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

My Response:
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.

Prepare for Psychiatry Oral Boards

Prepare for Psychiatry Oral Boards


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).
SD


2 Comments

Staci · October 7, 2008 at 10:39 pm

Thank you so much for taking the time to anwser my questions. You were of great help. I honestly believe staying on methaone is my best bet. I was on cymbalta 60mg since Nov 2004 and it definitely helped my phantom pain but I decided to get off of it this past April due to side effecs I thought were coming from that med. Every afternoon I get very clammy and sometimes can’t even move because of how hot, cold and wet I got. It’s extremely uncomfortable. It has gotten better but my phantom pain is now worse. Medications prescribed in the past Neurontin, Gabitril,Tegetol, Pamelor, Elavil, Trazadone, Clonidine, Ativan, Xanax, Duragesic Patch, Roxanol Loiquid,Ultram,Topamax, Baclofen, Oxycodone, Hydrocodone,Depakote, Mexilitine and more.These are meds only elated to my amputation and not the hundreds that came before all of that. I have an appointment in Ann Arbor MI with my Internist-Pain Specialist at the end of October and I definitely have nemerous questions for him. As I said before- I am the fortunate one as I don’t crave these drugs and never have in the past 25 years.I endured two catastrophic accidents within two years of one another starting at the age of 13. I had spent over 1400 days as an inpatient, had 23 broken bones, was in the U of MI burn unit due to a complete degloving injury to my leg.Had 68 opertions then finally it became inevitable that my leg be amputated. I couldn’t of imagined that phantom pain could be so excrutiating, life draining, knawing burning crushing pain. I’m a fighter, race snowmobiles, ride four wheelers, there is nothing I can’t due but I sure wish the phantom pain would stay under total control so I wouldn’t have to take medications because it’s the side effects of the meds that really are tough to deal with. I have read thousands of hours of material educating myself on every aspect of this stuff. I don’t like it when a doctor treats me or anyone else like another number or file. I don’t want to be put in a category or assumptions made that Oh’ for what yu’ve been through you must be this or that. I’m not a textbook. I have dreams, goals, desires, and feelings. I will not let this define me or be my Identity. I can be changed by what has happened to me, but I refuse to be reduced by it. Thank you for listening

Staci · October 8, 2008 at 5:29 am

I copied and pasted this article. It’s been my impression that bupenorphine isn’t superior for chronic pain. I also read an article that three amputees with phantom pain got adequete relief from using buprenorphine suppositories. Is there a difference between using the under the tongue med in comparison to these other methods?
TRANSDERMAL BUPRENORPHINE EFFECTIVE FOR SEVERE CANCER PAIN
Date updated: September 30, 2008
Content provided by Reuters
NEW YORK (Reuters Health) – Transdermal buprenorphine appears to be effective and safe in a study of patients with severe cancer-related pain, European investigators report in the Journal of Pain and Symptom Management.
Dr. Philippe Poulain of Institut Gustave-Roussy in Villejuif, France, and colleagues compared transdermal buprenorphine 70 micrograms/hour with placebo in 289 opioid-tolerant patients with cancer pain requiring strong opioids in the dose range of 90-150 mg/day oral morphine equivalents.
The patients were enrolled in a 2-week run-in phase, during which time they converted to transdermal buprenorphine or a placebo patch. Rescue analgesia with buprenorphine sublingual tablets 0.2 mg was allowed as needed.
The researchers defined response as a mean pain intensity reduction of 5 points on a 10-point scale and a mean daily need for two or fewer buprenorphine sublingual tablets.
One hundred patients dropped out of the study during the run-in phase due to a lack of efficacy or because of adverse events, while 189 patients continued on to maintenance treatment. Thirty-one more patients dropped out at that time, most of whom were on placebo.
A response was seen in 74.5% of patients on transdermal buprenorphine and in 50% of patients on placebo.
“This result was supported by a lower daily pain intensity, lower intake of buprenorphine sublingual tablets and fewer dropouts in the transdermal buprenorphine group,” Dr. Poulain and colleagues write in the August issue of the Journal. “The incidence of adverse events was slightly higher for transdermal buprenorphine.”
Dr. Poulain’s group concludes that “transdermal buprenorphine 70 micrograms/hour is an efficacious and safe treatment for patients with severe cancer pain.”
J Pain Symptom Manage 2008;36:117-125.

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