1. John Nienow MD

    What can possibly be the point of such data? Buprenorphine is not a drug that one “converts” to from an “equianalgesic” dose, in the same manner as switching from oxycodone to fentanyl. It’s hard for me to understand what the utility is. Do authorities not even understand the unique pharmacology?

    • The paragraph on the PDMP web site says that the information shouldn’t be used to convert between opioids, but at the same time, the data is presented as opioid-equivalency compared to morphine. I see your point, that it isn’t really even appropriate to include the data in that way.
      Interestingly, the PDMP in Wisconsin does NOT include methadone dispensed for addiction treatment, even though drug interactions are potentially more dangerous in those cases. In a logical world, the methadone data would be more important than the buprenorphine data.
      As for the unique pharmacology, I don’t know if anyone receiving my emails understood my point. Nobody acknowledged the simple point I was trying to make– that you can’t just take the potency at 200 micrograms and extrapolate in a straight line.

  2. JEFF

    Very interesting post. This is kind of scary — it is unbelievable how little most doctors know about this drug which is why a lot of them will go to sites like this for information. 900mg of morphine equivalence is just ludicrous. Makes ya wonder just how this could be published on such a “revered” site. I have observed too many idiots holding jobs of high positions – it’s not what you know but who you know on how you rise to the top and this was likely written by someone who shouldn’t be in that position. Anyone ever heard of Double Checking or Verifying data – Especially on a CDC website in which MD’s go for info???

  3. I applaud you on this article. I sent an email to the folks at the RI PMP about the morphine equivalents reported for Suboxone as well and received no reply. I don’t think they know how to address this issue so they ignore it and we, as providers, look like we are irresponsible with our prescribing which clearly is not true!

  4. Courtney Brown

    First, I just wanted to say thank you for your continued efforts, Dr.Junig. I agree, this is very scary. I wondered, as Dr. Nienow did, what could be the point of this data? Also, is this the same in the state in which I currently reside (DE)? Turns out it is. So now my question is, what can we (your readers) do about it? As always, I will be sharing your blog with the groups I’m currently involved with and would just like to know if you have any suggestions?

    • I’m not sure how it is displayed for other states, but when patients are looked up in Wisconsin a graph is displayed that shows the dose of opioids over the past few months. That information is charted alone with reference lines for 50 or 90 mg morphine per day, and the entire chart is shaded red if benzodiazepines were prescribed at the same time. If the patient fills the prescription 2 days early, the line indicating use spikes higher, as if the medications from those two days were suddenly added on to the amount of opioid taken by the patient.
      I’m admittedly cynical on this issue, but I don’t want to assume the motives for the graph. The PDMP is very useful in other ways. The good thing about the graph, I suppose, is that it gives a quick, superficial look at the amount of opioid taken by the paitent (or more accurately, taken out of the pharmacy by the patient!). The cynical view is that the graph is intended to shame doctors for prescribing opioids, or to encourage them to reduce prescribing opioids. And of course that is a goal right now for public health agencies as well as law enforcement. I suspect some physicians feel a cold chill about having their prescribing practices displayed in that way. And maybe they SHOULD feel a chill.
      I don’t think anyone is deliberately trying to make buprenorphine treatment look bad. But so many physicians lack even basic understanding about buprenorphine, a medication that has been prescribed in the US for almost 15 years– and it won’t help anyone to throw out more misinformation.
      I don’t know what else to do. One idea is to leave buprenorphine off the chart completely, just as methadone is left off for privacy concerns. But my argument has also been that addiction should be treated just as we treat every other chronic illness, and it may be harmful in the long run to keep pretending that there is a dividing line between the disease of addiction and other diseases that have a behavioral component (which would be most diseases).
      The best thing would be to just get the data correct. That would not be difficult; the challenge would be arriving at consensus on the maximum opioid effect possible from buprenorphine. My calculations, based on numbers we all agree upon, place that morphine equivalence at about 110 mg oral morphine.
      Finally I’ll note that there are a number of opioid conversion calculators on the internet. Some are better than others, but they all make a similar mistake. But the data is much more dangerous when placed on a site associated with the US Government, as doctors are more likley to assume the information to be accurate.

  5. Kevin

    I have switched from methadone to suboxone before and my pain management doctor-fearutred on many shows talking about how buprenorphine is a great medication. He is well aware of your work also. Any way when I wanted to switch to suboxone he had me to get down to 30 mg of methadone and then not take any for 48 hours – he gave me a few morphine tablets to help deal with withdrawals. I was inducted after 48 hours with no problems. My question is I eventually switched to hydro morph contin 24 mg twice daily. I want to get back on the suboxone. I no longer have access to my last pain management specialist and my new one is nice but I don’t think he understand as well how to switch back to buprenorphine. Could you give some guidance that I can discuss with him please it would really be appreciated. Thanks so much. Also thank you for your blog and videos I am sure they have helped thousands and thousands of people and tons of doctors. Kevin

    • Thank you very much for your nice comments. I appreciate your comments about induction after methadone; I do those from time to time and I wish I had more data on the length of time necessary before induction. Methadone is SO variable between people, in so many ways– different metabolisms, different degrees of protein binding, different sensitivities to side effects like sedation, etc– so maybe the problem feeling comfortable comes from the fact that some people need more time than others.
      I’m not that familiar with hydromorph contin. You must be Canadian? That’s a hard-core opioid…but anyway, your first doctor was incredibly kind to give you morphine while waiting for the methadone to leave your system. That is not exactly legal in the US since about 1913 (maybe it was legal, since you were treated for pain). But with the hydromorph the induction delay depends on whether you swallow the pills, or cruch them and use them nasally or IV. The drug itself is metabolized quickly, on the same order as heroin. But since it is extended release, it sits in your gut for 12-24 hours. I don’t have direct experience but I would want a person to wait 36 hours after swallowing hydromorph contin. If the person was crusing it and using it, I woudl think 24 hours would be plenty of time.

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