On Suboxone, Confused, Wanting to be Pregnant

A person added a comment asking a question related to pregnancy. I have moved her comment/question up here:
Please help. I am confused by the information I am finding on the internet. I am on Suboxone, it will be 2 years in April ’09. I was planning on getting off Suboxone this summer — as I teach & summer would be the best time to try to get off this med. The reason I am pushing to get off Suboxone right now is because I want to have a baby. And of course it would be in the best interest of the baby to be off. Here is the problem —- FIRST, I may be pregnant right now. This terrifies me because I was pregnant last November & I had a miscarriage. I have one child, so I know I can be pregnant. The OBGYN said I could have miscarried for a number of reasons, it didn’t necessarily have to do with Suboxone. IF I AM PREGNANT, what should I do? I suffer from chronic pain — which is what lead me to become addicted in the first place. With Suboxone I was able to live a normal life, without a high. And so I am terrified to be WITHOUT the drug & terrified to be WITH the drug. Any advice from anyone, especially any woman who delivered a child while on Suboxone would be a blessing. PLEASE, PLEASE, help me…I am terrified.
My Thoughts:
There certainly is a great deal of confusing information out there– it is concern about that mess that fuels my blogging.  Something to notice about the information– there is something about having an addictive disorder that causes people with no training to consider themselves ‘experts’.  The phenomenon is somewhat unique to addiction;  you don’t people with heart disease or prostate cancer arguing with physicians over which treatment is best– at least not in a way where the person with no medical education is putting out advice counter to the medical experts, and people are trying to decide which one to choose!  Then again, you don’t see patients with heart disease who are managed medically get their undies in a bundle over the fact that some other patients are being managed surgically!  Only with addiction do we have both of those things– 1.  An intense nosiness of some people about the treatment choices of others;  and 2. People with no training in addiction treatment, no years spent learning about how the mind works;  no education or research into mechanisms of tolerance at the receptor level…  who based on their own (often limited) sobriety feel confident enough about their knowledge to make recommendations to others.  Intrusiveness and ignorance–  THAT’S a dangerous combination if there ever was one!
Anyone see The Apprentice tonight?  Wow– Trump doesn’t like drunk drivers very much, does he?  I was in a bookstore the other day and I browsed through one of his books– he has a bunch of them, but they are all pretty much the same– this one called ‘Think big and KICK ASS!’ I’ll confess to something… one of the reasons I looked though it is because of the comments that I sometimes receive on this blog.  A person wrote the other day something I considered helpful– he wrote that I seemed to take another person’s comments about Suboxone personally.  One thing I have learned as a psychiatrist:  a person cannot figure himself out, no matter how smart or insightful or deep he may be.  If you want to understand yourself– REALLY understand yourself– you need to listen to others, and to accept what others are saying.  At least when you hear it more than once, anyway.  The writer was correct;  I do take the comments personally… and that bothers me.  If anyone is an expert with Suboxone and opiate dependence, it should be me– (geez, I get a bit uncomfortable saying that).  After the person’s comments about taking things ‘personally’ I realized that it is tough to be an expert;  people always take shots at the person who takes a stand, whether the stand is based on facts, morality, idealism… if you are going to ‘put it out there’, people are going to try to cut it off.  Gosh, this is running on forever….  OK– I read Trump’s book because I wondered how he ‘feels’ about all of the stones thrown his way.  No, I am no Trump!  But reading his book I realized that the awkward, lonely feeling of being an ‘expert’ happens to other people as well, and the way Trump recommends dealing with them is to just talk LOUDER, assert your expertise more STRONGLY, and GET EVEN– ALWAYS!
I would never be able to pull all of that off… but I will try to let things roll off my back a bit more.  I’m not sure whether it is good advice to keep boasting about one’s expertise;  it works for Trump, but he has become a bit of a caricature of himself.  Plus there can only be one ‘Trump’!
Sorry about going on a bit.. So, why is it that addicts tend to act like ‘experts’?  I think a big reason is that addicts are playing doctor all the time, when they are using!  No addict ever reads the instructions on a bottle of pain pills– sometimes I will tell a patient to ‘take the pills as they are prescribed– as written on the bottle’ and the person acts as if the concept has never occurred to him!  This brings us to a point about ‘getting better’ on Suboxone, or in Recovery without Suboxone:  you must stop treating yourself as your own physician.  Even doctors must stop playing doctor on themselves.  This is a boundary critical to sobriety;  once a person starts to treat himself, he is on a slippery slope that leads back to using– eventually if not right away.  But back to the point of the original question:  as to the confusing mass of information and the contradicting comments across the web, I strongy recommend that you screen out the medical comments made by people who are not trained in medicine.  That’s not to say that a person’s experiences are not useful;  but often the experiences are translated into comments that are simply silly.  Whenever you read anything about ‘endorphins coming back to normal’ or needing ‘amino acids to remake neurotransmitters’, you are reading nonsense.  I have a PhD in Neurochemistry, and I can tell you with complete certainty that WE HAVE NO IDEA what ‘endorphin levels’ do during addiction, especially at the synapse, where all of the action occurs.  Yes, I could come up with a neat story about what they ‘might’ do… but when I do that, I will try to say ‘this is all just made up on my part’.  Unfortunately the people who know the least seem to make up the most complicated, detailed stories– and act the most certain about them!
I will take on the pregnancy issue in my next post, since I wasted the night with this other stuff.  I don’t want to simply repeat myself though, so please search the blog for ‘pregnancy’, as there are a few posts already.  One of the posts includes several articles about having babies while taking Suboxone.  A couple quick points:  the least safe thing is to be on nothing, and relapse once or several times, exposing the baby to several drugs and possibly to hypoxia or toxins.  The safest thing is to be in solid recovery, off all medications.  Somewhere in the middle like buprenorphine and methadone.  I have seen no published evidence (or anecdotal evidence) for miscarriage caused by buprenorphine or naloxone.  I have had six patients who were on Suboxone throughout their entire pregnancies;  the only sigificant problems were related to fear on the part of uneducated doctors– by that I mean doctors who should have/could have read up on buprenorphine ahead of time, and didn’t,  and so they treated the newborns as if they had been born to mothers on methadone– despite evidence that the NAS (neonatal abstinence syndrome) is much more mild with buprenorphine.
Finally, in the right sidebar you will see a list of news stories about Suboxone, including one relating to pregnancy;  I might write about the article at some point as an example of a very bad ‘study’ in a throw-away journal.  There is no randomization, no control group– a subset of 15 babies are described, out of a patient population of 150… with no description of why they chose THOSE babies.  There are also many confounding factors– for example, the fact that many of the babies were in special education later in life– we know nothing about their addict-mothers, their upbringing, their nutritional status, whether they were physically abused, etc.  One can always find data to support a certain position– particularly if there is no need to explain where the data comes from!
I do recommend that women trying to become pregnant or who are pregnant change from Suboxone to Subutex;  we don’t know of danger from the naloxone, but it is always good practice to expose the baby to as few drugs as possible, and since Suboxone and Subutex work in an identical fashion there is no reason to stay on Suboxone.
More later…

Deaths on Suboxone

I wish I had more time to devote to this topic right now, but I am on my way to a short vacation… so I will not be available by e-mail for at least a few days.  Everyone is pacing around the house right now, waiting for me to finish with ‘that stupid computer’.
I had to to write, though, because of a horrible incident in Milwaukee a couple days ago that took the life of a 15-year-old girl named Maddie Kiefer.  According to news stories, she snuck out from her house in Whitefish Bay, one of Milwaukee’s’nicer’ suburbs– by nicer meaning a place where the houses are kept up, many children grow up with two parents, and the public schools send a high proportion of students to colleges.  The suburb lies just north of Milwaukee, and along with other northern suburbs has seen a significant increase in heroin use by young people over the past 5-10 years.  I live another hour or so to the north, and we are seeing more and more heroin ‘up here’ as well;  the opiate addicts that I treat used to report taking oxycodone mostly, followed by methadone, then fentanyl;  now I am hearing histories of heroin use almost as often as oxycodone.
Most people know about some vague danger of combining Suboxone with ‘benzos’ like Xanax (alprazolam);  the risk is respiratory depression, which can kill a person– and is usually the cause of death in overdose of opiates.  Opiates desensitize the brain’s response to carbon dioxide, causing the person to breathe at a slower rate and allow carbon dioxide to build up.  The high level of carbon dioxide isn’t fatal, but if a person breathes slow enough, or stops breathing altogether, the oxygen level eventually falls… and the low oxygen level either makes the brain stop working– including ceasing the urge to breathe entirely– or the low oxygen level triggers a cardiac arrhythmia that halts the flow of blood, which then affects the brain, causing unconsciousness, apnea (no breathing), and death.
A couple quick points:  Suboxone and benzos are a dangerous combination particularly if a person is naive to both.  If a person is opiate-tolerant, for example is addicted to opiates, then the risk of death from such a combination is very low.  In any case, the risk of Suboxone plus benzos is MUCH LOWER than the risk of combining a benzo with a full opiate agonist, like oxycodone or methadone!  There is nothing especially dangerous about Suboxone in this regard;  in fact, it is much safer than a full agonist.
I suspect that the teen killed in Milwaukee was not used to opiates;  in such a alcase Suboxone alone would almost never be fatal… unless combined with other respiratory depressants, such as alcohol or benzodiazepines.  The story of her death is horrible– it displays the utter lack of concern for others that takes over the soul of a person addicted to opiates.  I will not make any excuse for a person who dumps someone in a driveway who needs life-saving assistance– but I understand how people get that way.  Many opiate addicts do things that are similarly devoid of conscience– and that is behind the ‘split’ that occurs with addiction, where the addict represses the horror of who they have become, and carries a fake outside personna that is cocky, glib, annoying, and easily recognizable to those who understand addiction.
When I talk about tapering, I assume people are working with a physician;  I do not condone the practice of buying Suboxone on the street or sharing it with friends or ‘loved ones’– even out of concern for them.  When people treat themselves, they are fooling themselves;  the addict is firmly in control and there is minimal chance that the person will recover.  People who share or sell Suboxone with others deserve to be incarcerated.  Period.

Having Surgery: When to Stop Suboxone?

A question about Suboxone and Surgery:
Hi-this is in reply to your message back to me. I am the girl who is soon to have surgery. You said that 3 days would be good to be off the suboxone, but you said the worst withdrawal takes about 3 days to hit, so it’s a bit of a compromise. But, won’t the withdrawal be halted once the pain medication gets into my body? Are you just saying that I will have to deal with some detox discomfort during the 3 day period? I, unlike many people, know quite a bit about suboxone (it is so surprising how many people are clueless), but the one thing I am not clear on is how long it would take to “feel” opiates after stopping suboxone (thank God I am ignorrant in this area!). On one of your blogs you said that opiates would work as short as a day afterwards, but that you would have to have quite a bit to get past the buprenorphine. I just dont think I can go off of them for 3 days prior to surgery. I am on 16 mg 2x a day.
My Response:
You are on a pretty large dose of Suboxone.  Everything is relative, but about 4 months ago the manufacturer of Suboxone sent a notice to doctors and pharmacists saying that because of the ceiling effect of buprenorphine, and because of the diversion of the drug, the maximum dose should be no more than 16 mg per day. The notice went on to state that a rare patient may require doses of up to 24 mg for a very short period of time, but that higher doses were never indicated.
In my local area, one clinic uses a max dose of 4 mg per day, a dose that I consider to be too low, but in my own practice I almost never use doses about 16 mg per day.  Overall, 30% of my patients take 8-12 mg per day, 60% take 12-16 mg per day, 3% take 16-24 mg per day, and the remaining 7% (7 patients) take less than 8 mg per day.
If the dose is taken correctly so that maximum uptake occurs, there is no subjective difference between 8 and 16 mg per day.  I have taken a number of people down in dose from 16 to 8 mg, and there is never any significant withdrawal;  there is, though, the ‘imaginary withdrawal’ that happens so much with early use of Suboxone. What is the difference?  Real withdrawal lasts until the person takes another dose;  the ‘imaginary withdrawal’ comes in waves, and then disappears as soon as the person is distracted a little bit.
Grrl, I strongly recommend that you get your dose down to 8 mg or so per day before surgery.  The blockade of the receptor is competitive;  it will be almost impossible to get enough agonist to overcome the blockade of 32 mg of daily buprenorphine.  Yes, 1000 mg of oxycodone might do it, but you will never get anyone to give you that amount in a hospital.  Even the less-ridiculous doses are hard to get, as every person in the chain gets in the way.  The surgeon doesn’t want to write for such high doses, as he doesn’t want to take the time to explain why he is doing so to all of the people who will be calling him.  The unit secretary doesn’t want to transcribe the order until she calls the surgeon to say, ‘are you sure you want THIS MUCH?’  Then the nurse won’t want to  give such a large dose, especially without monitoring– meaning that he/she will suddenly be pushing to get you transferred to the ICU.  The pharmacist may nix the whole thing, and simply say that ‘he isn’t going to risk his license by releasing so much narcotic’. Meanwhile, you will be writhing in pain as the hours go by.
The lower you can get your daily dose, the less buprenorphine you will have in your body to block the post-op medications.  Yes if you stop entirely three days in advance, you won’t have significant withdrawal for a few days… and by that time you will be getting the post-op pain meds.
A couple things… an anesthesiologist wrote and said that in his experience the lipid-soluble and high-potency opiates seem to ‘compete’ more effectively at he opiate receptor, and that they therefore are better choices for post-op pain.  Remember, though, that you will have TWO problems with getting pain relief;  the first is the competetive block of your opiate receptors, and the second is the high tolerance you will be left with, even after the buprenorphine is gone.
Your last question about how long it would take to ‘feel’ agonists after Suboxone… it would depend, of course, on the dose of agonist, the type of agonist, and the dose of Suboxone.  The bottom line is that it always takes much longer than people expect.  I have had a couple people who needed to go back to agonists for pain, and they said something similar to each other– that even after weeks off the suboxone, they could never get the same old ‘euphoric’ feeling again.  I don’t know if that is from some small lingering amount of Suboxone, or from the remaining elevated tolerance persisting for a long time after stopping the drug… But whatever it is, it will be difficult to get relief from opiate agonists for some time after stopping Suboxone.  And the people who stop Suboxone for a day, hoping to catch a buzz from a couple 40’s, will be disappointed!

Physical Dependence vs. Addiction in Chronic Pain Patients

A question from a reader about taking Suboxone for chronic pain, and about physical dependence vs. addiction:
Thanks for the web page. It gave me a lot of information that I had been searching for. Most of your blog deals with addiction. Will Suboxone work for dependence? I have been on Oxycontin for 7 years due to nerve damage in my back and Fibromyalgia. I have been able to get down to 30 mg per day with the help of RF ablations but unfortunately there aren’t any pain doctors in my area that will take medicare anymore. RFA’s don’t last forever and I’m being forced to increase the Oxycontin again to manage the back pain. The severe cold with snow has made this a very miserable winter which is why I’m looking for a different answer.
From what I’ve read, I don’t believe addiction is as big of a problem as the dependence in my case. I’m using the medication as prescribed and the doctor is working with me and is more than willing to increase the medication if needed. The problem is my life revolves around that once a month prescription. Every time I try to leave the state, it is a major production since the nurses think I’m trying to pull something if I ask to fill my meds early. The doctor trusts me but getting through the technician that handles the refills for the office is like dealing with the Nazi’s…and I’m being kind. I’m not sure that switching to Suboxone will change anything. I’m thinking maybe at least this way I might be able to someday get completely off all this kind of medication. I don’t actually want to increase my medication again and if I understand correctly Suboxone will take some of the pain away.
Any insight would be greatly appreciated.
My Response:
I hear your frustration over the attitudes and hassles associated with opiate treatment.  I find it ironic that many doctors act as if patients are criminals for using the very medications that the doctor prescribed!
You question is a difficult one;  I struggle with deciding the best course of action for patients who are physically dependent on opiates but who haven’t shown signs of addiction.   Just to clarify,  I do think that many pain patients do cross the line without realizing it;  it can be very difficult treating opiate addicts who initially started through legitimate use for pain, as those patients see themselves as ‘unique’—and that feeling of uniqueness gets in the way of the changes that need to occur during the recovery process.  So it is important that you take an honest look at what is happening in your own situation.

Buprenorphine is being studied for use to treat chronic pain, as are other medications (search for ‘oxytrex’ or ‘embeda’).  Partial agonists including buprenorphine (including the medication Suboxone) do offer some advantages over agonists, but have some potential drawbacks as well.  Even a pain patient not ‘addicted’ to opiates would likely notice a profound difference with Suboxone;  the feeling of needing ‘more’ would mostly go away, as would the fear of being without medication.  I use Suboxone for pain patients, and they universally report that in retrospect they see how much the pain medications were controlling their lives, and they are grateful for the change to something that leaves their mind free of those thoughts.  Some people find that their pain lessens—in my opinion because they are out of that cycle of feeling/dosing/feeling that makes up opiate pain treatment.  With Suboxone there is much less risk for ‘dose escalation’; the effect is capped at a level equivalent to 30 mg of methadone, and increases in dose do not provide much more pain relief.
The downsides of Suboxone are related to the benefits;  the ceiling effect that limits dose escalation also limits… dose escalation.  If you really DO need more analgesia, you won’t get it from Suboxone—and you will be blocked from getting it from other medications.  ALTHOUGH—the increase in analgesia from dose escalation is mostly a ruse;  you only become tolerant to the higher dose anyway, so there is little value in being able to increase the dose of oxycodone or other agonists.  Suboxone and other partial agonists present challenges during periods when big increases in analgesia are required, such as after surgery or injury.  Finally, patients taking Suboxone quickly become tolerant to the effects of buprenorphine, so I wonder sometimes whether the medication is truly reducing pain, or whether it is causing a ‘placebo effect’.  ON THE OTHER HAND—a ‘placebo effect’ feels as good as a ‘real’ effect, so the question isn’t that important.  Plus, patients will get tolerant to EVERYTHING—including agonists—and so the tolerance to buprenorphine is not specific to that medication.
A tough call—but in patients who cannot prevent the run-up in dose that occurs with opiate agonists, Suboxone is a better choice.  There is no future in being on runaway doses of oxycodone;  those situations will always end badly eventually.  I believe that for those patients, Suboxone restores a great deal of sanity to the treatment process.  With Suboxone, the patient can free himself/herself from the constant thoughts about pain medicine, and get the person to move forward into the appropriate non-narcotic treatment strategies that are usually the true road to better function.
Good luck!

Chronic Pain Treatment Approaches

I write for a couple of medical sites– not the ones I have mentioned here, but sites where they actually allow doctors to identify themselves so that the person asking the question knows the credentials of the person providing the reply.  Oh, what the heck– I think it is OK to name them…  I answer questions ‘formally’ for MedHelp.com and for DoctorsLounge.com.  Go ahead and check them out if you like– if you do, be sure to give me good feedback!!  They are unpaid positions–  as I have whined about many times, I cannot find a way to make money as a doctor on the internet!  But I do them for the publicity– although what the publicity does for me, I’m not really sure…
Here is something I wrote recently about chronic pain;  I figure that the readers of this blog might find my basic approach useful.  The question was a generic request for help with chronic pain in a family member.
My Reply:
When treating pain, physicians generally separate acute pain from chronic pain in order to decide upon proper strategies for treatment.  We then tend to separate cancer pain from non-cancer pain; perhaps a more useful approach is to separate pain in the presence of limited life expectancy vs pain in a person with years of life ahead.  The reason for these distinctions relates to the problems with narcotic pain medications, namely tolerance, physical dependence, and addiction.  If a person has pain but has only months to life, the tolerance and addiction issues are unimportant;  the person can be treated with narcotics without much concern about addiction.  Likewise, ‘acute’ pain is pain that is time-limited;  narcotics can be used without a great deal of concern, providing the patient is monitored for signs of developing an addiction to the medications, and provided that the medications are discontinued as soon as possible.
The big challenge is dealing with chronic, nonmalignant pain.  I recommend anyone with this type of pain do an internet search using the terms ‘chronic’ and ‘nonmalignant pain’ and read up on the concerns and options.
The problem with any narcotic, including morphine, is tolerance and dependence.  The dose that works today will be ineffective in a month or two.  If the doctor or patient keeps increasing the dose, eventually there will be significant problems related to dependence and withdrawal– the patient will be on a huge dose of narcotic that no longer works.  So caution must be taken to prevent dose escalation;  many doctors are guilty of giving in to requests for ‘more, more, more’ until they eventually get scared of the dose, throw up their hands and say ‘I can’t treat you anymore’.  Ouch!    It is a difficult spot for the doctor, but of course worse for the patient–  it seems that more medication is the answer… but it simply isn’t.  There MUST be a reasonable limit.
OK, back to the question… there are many alternatives to morphine; some narcotic, some non-narcotic.  For narcotic medications, the general approach is to combine a long-acting narcotic, say a once per day or twice per day medication, with a short-acting medication for ‘breakthrough pain’.  There are many long-acting narcotics out there– oxycontin, opana ER, the fentanyl patch, once-per-day morphine preparations… but again, they all have the danger of tolerance and dependence.
Non-narcotic options require an understanding of the cause of the pain;  pain from nerves (damaged or compressed nerves) will often respond to anticonvulsant-related meds like gabapentin, tegretol, or lyrica; inflammation-related pain responds to NSAIDS like ibuprofen or naprosyn; and acetominophen often adds some relief to any other medication.  Depression makes pain worse, and antidepressants that might help include mainly the SNRI’s like Cymbalta, Effexor, and Pristiq.  The older tricyclics like amitriptyline, in small doses, have proven helpful– particularly taken at night, as they are quite sedating.
For many patients, non-narcotic medications don’t seem to be enough, and there is strong temptation to take narcotics.  That is a huge step;  once a person moves to narcotics for chronic pain it is VERY difficult to ever go back to life without them.  Narcotics usually affect the personality over time;  the person taking them becomes more and more focused on the pain, and on the narcotic, until both become the center of the person’s life.  Hobbies disappear.  Relationships suffer.  Through ‘denial’, the patient doesn’t see this happen, but simply thinks that more medication is the answer.
Because of this problem, there is growing attention to the use of buprenorphine for chronic pain.  The medication has been around for 30 years, but more recently has been developed as an oral preparation used to treat opiate dependence, called Suboxone.  A search for buprenorphine at clinicaltrials.gov will show the growing interest in the medication for pain.  I talk about buprenorphine extensively on my blog Suboxone Talk Zone so I won’t go on and on here, but basically buprenorphine is a ‘partial agonist’ that has strong opiate properties– as potent as about 60 mg of oxycodone– but it has a completely different effect on the patient’s psyche.  When given to opiate addicts, the medication virtually eliminates interest in opiates;  when taken by pain patients there is much less desire or urge to take more than prescribed.  The medication has a ‘ceiling effect’ that helps reduce (but not eliminate!) the risk of overdose.
As I guessed would happen, other companies are jumping onto the R and D bandwagon;  I wrote about a couple other meds in testing in one of my last posts.  Time will tell which meds will make it all the way to the market– a very long trip in the US.

Naltrexone Implant vs Suboxone: Mano a Mano!

I am going to share an interaction with a person who wrote to me about using the Naltrexone implant. I am always a bit suspicious about the motivations of people who want comments posted about a different type of treatment, or who come with pot-shots against Suboxone. I don’t go to methadone clinic sites or ads for rapid opiate detox and hound people for their choice of treatment—even though I don’t agree with their choices. But the point of my blog is to educate people (that better be the point, as it certainly isn’t a money-maker!), so I will share the material and let people decide what is right for themselves. I did make some comments at the end of the discussion—the owner of the blog gets the last word!– because there were some things written about Suboxone and Naltrexone that I don’t agree with, based in some cases on the literature, and in other cases on personal experience.
The message about Naltrexone:
I just wanted to add a thought to the doctor’s paragraph about Naltrexone and how it could be used as a tool to help in recovery but it can’t because it doesn’t last in the body for long. I want to tell everyone about the Naltrexone implant. It has been around for a long time but not many doctors have the knowledge of it. I detoxed off heroin six years ago and went onto the Naltrexone implant for twelve months. The implant lasts about 8 weeks and then you have to go back for another. I have to tell you that it was the best twelve months in my whole life. I wish everyone knew about it. I had a great doctor that was a recovering addict and really understood what it takes to be clean and stay clean. I would suggest ANYONE that wants to really be clean…STOP hiding behind Suboxone and get to a doctor that knows how to detox you and put you on something NON ADDICTING like the implant.

Naltrexone vs Suboxone
Naltrexone vs Suboxone

My Reply to the Writer:
Thank you for your comments. I will add your perspective, but will also discuss the problems with the Naltrexone implant that have kept it from becoming more popular.  I’m glad it worked for you, but for many who have it implanted (usually as part of a rapid opiate detox weekend) there have been significant complications.  There is the liver damage from Naltrexone of course, but that is not the only issue.  I have met addicts who dug the implants from their belly or arm out of desperation to get ‘high’; there also have been several documented suicides in patients after rapid opiate detox and Naltrexone implantation.
As a board certified anesthesiologist, one of my initial plans after getting clean was to set up a rapid opiate detox place with a friend who was an internist.  After research of the literature I learned that the medical community sees rapid detox mostly as a gimmick that pays well but that does little to ease the suffering of addicts.
I also take issue with your comment about ‘hiding behind Suboxone’.   Most people would see the implantation of Naltrexone to be at least as significant an undertaking as taking a Suboxone tablet once per day. I’m not sure which person is actually ‘hiding’.

The Writer’s Response:

I completely understand your thoughts about the implant.  I do know about these types of cases and they are unfortunate.  However, because I took that step and did my best to use it correctly as a tool in my recovery, while working VERY VERY hard with a counselor, it worked for me.  Since then, I have devoted a lot of time to speak with other addicts about it and have “sponsored” hundreds and hundreds through this option and I have seen more people stay in recovery longer because of it.  I also was part of a Naltrexone implant study over the course of 12 months to see if people on the implant really achieve longer sobriety than someone on the oral form and even the injectable.  As far as liver damage, case studies show no liver damage within the first 12 months of staying on Naltrexone.  If that was the case, then I truly believe Vivitrol would not have been FDA approved for alcoholism (and they are more prone to have liver damage than an opiate addict).
I went through a rapid detox but with sedation….no anesthesia.  I have been through both and the sedation detox was SO much easier and more comfortable process to go through.  The doctor was great (he too was a board certified anesthesiologist) and I was awake through most of it to learn a lot about the process of which my brain and body was going through.
However…there are still several addiction specialists that can offer a detox (no anesthesia or sedation) on an outpatient basis and still complete it with the Naltrexone implant on the last day.  There are usually several options to offer a patient to help them even get through the tough time.
And with the Suboxone…there are truly people who need to be on it; pain management, people who are NOT ready to be clean, etc.  But there are some who did NOT know enough information about it, took the advice of their “MD” and then now are having a hard time getting off it and have no idea what to do.  I am “sponsoring” a woman now who is a school teacher in AZ….she called me this week and is so upset that her MD keeps writing her scripts for Suboxone, then she talked with him and told him she wanted to stop, and he doesn’t know how to get her through it…..because is in NOT an addiction specialist.  She is only on 2mg per day but she cannot get off of it.  I sent her to a specialist who will detox her in 5-8 days comfortably and then put her on the Naltrexone implant……it will take away her cravings, temptations, and provide her that “safety net” during the first 2 months of her recovery.  She knows it won’t be easy to be dependent for 2 years and all of a sudden not be dependent, but she is so excited to have the “opportunity” that she was never offered before.
I hope you will consider posting my blog…..it may help some and it may not.  But, addiction is non-predictable anyway and there is never a guarantee.  Thanks for the good work you are doing…..look forward to reading more stories.

Suboxone vs Naltrexone
Suboxone vs Naltrexone

My Last Word:

I appreciate the writer sticking with the discussion; too often a discussion will degenerate into name-calling, as I mentioned in my prior post.
I am not aware of anyone using the Naltrexone implant in my part of the country (the upper Midwest). I know that there are places in Florida that advertise heavily on the internet, and I do have one current patient who had rapid detox in Florida and the implant several years ago. He now takes Suboxone.  I will admit to some real stupid behavior on my part, borne from desperation:  on three occasions during my active using days I performed unmedicated rapid opiate detox… on myself!  On one of the occasions I injected the contents of an unlabelled syringe– something that often results in a dead anesthesiologist– but which in this case resulted in an anesthesiologist who only felt dead.  The unlabelled material turned out to be naloxone.  It was when I recognized this level of addiction– and this level of dangerousness– that I decided to leave anesthesiology behind and do another residency.
The other two occasions were equally stupid.  Again, understand that I hated being addicted to opiates from day one;  I took naltrexone tablets (which unlike naloxone are active orally) thinking that the block would set me free.  The first time, I was in a meeting with my partners after I took about 100 mg of naltrexone;  by 60 minutes I had to run from the meeting, much like a disgusting scene in the movie Trainspotting (I won’t say more, but those of you who have seen the film likely know the scene I am referring to).  The last time was late in my active addiction at a time when I was truly going crazy, and I don’t remember the event very well. Yuck.
Back to the writer’s comments– I don’t agree with the idea that Suboxone is for ‘pain patients’ and ‘people who are not ready to be clean’. People taking Suboxone are as ‘clean’ as a person on Naltrexone in my opinion; in both cases the person feels ‘normal’. There is no ‘high’ or any other subjective opiate effect associated with proper use of Suboxone. In fact, I have concerns when I start Suboxone in a patient having significant pain, knowing that the use of opiate agonists will be impossible on Suboxone and that tolerance develops to the agonist effects of buprenorphine.
As I have said in other posts, I see buprenorphine to be in line with Naltrexone, but an improvement upon it. I have not seen evidence that buprenorphine reduces opiate cravings; in my experience the cravings on Naltrexone were if anything more severe. Yes, Naltrexone reduces cravings for alcohol, but that is a completely separate effect. On the other hand, buprenorphine clearly does reduce opiate cravings, very effectively.
Everyone will have his/her own way of seeing things. Here is mine: Naltrexone provides assistance with sobriety by assuring the addict that use would not result in intoxication; the addict therefore can tell himself, as a last-resort measure to avoid use, that ‘even if I did use, nothing would happen’. In my model, ‘addiction’ consists of the mental obsession to use. Since Naltrexone doesn’t treat cravings, it doesn’t treat the ‘obsession’—it doesn’t treat ‘addiction’. So a person taking Naltrexone is truly in a ‘dry drunk’; the obsession to use is STILL there, and so active involvement in a 12-step program is necessary to regain a sense of freedom from substances. I think this is why rapid opiate detox and Naltrexone implantation has sometimes resulted in disaster; an addict stumbles out of a hotel after rapid detox, blocked from using, but still obsessed with opiates—without any exposure or experience with a recovery program (again, the steps are the ‘gold standard’ here). So the blocked addict is miserable—and sometimes digs out the implant, or worse.
ON THE OTHER HAND… and as I have written about many times, buprenorphine gets to the heart of addiction—the obsession to use. A person taking buprenorphine (in Suboxone) is relieved of the obsession, and so in my mind is not in a ‘dry drunk’. For that reason I see twelve step meetings as less of an issue in patients taking buprenorphine. This is a tough point, so I will word it another way: the meetings are necessary with Naltrexone implants in order to stop the obsession (which meetings stop through the adoption of powerlessness and a higher power); Buprenorphine ITSELF stops the obsession in patients taking Suboxone. This leads to my frequent caveat– if a person stops buprenorphine, he needs to take up meetings—or the cravings and obsession will eventually return.
One final comment: there are currently trials underway for a buprenorphine implant, Probuphine, owned by Titan Pharmaceuticals. I have tried to make contact with people at that company on a number of occasions but cannot get a response; if you have contacts with anyone there, please contact me at [email protected]

Suboxone (buprenorphine) and Opiate Withdrawal in Newborns

I received an e-mail today related to an article I had placed on a different web site about using Suboxone during pregnancy:
My son was born November 19th 2008 and is still in the hospital because the mother is on Suboxone. He has tremors, has trouble sleeping and is excessively strong and ‘tight’. The doctors placed him on methadone to treat these symptoms and they are weaning him off the methadone. It is a very emotionally frustrating, confusing and strained time for us all. I see the side effects of the Suboxone and they are real and do happen. For more info. on my case email me. I would be happy to fill you in on more. I am dealing with it right now.
I am frequently frustrated by the lack of knowledge about Suboxone among physicians;  the manufacturer of Suboxone sponsors educational seminars and courses, but doctors tend to see addiction as something other than a fatal illness that deserves their best efforts.  In just my own collection of patients I have had several encounters with physicians who were literally just ‘guessing’ over their management of patients on Suboxone;  they weren’t reading the literature (which there is plenty of), they weren’t asking for consultation from other doctors (who would guess that doctors have egos!); and worst of all, in some cases they were treating the patients on Suboxone with patronizing or disdainful attitudes.

Methadone is harder for newborns to kick than Suboxone.
Methadone is harder for newborns to kick than Suboxone.

As a Suboxone patient you bear the burden of educating yourself and perhaps educating your physician.  Do not assume that every doctor knows what he or she is doing in regard to buprenorphine;  you may want to seek second opinions, particularly if your doctor recommends something that isn’t consistent with what you have learned about the actions of Suboxone and buprenorphine.
My response to the e-mail about the newborn with tremors:
Thank you for writing, and I am sorry about your son.  I don’t know how you will take what I am about to say, but I am not interested in an argument so please don’t reply with one—I would not read it even if you did, as the issue is your son—not my opinions.

For your own interest, and for your own concerns taking care of your son and finding your son the best care, understand that there is a vast amount of information on buprenorphine, the active ingredient in Suboxone.  Unfortunately, there are also more and more examples of improper diagnosis and care related to doctors not knowing enough about buprenorphine.  I have seen a number of mistakes made by physicians because of their lack of knowledge about buprenorphine, including mistakes by obstetricians and neonatologists.  I don’t know where your son is, but to be frank, their use of methadone to treat ‘Suboxone withdrawal’ is so improper that I have to think that your son is not where he should be.  I am sharing some articles with you that will likely make you more knowledgeable than your son’s doctors;  I encourage you to read and learn about buprenorphine so that someone can lobby for proper treatment of your son.

I am someone who does know about buprenorphine;  I have worked with it for over 10 years, and buprenorphine has been around for over 30 years.  In fact, before epidurals buprenorphine was used to treat pain DURING LABOR, as it doesn’t carry the same risk of respiratory depression as other opiates.  So understand that buprenorphine has been used for years as a ‘good medication’ for treating pregnant women in labor.  It is NOT a ‘new drug’—only the patent and formulation are new.

I keep current in the literature about buprenorphine and Suboxone.  There are a number of articles that provide information about the medication, although simply understanding the typical actions of opiate agonists and antagonists is sufficient to understand that it makes no sense to treat Suboxone withdrawal with methadone.  You can read the articles, but one pertinent conclusion from the review article is:

From these reports it appears that buprenorphine use during pregnancy induces a more mild withdrawal syndrome in neonates, when compared with methadone.

From another of the attached papers:

Regarding Subutex and buprenorphine:  it does not seem to be teratogenic in humans or animals. Administered in monotherapy form as Subutex, it has been used successfully in opioid-dependent pregnant women as a maintenance replacement opioid.  A 2003 review of the available clinical studies has been published covering approximately 300 pregnancies. Compared with methadone, a lower incidence of NAS (neonatal abstinence syndrome) has been reported in buprenorphine-exposed neonates. The severity of NAS is reduced as assessed by total opiate required to treat and length of hospital stays. Some data suggest that the placental transfer of this opioid may be limited in comparison with others, such as methadone, thereby limiting fetal exposure and the development of dependency. Deshmukh and colleagues have demonstrated that a large proportion of buprenorphine is metabolized to Norbuprenorphine, the only metabolite formed as determined by high-performance liquid chromatography and mass spectrometry, by placental aromatase (CYP 19) within the microsomal fraction of the trophoblast.

From the attached case report:

If methadone cannot be withdrawn before birth, mild to strong withdrawal signs in the newborn are frequent.4 The present case suggests that buprenorphine might be considered for the treatment of pregnant women addicted to heroin because (1) it does not induce teratogenic or embryotoxic effects in animals, (2) it apparently induces only a weak withdrawal syndrome in the newborn, and (3) the dose absorbed through maternal milk is negligible.

I don’t know the cause of your son’s tremors, but I strongly doubt they are related to the mother’s use of Suboxone or Subutex.  Attributing the tremors to those medications would require tossing out all of what we know about the medications—which is a large amount of data.  One thing that we absolutely DO know is that methadone causes a much greater ‘abstinence syndrome’ than does buprenorphine—and so if anything, the tremors are likely due to the methadone withdrawal!  Since neither buprenorphine nor methadone harm the fetus, however, I would be most concerned that your son’s doctors are doing what is unfortunately typical—focusing on the buprenorphine since it is something they don’t know enough about, and perhaps overlooking the real cause of your son’s tremors.  I encourage you to print and share the attached papers with your son’s doctors.


The papers I mentioned in my message:

Elkader A and B Sproule. Buprenorphine: Clinical Pharmacokinetics in the Treatment of Opioid Dependence. Clin Pharmacokinet 2005; 44 (7): 661-680.

Marquet P, J Chevrel, P Lavignasse, L Merle, and G Lachltre. Buprenorphine withdrawal syndrome in a newborn. Clinical Pharmacol Ther 1997; 62(5): 569-571.

Helmbrecht G, and S Thiagarajah. Management of Addiction Disorders in Pregnancy. J Addict Med 2008; 2: 1–16.

Fentanyl patch for post-op pain, on Suboxone?

I’m in a bad mood tonight– squabbling with my 13-y-o daughter will do that to me– so I’m going to cheat and copy an e-mail that I recently sent to a reader.  She takes Suboxone and will be having surgery;  she did everything correctly, tapering her dose and then stopping the Suboxone for a few days before surgery.  Ideally her addiction doc or her surgeon would prescribe her a large dose of oxycodone to treat the post-op pain, but instead she was told that she is already treated for pain from being on the Suboxone, so she doesn’t need anything more.  After her appropriate objection, he told her that he would recommend that the surgeon prescribe– of all things– fentanyl patches.  Never mind that fentanyl patches have a ‘Black Box Warning’ by the FDA, that they are contra-indicated for treatment of post-op pain!.
As I mention in the e-mail, fentanyl was my ‘drug of choice’– it is a staple of the anesthesiologist’s ‘sleep kit’.  I have had a number of patients who abused fentanyl;  one person was drying and smoking the stuff that she scraped from the patches (it gets even more disgusting– she collected used patches from the backs of old people in nursing homes, pooling them together to  get enough used-up resin to get high (the patches are sometimes put on the mid-back area of demented, elderly patients so they don’t peel them off and throw them away).  I wouldn’t normally write about something that would provide a ‘tip’ about how to use– please continue reading.  She smoked this dried mess, and the vapors from whatever chemicals it consisted of trashed her lungs.  She developed ARDS (Adult Respiratory Distress Syndrome) and almost died, eventually leaving the ICU with permanent pulmonary problems (try saying THAT three times real fast!).  So don’t smoke that garbage.
OK… my message, filled with righteous indignation:
Yes, just to validate what you already know, you DO need extra opiate to compensate for pain—people on Suboxone are on that level of opiate as their ‘baseline’, and so of course you need something more potent when pain control is needed!  I wonder—does your Suboxone think that everyone on the medication is covered for all their pain control needs?  Is there ANYTHING he would consider providing pain medication for?!  I worry about this type of situation, since the people who end up treating addiction and prescribing Suboxone are not the same docs who have experience in prescribing pain medication.

I like your idea of letting the surgeon see the recommendation and then asking for something a bit less potent.  I don’t think the fentanyl patch would kill you (how reassuring that must sound!), and there are things you can do to make it safer–  there actually have been deaths associated with the patch, and I think there might even be a warning that comes with it now that it is not to be used for post-op pain—but by understanding some things about the patch you can make it a bit ‘less inappropriate’.  The first thing is to never cut the patch in an attempt to make it less potent.  Different brands have different things inside—some have gels, some have a semi-solid matrix, some have liquid—and some are safe to cut, but most aren’t, so just don’t do it.  The risk is when it is cut, the fentanyl leaks out and gets absorbed through the skin at a much faster rate than 100 micrograms/hour, leading to respiratory arrest.  The second important thing is to avoid heating the patch when it is against your skin, as that will increase skin blood flow which will cause greater absorption of fentanyl… again leading to respiratory arrest.

Fentanyl is an interesting drug—so interesting that I made it my drug of choice during my days as an anesthesiologist!  I was ‘outted’ (is that the right spelling?) by Men’s Health magazine—Google ‘men’s health’ and ‘junig’ and you will find the story–  and in the article they suggest that anesthesiologists breathe vaporized fentanyl that leaves the body of the unconscious patient through the opened abdomen, and they cite a study that found plasma levels of fentanyl in anesthesiologists just from a day’s work.  The guy who interviewed me for the story, Chris McDougall, suggested that this is why anesthesiologists become addicted to opiates.  I told him I thought the idea was silly—but he wrote about it anyway.

In small IV doses, fentanyl (which is a fat-soluble molecule) hits the brain and then ‘redistributes’ into the fat compartments of the body, so that the level in the bloodstream and at receptors rapidly decreases.  As you give more and more fentanyl, eventually the fat compartments become filled with fentanyl, and there is no place for it to ‘redistribute’ to.  At that point the blood level builds up, and is any decrease is dependent on breakdown at the liver—a slow process.  So in some cardiac anesthetics, where very large doses of fentanyl are given, the patient remains on a ventilator for up to 24 hours and sometimes even longer.

Wearing a fentanyl patch has effects similar to being on an IV infusion of fentanyl.  Initially, the fentanyl enters the blood and at the same time leaves the blood by entering fat compartments of the body.  After a few days, the fat compartments become saturated and there is nowhere for the fentanyl to go… and the blood level therefore rises.  The deaths from fentanyl patches often occurred after several days, because of this phenomenon.  Overdose from opiates occurs from respiratory depression, and the degree of depression can be measured by the respiratory rate.  I should add that benzos like Valium or Xanax greatly increase the respiratory depression from opiates.  You can help reduce the risk of overdose by having someone count your respirations when you are at rest or sleeping—you can’t count your own because you will change the rate if you pay attention to it!  The way doctors do it during exams (I am giving away a secret here!) is to hold the patient’s wrist and pretend they are counting the heart rate, and watch or listen to the patient’s breathing and count that instead, while watching the second hand on their watch.  Anyway…  if someone follows your respiratory rate while you are resting or sleeping, a normal rate is about 16;  the rate of a person in pain is usually above 24;  a person who is getting too much narcotic will have a rate of 12, then 10, then 8, then 6…  and after that they might just stop.  People who snore are at greater risk, because as the drive to breathe goes down, they are more and more likely to stop moving past the obstruction.  From a practical standpoint, if your respiratory rate drops below 12, I would suggest removing the patch, and keeping if off until you are alert and the pain has returned.  There will be a lag time with patches—it takes an hour or two for them to start working, and after removing them there will still be some absorption of fentanyl from the skin for an hour or two.

I had better send this off.  Again, I’m sorry your doc isn’t more enlightened.  Be careful out there… and keep us up on how things go!


As If!

A comment and question from a reader:
How’s it going people thanks for the education dr. I’ve been on Suboxone for 3 months now and am down to 2 mgs a day, I have found that getting physical exercise is such a key to my over sense of well being. I believe that it is one of the major parts in the tapering process because of the addition of natural dopamine release and just the overall feeling of wellbeing of doing something positive and constructive. I do have a question in regards to how I should taper down from 2mils should i keep doing it by halves every week or should i try and take it at 2mils every other day but i know if i get to low then it brings up cravings. Any advice would be great. Me personally I try eating a lot of fruits especially bananas along with good exercise in the sun is really helped me a lot. which when I was on opiates I would have to get loaded in the morning so I didn’t get wds which limited all my activities and made me lazy leading to an overall degraded self esteem and image when I feel so much better being able to feel good about constructive behavior and radiate positive energy to people. But ids rather stay at 2 mgs a day for the rest of my life and be happy, and positive, then go off when im ready. Rather than be in a constant struggle with trying to be happy, feel well and also the cravings. Finally what’s the long term consequences of maintenance Suboxone use I’ve heard rumors it might affect memory or something like that (at let’s say 2mg)??
My Response:
That is great that you are exercising! There is no doubt that exercise will reduce the severity of the withdrawal process—unfortunately people don’t feel like exercising when they are in withdrawal, so they usually don’t. Exercise helps so many things… it will have a positive effect on depression as well. I often tell people to ‘act as if’– a common Recovery phrase that is said in reply to the complaint ‘I don’t feel like it’. Act as if you DID feel like it—and the ‘feeling like it’ will follow.

We have to act ‘as if’ on many occasions as addicts trying to stay clean. An actively using addict does what he/she wants, and that’s that. So it is important to have a goal out in front of us—an image of who we would like to be at some point. When we feel like taking a day off, or doing something inconsistent with Recovery principles, instead we can remember our goal and act ‘as if’ we were that person already. Acting ‘as if’ is one of the little things that I have carried around since treatment that has certainly kept me out of trouble on many occasions. All alone in a relative’s home, where there are certainly going to be pill bottles? Act ‘as if’ I am not alone, or act ‘as if’ I had a urine test later in the day. Nervous about applying for a job? Act ‘as if’ you aren’t nervous. Etc.

Tapering down from 2 mg per day is tough. One thing to do is take a tab every other day for a week, then stop… the problem is that once you get to such low doses, you run the risk of going into minor withdrawal at the end of every dosing interval. Once that starts to happen one might as well just stop completely, otherwise the misery only becomes dragged out. The general mistake I see people make is that they change the dose too rapidly, given the long half-life of the drug. During the early stages of a taper, the dose should be changed no faster than weekly. I usually recommend going down by 2 mg every week, but everyone has their own preferences. But if a person goes too fast, the WD becomes ‘stacked’ up and is as severe as it would be with no taper. To explain… WD takes 3-5 days to develop in an average person on 16 mg. If a person tapers each day, he will be almost to zero per day by the time the WD starts—and will feel as if he abruptly stopped the medication.

I have not seen any credible threat to health from long-term use of buprenorphine at this point. There are plenty of junior scientists out there on the web, extrapolating from studies on mice or tissue culture—there is little relevance to clinical use in humans from what I have seen rumored on the web. There is a decrease in sex drive associated with chronic opiates, and I would assume that buprenorphine would fall into that category. When I have a patient with that side effect I usually treat it with a Viagra-type medication, or sometimes with a small dose of testosterone, particularly if their testosterone level is below the normal range for age.

Many of my patients report similar mood effects as you describe.  I interpret the effects as a bit of euphoria from the opiate action, and maybe something else– maybe the sensation of a more ‘level’ mood because of a reduction in cravings.  Opiate cravings can be manifest by irritability, depression, anger… and since buprenorphine so effectively eliminates cravings, I would anticipate a reduction in those ‘negative’ symptoms as well.

I certainly have many patients who intend to stay on Suboxone indefinitely. There are currently trials looking at other forms of buprenorphine, such as ‘Probuphine’, an implant of buprenorphine intended to last for six months. My prior post refers to all of the ‘Suboxone experts’ out there who use PubMed or another reference site to download articles, then send them to me or other people to try to prove some point—I encourage people to ignore the attempts of others to scare you off of Suboxone—or any medication, for that matter. Speaking as someone who has published a number of scientific articles I can tell you that the people who do that are always much less bright than they try to appear. I have a guy right now who is sending me articles to try to back up his argument that opiates are safe to use long-term– the last set of articles he sent have nothing to do with the issue at all, although a person in a non-science field would be swayed by the sheer volume of material! Don’t let some idiot spouting off with anger about Suboxone change your mind about how to handle YOUR health.