Some excellent questions about chronic pain:
Question.I am an above knee amputee and have chronic phantom pain for 12 years. I have endured 68 operations. Numerous medications have been tried for this but the side efffets are pretty hard to take. I have been on a stable dose of methadone 80mg for 10 out of the 12 years. My doctor has stated and I 100% feel I have no addiction tendencies. Thats not to say I have a tolerance. My pain is at an acceptable level although I do have some intense flare-ups but when I was taking no medication I coyudn’t even sleep. A doctor who I have seen for his opinion-not my prescribing doctor has offered to put me in the hospital and convert me from methadone to buprenorphine. Does this make any sense at all for the treatment of my chronic pain when I am at a level of 80mg? What is the difference betweeen suboxone and subutex? Do these meds block the ANALGESIC effect of breakthrough meds? Thank you so much for any input
The simple answer is to just stay on the methadone if you are doing OK. Many people, perhaps most people, cannot handle staying on the same dose of an opiate agonist. Over time they develop tolerance and want MORE, always more… eventually losing control and running ou to scripts early. At that point all hell breaks lose. The simple answer is to continue… but I imagine that is not possible, or you wouldn’t be looking at Suboxone. Docs sometimes suddenly decide that they are not ‘comfortable’ prescribing all that narcotic. There is often fear that the licensing board will get involved in some way. Or perhaps your doc sees something in you that you cannot see– maybe you are having a problem that seems small to you but that your doc is concerned about.
To answer your questions, Suboxone is about as potent as 30-40 mg of methadone. You will get less analgesia from Suboxone than from your current daily dose of methadone, so from an analgesic standpoint I don’t see the benefit. I have done similar conversions for other reasons– for example for a person who has become obsessed with the opiate and who thinks about it all the time, even if the use is still under control.
Going into the hospital is a bit of ‘overkill’. I could see it being necessary for something like IV narcotics, but that isn’t the case. You have two options for converting; one is to slowly taper the methadone down to about 40 mg per day and then convert. A quicker way is to stop the methadone, experience withdrawal for a few days, and then take Suboxone. I usually have people go 16-24 hours before the induction but with methadone, which has a longer half-life, I have them go a bit longer. Your dose is not that high though– the standard instructions are to get the methadone dose lower but I have converted people from as much as 200-300 mg of methadone per day without too much difficulty. Were I your doc, I would give you clonidine to take every 6 hours or so, have you stop the methadone after your last dose tonight, give you some ativan to use on Sunday and Sunday night, and then start you on Suboxone on Monday. You would in all likelihood do fine from a withdrawal standpoint, but your pain might be a bit worse because of the decrease in opiate effect.
Breakthrough pain would be a problem. Opiates will not work– I should point out that I do have one person who insists that he gets relief from 10 mg of oxycodone while being on 16 mg of daily Suboxone, but I think it is all a ‘placebo effect’. I have had occasions to try to treat pain in people on Suboxone– after surgery for example– and it is darn difficult! The person usually has to go in the ICU for high-dose narcotics. The ICU isn’t so much ‘needed’ as much as the nurses on the floor are just not comfortable giving such high doses of narcotic as are needed in such cases.
For breakthrough pain I have given Ultram, or Tramadol, which has some mu opiate activity blocked by naloxone (and buprenorphine) and some other actions mediated through receptors for serotonin and norepinephrine. The full actions are not completely understood and it can cause seizures, particularly if taken in higher than indicated amounts. Other choices include the NSAIDS– naproxen or toradol for example– and anticonvulsants like gabapentin (Neurontin) and pregabalin (Lyrica).