and for about 20 years as a physician, suggest a number at least five times higher.
More and more doctors are realizing that for most people, opioid pain medications do little to increase function. People become tolerant to whatever dose of pain medication they are taking, and with that tolerance, the pain relief goes away—unless the dose is increased, which only repeats the cycle at a higher tolerance level. Patients become slaves to their medications, developing severe withdrawal from missing even one dose. Their high tolerance makes it difficult to treat pain from surgery, or from other painful conditions that the patient may develop. Finally, there is more and more evidence for the phenomenon of ‘opioid-induced hyperalgesia’ where pain symptoms are ultimately increased by opioid pain medications.
But patients still want pain medications when they are in pain, no matter how many lectures they hear about ‘decreased function,’ hyperalgesia, or tolerance. Doctors are placed in the position of giving patients what they ask for, even if it is ultimately bad for them— or protecting patients and standing up to their anger. Standing up to patient anger is not what many doctors signed up for when they went to medical school, and goes against their desire to help people—and to be liked for helping people.
And I don’t know if any course or certificate will help doctors deal with THAT.

Buprenorphine for low-dose opioid use

A reader wrote with a question that I don’t think I’ve addressed on the blog.

Do you have a threshold for how much narcotic a patient must be using before you will put them on buprenorphine? I am concerned about narcotic addicts that are using 6-10 Vicodin (hydrocodone) a day for example.  Many have very mild withdrawal symptoms, but are never-the-less unable to stop on their own.
This is an insightful question that provokes enough discussion to fill at least one blog post.  I don’t have a simple answer, other than to go on a case-by-case basis and try to determine who, if anyone, might be able to walk away from opioids completely (i.e. a person who I would be less likely to put on buprenorphine, as doing so would drive tolerance higher) vs. those who will need maintenance treatment eventually, even if their doses are not yet very high.

Patients have a right to know if they are having their tolerance increased in my opinion, given the misery involved in bringing tolerance down.  It is also important to tell people with lower tolerances that they are going to get a buzz from buprenorphine for a few days because of the potency of buprenorphine.  This opiate stimulation is likely to occur even with a very small piece of a Suboxone tablet; a quarter tab or 2 mg of buprenorphine has almost the same potency as 16 mg because of the ‘ceiling effect.’  The potent opioid effect may make the doctor liable for a car accident, or could even lead to overdose if the patient combines buprenorphine with other respiratory depressants.

In general,  the ‘break even’ point on the tolerance scale is 80-100 mg of hydrocodone or about 60 mg of oxycodone per day.  In other words, if the person is taking 8-10 of the larger-strength Vicodin per day, I would consider Suboxone to be of about equal potency.

In considering whether a person’s use and tolerance are high enough to call for buprenorphine, some people focus too much on the initial potency relationships, and forget that opioid dependence is almost always a long-term condition.  I’m not sure by your last sentence whether you realize or not that the presence or absence of bad withdrawal is a red herring for acheiving sobriety from opioids.  Many addicts mistakenly think that withdrawal is the primary force that keeps them actively addicted.  In late addiction they find that desperation helps them get through withdrawal over and over, but they continue to relapse– as soon as they feel well!

From a scientific perspective, I have not seen evidence of a correlation between the severity of addiction and the addict’s tolerance level (if anyone has seen such a study, please forward me the reference).  At the same time, I don’t think I would feel comfortable starting buprenorphine in a person taking a couple Tylenol 3’s per day.  Luckily (?), this type of situation has been rare in my experience.   I should do chart reviews and publish the exact numbers, but out of the 500 or so people presenting with opioid dependence over the past 5 years, I would guess that the average tolerance level is approx. 120-150 mg of daily methadone (range of 30-400 mg per day), or approx. 160 mg of oxycodone per day (range of 40-700 mg of oxycodone per day).  Yes, I had two people—interestingly, both women– come in at those upper daily doses of methadone and oxycodone.   The methadone patient had been labeled a ‘fast metabolizer’ of methadone as reason for the ridiculously high dosage.  The reason seemed good enough, until I found, when converting her to other agonists for pain, that her tolerance was ultra-high to ALL opioid agonists—telling me that she was not metabolizing the methadone fast enough to prevent her body’s response to the high dosage, and calling the entire ‘fast metabolizer’ issue into question.  The woman taking the large amount of oxycodone had inherited a tidy sum of money; hundreds of thousands of dollars, all gone after one year of using.

Ouch.

New Formulation of Oxycontin– Will it make a difference?

Oxycontin was not my drug of choice so I don’t know the ins and outs of abusing the medication. But I suppose anything that makes the drug harder to abuse is a good thing. The other things that are being looked at for approval are combinations of agonist with antagonist in small doses– for example Embeda is morphine plus little beads of naltrexone, and orally-active form of naloxone. The naltrexone is only released if the pill is crushed, and there is not enough naltrexone to cause withdrawal, but only enough to reduce the ‘high’. I guess my thought is why limit to a small amount of naltrexone? The drug is not to be injected or snorted, so why not put enough naltrexone in it to make any tampering a very serious downer?
I thought I’d share the article below with you, so you can see how thrilled the FDA is with the new formulation.  Read on…
FDA Panel Recommends Approval of New Oxycodone Formulation
By Emily P. Walker
Published: September 24, 2009
Reviewed by Zalman S. Agus, MD; Emeritus Professor University of Pennsylvania School of Medicine.
GAITHERSBURG, Md. — An FDA advisory panel voted to recommend approval of a new formulation of oxycodone hydrochloride (OxyContin) that is more difficult to crush or dissolve, and which may deter drug abuse.
By a 14-4 margin, with one abstention, the panel recommended that the FDA approve Purdue Pharma’s application for a new, resin-coated formulation that it hopes will eventually replace the original version, which has been on the market since 1996.
The FDA does not have to follow the advice of its advisory committees, but it usually does.
The advisory panel’s endorsement was less-than-enthusiastic in this case, and members complained that there’s no proof the new version of the drug is any safer than regular oxycodone hydrochloride — one of the few drugs on the market that can be deadly in a single dose.
Purdue’s current pill is meant to be swallowed whole, but abusers can easily chew it or crush it and then snort it, smoke it, or dissolve it in liquid and inject it to achieve a heroin-like high.
Although there is no proof that the new formulation is safer, the panel agreed that making the pills harder to crush, chew, or dissolve into liquid may deter abusers. When the new version of the drug is dissolved into water, it produces a gel, which makes snorting the drug more difficult.
“Clearly the old [formulation] is worse than the new, although I think the difference is relatively small,” said panelist Randall Flick, MD, an anesthesiologist at the Mayo Clinic who voted to recommend approval of the drug.
“My feeling is that there would at least be some incremental improvement in the safety profile,” said panelist Stephanie Crawford, PhD, a pharmacist at the University of Illinois in Chicago.
Some 1.2 million people age 12 and older used OxyContin in 2006 for nonmedical purposes, according to the Department of Health and Human Service’s National Survey on Drug Use and Health.
Purdue originally sought FDA approval for low-dose versions of the new product in 2008, but the agency told the company to develop more clinical data and to apply the technology to all dosages of the drug.
Also, it took until 2008 for the company to convince the advisory panel in 2008 that the drug was any more difficult to tamper with than the original formulation, said panelist Ruth Day, PhD, director of the Medical Cognition Laboratory at Duke University.
This time around, the company convinced the panel that new tablet is harder to dissolve or crush and that the resin excipient might make it harder to take the drug in an unprescribed manner, said Day, who was also a member of last year’s panel.
In one lab test, Purdue researchers used 16 household tools to attempt to crush the tablet into small particles. All 16 tools handily crushed the original OxyContin tablets to a fine powder. Although four of the tools managed to break down the new tablet into shavings or particles, none could turn it into powder.
Even so, FDA staff reviewers concluded that the technology does not make a huge difference in OxyContin’s abuse potential.
Hardcore abusers are likely to devise new ways to break down the harder tablet or figure out which solvents will dissolve it fastest, within “day or weeks of the product’s release on the market,” Flick predicted.
The panelists who voted for approval said they were concerned that Purdue had not developed an adequate Risk Evaluation and Mitigation Strategy for the drug.
The new formulation will keep the name “OxyContin” and be used in seven available doses. Purdue said it will not market the reformulation as a “safer” version.
If it’s approved, Purdue will produce only the newer version and stop shipping the old one.
“Within six to eight weeks [of production] roughly 90% of drug in the supply chain will be the new product,” said Craig Landau, MD, Purdue’s chief medical officer.

Thanksgiving and Suboxone… Is My Surgeon A Turkey?

Thanks to Mike for this question:
I’m having surgery the day before Thanksgiving.I take 24-32mg a day for the past year,and I’m a little worried about surgery.I told my surgeon I take suboxone and I’m a recovering addict,and I don’t take pain medication. But he told me he will treat me as a normal patient,and with that percribed me 60 percocets. I went to my pharmacist and talked to her about it,she called the doctor and he called me back to his ofice, I told him I was concerned about the 60 percocets he gave me,his reponse was again “I’m going to treat you as a normal patient” what ever that means? Anyway I did’nt fill original perscription,so he gave me a new one, 40 percocets,hmmmm. Anyway NO one in my family know’s I take suboxone,and they also don’t think I have a perscription for painkillers,my problem(other then lying about the two medications) is the day of surgery,and the fact that I have a doctor who does’nt understand addiction.I know I will be given fentynol,I stopped taking the suboxone two days agos’which will give me 3 days to get the suboxone out of my system,will that be enough time,considering my daily dose?
My Response:
That is a fairly high daily dose of Suboxone;  R-B sent out a mailing a few months ago setting (or ‘resetting’) their recommended dose range, taking into account the current problems with diversion of Suboxone onto the street.  I often say to patients that ‘the main problem with taking such a high dose, other than the waste of money, is that if you ever needed surgery it would be very difficult to overcome the block from that much buprenorphine’.  So I am glad that you will be off the Suboxone for several days.  Even after 3 days you will still have a significant amount of Suboxone;  the half-life is about three days, so if you took your last dose of 32 mg three days ago, you would have the same amount of buprenorphine in your body as a person who took 16 mg this morning.
I have one patient who had emergency surgery a few hours after her morning dose of 16 mg of Subutex (she had a C-Section).  The surgery went fine– she had a spinal, but as I have mentioned here before there is no significant problem with anesthesia, whether it be by epidural, spinal, or general.  For procedures on the lower extremities or abdomen an epidural is ideal, as then the catheter can be used for providing analgesia post-op by infusing a low concentration of bupivicaine or another local anesthetic. If an epidural isn’t an option, the main problem with surgery on Suboxone is controlling the post-op pain.  My patient with the C-Section had to go to the ICU– they weren’t comfortable on the ward–to get morphine every couple hours, in doses as high as 30+ mg.
I’m a little confused, Michael, by the conversation between you and your surgeon. I’m not certain what you meant when you went back and said you were concerned about the 60 percocets– were you concerned that there were so many, or that there weren’t enough? 60 percocets may be too few or too many, depending on the nature of the surgery and the size of the percocets.  One thing that isn’t relevant, that many people get confused over, is your dose of Suboxone– at least from the perspective of your tolerance.  Because of the ceiling effect, your tolerance will by the same, whether you take 8 mg Suboxone or 32 mg Suboxone.  Of course, the residual Suboxone in your system will be higher from the higher dose, and so you will need more post-op medication taking that into account.
First, though, I’d like to point out something that is the result of ‘stigma’.  Your surgeon said and did something that is unfortunately quite common when he said he would ‘treat you like a normal patient’.  On the surface, and from the surgeon’s perspective, that sounds quite big of him;  he isn’t going to punish you for being a ‘scum-of-the-earth-drug-addict’– he is going to act as if you are a genuine human being!  Gee, thanks, Doc!  I admit I don’t know what is in his head– is he thinking ‘I won’t discriminate against him’, or is he thinking, ‘I’m not going to fall for some addict story about increased tolerance!’  I don’t know which– but in either case, he is making a mistake:  You’re NOT a normal patient!  If you were three years old, would he treat you like a ‘normal adult patient’?  If you had severe respiratory disease or a head injury would he treat you ‘like a normal patient’?  And if you had cancer, and had been taking high-dose narcotics for six months, would he treat you like a ‘normal patient’?  Here is where I should say: THIS REALLY MAKES ME SICK!!
You have two reasons to need higher doses of pain medications post-op: residual buprenorphine in your system, and high tolerance.  Even if the buprenorphine is completely gone, your tolerance is such that it will take about 60 mg of oxycodone every 6-8 hours just to ‘break even’!  If the percocet have 10 mg of oxycodone in them (some have as low as 5 mg), it will take about 20 percocet per day just to prevent withdrawal! (60 mg oxycodone or 6 tabs every 6-8 hours= 18 or 20 tabs per day).  When I am taking over for post-op pain management in a person on Suboxone, I usually start at about 30 mg of oxycodone every 4-6 hours.  I keep the acetominophen out of it i.e. I don’t use percocet because you end up taking enough to harm the liver when you are taking that many percocet.  I will treat the pain with extra opiates for as long as the surgeon would generally use narcotics– that is the only way that I treat people as if they are ‘normal’.  I know that the person will need higher doses, but I don’t see a reason why the patient would need an opiate for a longer period of time.  Sometimes the patient has a hard time giving up the opiate– there is that quick rekindling of the long-lost love affair… but I say ‘tough- get over it’ and get the person back on Suboxone!
Don’t forget– to go back on Suboxone you will need to have time between the last dose of opiate agonist and taking the Suboxone.  I like 24 hours– although you may get away with less time.
Two final comments.  First, consider decreasing your daily dose of Suboxone.  If taken correctly, the opiate effects of Suboxone hit the ceiling at about 4 mg per day– so even 16 mg is overkill.  We don’t know of any significant harmful effects of chronic buprenorphine treatment, but in general, doses of any medication should be kept as low as possible.  Plus it would be cheaper for you or for your insurer!
The final comment is that even recovering opiate addicts will occasionally need pain medications.  You mentioned that you ‘don’t take pain pills’– there are times when you will simply have to take them.  People who attend 12-step meetings take them as well, while attempting to minimize their use as much as possible.  Use of pain pills that are appropriately prescribed during an honest encounter with a doctor is not considered a break in sobriety, so you don’t have to start counting clean time from scratch again!  Many people find it helpful to put a trusted person in charge of the pain medications– someone with the guts to say ‘no’ to you after the opiates have done their thing to your mind, and you are begging for more, convinced that your pain is the ‘worst pain in the whole wide world’!  Picking the person to manage your meds is similar to an AA picking a sponsor;  there is a desire to pick someone who is a pushover, but you know down deep that you are safer with someone who is a bit tough.
Michael, I wish you the best with your surgery.  I hope you are able to at least nibble on the Turkey on Thursday.
SD