I took a look at my blog stats today, and one of the interesting things to review is the collection of keywords that people have used on their way to this site. Some of the keywords consist of questions, and I will try to answer the questions as time allows. The following question appears several times on the list of keywords:
How can I get emergency pain relief while on Suboxone? If I am on a small dose of Suboxone and need emergency pain relief is it dangerous?
The fast answer is no– it is not dangerous. There is a common misconception among people using Suboxone that I hate to correct, as maybe it keeps people clean. But on the other hand, there will be times when Suboxone patients need pain relief– they are not immune from car accidents, skiing accidents, work injuries, etc– and they need to know the facts about the medication they are taking.
The confusion probably occurs because Suboxone will make a person sick– sometimes very sick– if it is taken while a person is still ‘high’ on opiate agonists (or on opiate agonists and not yet withdrawing from them). Agonists, remember, are the drugs that activate a receptor; opiate agonists include morphine, Demerol, oxycodone, hydrocodone, etc. At the molecular level buprenorphine, the active drug in Suboxone, binds tightly to the opiate receptor, blocking the area that agonists would otherwise bind to. (It is more complicated– you get into probability theory when you get down to what actually happens.
The molecule of buprenorphine associates and dissociates from the receptor so rapidly that the binding can be characterized by the ‘probability’ that the receptor is bound vs not bound at any moment). As the buprenorphine alternates between bound and unbound to the receptor, it is competing with any other opiate agonists, and winning the battle, as buprenorphine is a very good ‘fit’ at the receptor. If a person is tolerant to opiates, he/she requires agonist binding at the receptor in order to maintain the normal neuron firing pattern and avoid withdrawal. If buprenorphine is added at that point, it will out-compete the opiate agonist and ‘displace’ it, essentially making it less likely that the receptor will be occupied by the agonist at any moment in time. This causes less activation of the receptor, the neuron stops firing, and a series of brain events occur that result in withdrawal.
The question is concerned with a different sequence of events; a person is taking suboxone (which is therefore bound to the receptors) and suddenly needs pain relief, and takes an opiate agonist. In a person not on Suboxone, the goal is to over-activate the receptor and make the neuron fire more than usual, so that it sends messages down the spinal cord that reduce the ability of pain signals to get through. But if the receptor is blocked by Suboxone, the agonist is not going to work well. In fact, if the buprenorphine dose is high enough, the agonist won’t have any effect at all… unless it is given in very high levels. Remember that the drugs compete at the receptor, and buprenorphine is better at competing than most agonists; if you give enough of the agonist, it will eventually overcome the block by buprenorphine.
If a person taking Suboxone needs pain relief (or wants to get high), normal doses of opiate agonists will not have any effect. They won’t make the person sick either. I recommend that patients on Suboxone carry a card in their wallet that tells EMTs that they are on an opiate blocker, in case they are injured and are unable to talk. That way, if the person is writhing in pain in the ER as a chest tube is being inserted, the docs will hopefully give much higher doses of morphine than usual to relieve the pain.
There are two reasons to limit the dose of Suboxone to the lower range in my opinion– one is to save money, and the other is so that if an emergency occurs, it is not impossible to attain pain relief. I tend not to restrict the dose, by the way– I find that a dose of 16 mg works best at eliminating cravings and provides the highest margin of safety from relapse. But a person who has a higher than average chance of needing emergency surgery may want to consider taking a lower dose so that the block is easier to overcome during emergencies.
I have had a few patients who needed emergency surgery while on Suboxone. Most did OK– I had one poor woman though who took her morning Suboxone and then needed an emergency C-Section. I was called by the OB doc after the surgery when the patient was in pain in the recovery room and the spinal was wearing off. My first thought was that if they had called before the surgery, I could have told them to place an epidural– they could then run in a dilute mixture of local anesthetic and totally relieved her pain. But they did a spinal, so that was out (it is hard to go back and do an epidural after a spinal– positioning the patient, etc, but also, the hole in the dura mater from the spinal can make an epidural more erratic and potentially dangerous).
Other options included IV Toradol, an aspirin-type medication, as long as bleeding isn’t a problem. This patient still had severe pain though, so using the principle of competition at the receptor, I recommended that they move the decimal in their dosing of morphine and just give what it takes. She went to the ICU for monitoring and they gave her BIG doses of morphine– 20, 30, 50 mg at a time. Everyone was nervous, but it worked. (the concern is respiratory depression– that is why she went to the ICU, as the floor nurses were appropriately too nervous to give those kind of doses without being able to watch respiratory rate closely). The only problem with such high doses of morphine is that IV morphine can cause release of histamine in the bloodstream– the nasty chemical that makes you sneeze, itch, and swell during allergies. After a couple of doses the available histamine is ‘used up’ and not a problem, but the first dose or two should be smaller, and then gradually increase, in order to prevent a massive histamine reaction. Some Benadryl is helpful as well.
A couple of final comments: Do NOT engage in trying to ‘out-compete’ your own receptors using opiate agonists, while taking Suboxone. Doing so is very dangerous, as you can go from a non-competing dose to an out-competing dose without realizing it until too late– and the result would be a fatal overdose from respiratory arrest. Respiratory monitoring is necessary whenever this type of thing is going on!!!!
The other thing is that while the principle of competition is straightforward, do not be surprised if you doctor refuses to go along. Most doctors are freaked out by giving such high doses of narcotics. I was an anesthesiologist for 10 years, so for me, it is not a big deal… but most surgeons, unfortunately, are more comfortable with a moaning patient than with writing for really high doses of morphine. ALWAYS plan ahead for surgery if at all possible– talk to the anesthesiologist, the surgeon, and anyone else who will be involved in your care. Have a plan in place to deal with the pain.
If the surgery is planned I recommend stopping the Suboxone at least 3 days before the surgery so that it gets to a low level in your system by the day of surgery. It takes a LONG time to clear buprenorphine! And let your surgeon know that you are taking an opiate blocker, and your tolerance is higher than normal. I hate to generalize in a negative way but some doctors, when told of high tolerance and the need for higher doses, respond by being more stingy with the dosing!! (you know– BAD addict! BAD! BAD!!). The dose of every medication has limits, but people addicted to opioids have the same right to reasonable analgesia as other patients.
2023 Addendum: Use the search function of this blog to find more recent posts on this topic. My approach has changed a little bit over the years… For post-op pain I usually prescribe a high-dose opioid agonist and keep patients on buprenorphine, sometimes reducing the dose to 8 mg per day to allow the agonist to work better. Good luck!
180 Comments
April Stevens · February 11, 2017 at 5:09 am
You said “If a person taking Suboxone needs pain relief (or wants to get high), normal doses of opiate agonists will not have any effect. They won’t make the person sick either.” I was told by my physician and also the rehab facility I was in, that taking any opiates (normal doses) while on Suboxone would send me into precipitated withdrawal. I’ve also read that on every website I looked up. I know the opiates won’t have any affect as far as getting high but wouldn’t it have an effect as far as PW which would make someone very sick? I’m confused by the information you posted.
Jeffrey Junig MD PhD · February 14, 2017 at 9:49 pm
Not sure what to say, other than that information is not correct. If a person is on opioid agonists and then starts buprenorphine or Suboxone, that often will cause precipitated withdrawal. But PW is NOT caused if a person is on buprenorphine first, and then takes an agonist. Hopefully the articles you’ve read make that distinction, but if they don’t, they are simply incorrect. As for pain relief, high doses of oxycodone, dilaudid, or fentanyl will out-compete buprenorphine at the opioid receptor if given in high enough doses, and they will produce pain relief. In my experience it takes about 3 times more agonist than normal to get pain releif in patients on 8 mg of buprenorphine per day– but follow you doctor’s instructions carefully!
Jeffrey Junig MD PhD · April 13, 2017 at 1:17 pm
I don’t understand the first part of your post– whether they stopped or didn’t stop buprenorphine/Suboxone. But the second part is consistent with what I’ve written about adding oxycodone to buprenorpine.
David · December 24, 2017 at 4:01 am
Hello i came across your post when i myself was looking up some info on this matter. As of right now its 4:47 am christmas eve. No im not up waiting for santa to bring presents. I got an inflamed ear infection, virus maby dr dont know he just looked at it and said “its red”. Went in ror my suboxone apointment with this bad ear paib and was hoping to get fytanal like a 3 day dose or somthing to get me through until cipro helps out the ear swelling. But just gave me cipro i said will this help with pain? Yes he replied. He wouldnt have wrote me fytanal. If i asked. Told him i got a belly full of aleve and tylonal been taking for 3-4 days, but dont work but for an hour then pain come back and have to take more, after hours number did not help as they put a hold on prescription writing for pain meds for 48 hrs. Nothing like feeling their is nothing you can do to stop an invisable person punching you in the ear every time your heart beats. Well im rambling now. Anyways i appreciate your understanding that suboxone paitients are entittled to emergency pain care when needed. But just wanted to note: fytanal may work best to relieve pain when on suboxone. Merry christmas.
Shannon L McLaughlin · April 1, 2018 at 7:40 am
Dr I am having surgery in 15 days I am on suboxone 1 8mg/2mg strip I need to taper off can you help me
Rycee02 · March 5, 2017 at 5:04 pm
Subutex does not have naloxone in it. Suboxone has naloxone in it. The naloxone is what makes you go into immediate withdrawal. My wife was just given Subutex because she was not off opiates long enough and her doctor said if he have her Suboxone it would send her into withdrawal
Jeffrey Junig MD PhD · March 6, 2017 at 8:02 pm
Sorry, but you are mistaken. Naloxone will block heroin or oxycodone for about 20 minutes after it is injected, but naloxone has nothing to do with the withdrawal precipitated by taking Suboxone. Your mistake is a common one. Buprenorphine is what causes precipitated withdrawal, by displacing opioid agonists from the mu opioid receptor. There is no such things as ‘Subutex’; that drug was removed from the market by Reckitt Benckiser about 5 years ago, and now people use that term to refer to generic buprenorphine. Both generic buprenorphine and Suboxone (and also Zubsolv and Bunavail) will equally cause immediate, precipitated withdrawal if taken by a person who recently took opioid agonists.
Charles Anthony Foutch · March 8, 2017 at 7:17 pm
Why was Subutex taken off the market?
Jeffrey Junig MD PhD · March 8, 2017 at 8:01 pm
The manufacturer, Reckitt Benckiser, was trying to get rid of generic competition– so they came out with the film, then filed a citizen’s petition with the FDA claiming that tablets were unsafe. They stopped making Subutex, of course, to bolster their argument. They were trying to get the FDA to ban all forms of buprenorphine except their film– which they had a new patent on. The FDA didn’t buy it though, and actually recommended that they be investigated for unfair business practices. You can read about it here: http://suboxonetalkzone.com/suboxone-makers-petition-denied-by-fda/ and if you look at the bottom of that post there are related posts, including one that has a copy of the 30-page response from the FDA.
Marshall · May 23, 2017 at 6:24 am
Thank you Dr Jeffery Junig , my question is this I normally take a daily Suboxone dose and I cut my hand really bad while on the job I ended up in the ER and I took 5 milligrams of hydrocodone and I plan on continuing my usual dosage tomorrow do I have anything to worry about from the one time emergency use of the 5 milligrams of hydrocodone my normal daily dose is 8 milligrams a day of Suboxone thank you in advance X-Men
Jeffrey Junig MD PhD · May 23, 2017 at 6:46 pm
No. As long as you’ve been taking Suboxone each day, you will have no problems from taking opioid agonists. The only problems occur when buprenorphine is absent, and a person takes agonists. In those cases, taking buprnorphine can precipitate withdrawal. But if you’ve taken buprenorphine at least once each day, there is NO change of precipitated withdrawal.
George · May 25, 2017 at 7:59 am
Hi Dr my brother cut his Leg Sunday with a utility knife at work went to er they sent him home left wound open went back to same er last night cause still squirting blood here he cut a vein and a smaller artery all fixed now and k er packed with gause he takes .5 of suboxon a day he is in extreme pain still in er meds they are giving him aren’t helping oxycodone 10mg bringing in special dr to address the pain what can they give him
Jeffrey Junig MD PhD · May 26, 2017 at 2:06 pm
I’ve had dozens of patients go through major surgeries over the years while taking buprenorphine. They all did well with oxycodone, providing the dose was high enough. I have to stress that nobody should try to ‘treat’ themselves with opioids, and the exact dosage must be determined by one’s doctor. But in my experience, 10 mg of oxycodone is not effective for surgical pain. Hopefully the person who sees him will understand how these medications interact at the receptor– and provide something that helps.
Beyond oral medication, there are often other ways to reduce pain. The doctor could infiltrate the area around the wound with bupivicaine and epinephrine; that would provide excellent pain relief for up to 8 hours, maybe more. An anesthesiologist could do a block, using bupivicaine to block a nerve that provides sensation to the area around the wound. Your brother should ask the doctor whether he can use ice on the wound (there are reasons to avoid icing a wound, so it may or may not be appropriate). The leg should be elevated above the heart to reduce swelling. The doctor should also be asked if ibuprofen is OK to use (ibuprofen can cause bleeding).
Charles Anthony Foutch · May 30, 2017 at 10:45 am
When I shattered my heel bone while in hospital they would not give me enough pain meds to control my pain after surgery.At the time vanderbilt did not know what Suboxone was. They decided to put a nerve numbing or blocking agent in my foot (sorry I don’t know right term) They did this twice. The first time an intern tried to do it and he kept poking the huge needle into my foot. I already suffered from Neuropathy but after they got through to this day my foot is numb. It did not help so they took it out. The next day they put it back in easily this time then 4 hours later they removed it and sent me home. I told the doctors my foot was numb they said it was the Peripheral Neuropathy.
Jeffrey Junig MD PhD · May 31, 2017 at 8:35 am
I’m not sure what they were putting in the foot, but sometimes nerves are damaged when a doctor injects local anesthetic or hits the nerve with a needle. For shoulder or hand surgery for example, anesthesiologists sometimes do a ‘block’ that numbs the nerves, providing post-op pain relief. Many doctors will not do a block on someone who already has nerve damage because they are afraid that they will be blamed for it.
In your case, it might be hard to determine whether your foot is numb because of the block, or because of your neuropathy. If the injected foot WAS the same as your other foot, but then got much worse after the procedure, then the numbness in your foot might have been caused by the procedure.
Charles Anthony Foutch · June 2, 2017 at 6:58 pm
That is what happened the foot got much worse and to top it off the nerve blocker did not work. It was set up like a morphine pump where I could hit a button so often to get relief but I was in some of the worse pain of my life and I was ready to try anything. I have always read opiate addicts do not handle pain well.
NeedToBeSubFree · July 19, 2017 at 4:57 am
Dear Dr. Junig. I admire you and thank you so much for everything you’ve done for all suboxone users.
I’m new to this site and can’t really find my way around too good, as of yet but hopefully that will come in time.
I’m really trying to find information on weaning off 1 mg daily habit in order to have s pretty major surgery. Hopefully I can find this info soon.
Again, thanks for all your help to each and every one of us “forever addicted” fools.
Best,
NeedToBeSubFree
Jeffrey Junig MD PhD · July 19, 2017 at 6:23 am
One thing that confuses people is that there are two main sites. This site is a blog, and you can comment after articles. I try to visit now and then to answer questions, but sometimes it may take weeks if I’m wrapped up in other things. The other site is suboxforum.com, and that is an active forum. The registration, username, etc are all independent between sites–i.e. you need to register at both places to post. I don’t do anything with registration data; I encourage people to use fake names and data so that you have no concern about identity, in case I ever become a Presidential candidate and the Russians hack my sites! It is good to have a ‘throw-away’ email account for this type of thing, that you can use for any web site where there is risk of the site selling your name to spam lists. I have never shared names of email accounts and never would– but many sites do.
The main problem with tapering buprenorphine products is that all of the work is in that last 1 mg. The challenge with any taper off opioids is getting your tolerance to zero, and tolerance doesn’t start to go down on buprenorphine until the dose is below 2-4 mg or so (depending on the individual). So people try to find ways to consistently divide that last, small bit of medication. The easiest way is to get the 2 mg Suboxone Film, and dose with that twice per day. Cut two small templates out of hard plastic, using a scissors, and use that template to trim your doses. You’ll be starting with a quarter strip in the AM and a quarter strip in the PM; the next step is to remove an additional 10% of the AM strip each day for a week. Then remove an additional 10% of the PM strip each day for another week, then go back to the AM strip and trim 10% more.
The idea is to reduce your overall dose by 5% per week, and you will do that if you reduce one of the doses by 10% each week. Just stick with it; NEVER go back to a higher dose, and don’t pause in the process for more than an extra week here or there if it is really needed.
Use the forum; it really helps to have people there cheering you on, when you have a bad day and want to raise the dose.
If you are a pain patient, there are other methods… you can use Butrans for example, which is a patch that provides a lower amount of buprenorphine. If you are taking 1 mg sublingual, then you are absorbing about a third of that into your system- i.e. about 400 micrograms. The biggest Butrans patch delivers about 500 micrograms of buprenorphine per day, so you could start with the second-highest dose with Butrans, and then taper down from there (there are 4 doses of Butrans now, I think).
Finally… your dose is low, and you’re not too far from your goal. Good luck!!
Stephanie Emiliano · July 19, 2017 at 11:39 am
I’m not a doctor, but I thought I would give you my situation. I had to have minor surgery, but because I was on 4mg a day the doctor felt 24 hours off of Subutex would be just find. It was. So you probably can just stop taking it for 24-48 hours and be just fine. Again, just my experience. Good luck!
NeedToBeSubFree · July 19, 2017 at 2:23 pm
Thank you so much. My surgery is pretty invasive and involves general anesthesia so I guess that’s why I’m concerned. I’ve had twilight sedation in the past and had no problems. I’m just hoping if I wean down to .25 mg a day, a week before, that I should be fine. I appreciate your reply. It’s nice to know that there are people out there who care?
James Buttery · July 19, 2017 at 5:33 pm
You don’t really need to be off the suboxone for your surgery. Is there a reason why you want to be off 1mg for the surgery? 1mg is not really going to block the effects of opiates that greatly as say 8 – 16 mg daily. The only advice I can give you is to continue to slowly wean yourself — .75mg for a few weeks , .5mg for a few weeks etc. If you have been only on 1 mg for a long period of time the withdrawal off of that probably wont even be that bad…
NeedToBeSubFree · July 20, 2017 at 7:03 am
Thank you for your reply. I don’t necessarily want to be off subs forever, just trying to make sure I don’t have complications during the actual surgery because of the suboxone. I am really ashamed because most of my family are unaware that I even take suboxone and some evenntjink that addiction is NOT a disease. If they found out I have this problem I think I would die!
Anyway, thanks for your input. It it highly appreciated.
Best!
NeedToBeSubFree · July 22, 2017 at 12:30 pm
Thanks for your reply. Did you have major surgery and if so, what mg. Sub we’re you taking at the tone? Thx
Steph E · July 29, 2017 at 4:13 pm
It’s me again. My friend started asking me questions about Subutex. She’s on Suboxone, and feels that with her daily headache from the Suboxone that Subutex would work better for her. Cheaper too. So she today was in ER for back pain. They gave her .5 of Dilaudid, and one dose of Morphine. Now she’s to scared to ask her doctor when can she take the Subutex? I told her I don’t know if it’s like Suboxone and you have to wait. So I’m asking you. Help
Jeffrey Junig MD PhD · July 30, 2017 at 7:24 pm
Precipitated withdrawal is caused by buprenorphine, NOT by naloxone. How long to wait depends on whether your friend has been on buprenorphine continuously. If a person STAYS on buprenorphine, taking it each day in typical doses (4 mg or more per day), then there is no worries about precipitated withdrawal after taking opioid agonists like dilaudid. As long as a person stays on buprenorphine, that person can take agonists, and continue taking buprenorphine.
The problem comes if the person STOPS buprenorphine long enough for blood levels to go down. I don’t know the exact length of time when that is a problem– but I know that it is NOT a problem if the person takes buprenorphine once per day. If the person stopped buprenorphine for a couple days or more, then they are at risk for precipitated withdrawal, and should stop agonists for at least 24 hours before starting buprenorphine again.
Jaygee21 · June 7, 2017 at 4:42 pm
I’m on Bupinorphine/naloxone tabs also. I know exactly what you mean. Subutex tabs changed to generic Bupinorphine tabs with no naloxone and Suboxone is Bupinorphine w/naloxone. They just don’t get the whole thing with generic brand only now. Most medications prescribed today are generics.
Braudid · June 28, 2017 at 5:42 pm
Ok this is in fact incorrect I currently take subutex so you do not know wtf ur talking about! Jeuss
Jeffrey Junig MD PhD · July 1, 2017 at 10:22 pm
Take a chill pill. Look at your prescription bottle. It says ‘buprenorphine’ on it. You take generic buprenorphine. Subutex was made by Reckitt Benckiser; THEY DO NOT MAKE IT ANYMORE.
People who work in this industry remember when it happened, in 2011, in response to generic buprenorphine getting approved. Go read my posts from that time- you can read the Citizen’s Petition. Or go to NAABT.org and read the history of buprenorphine products, where they write: On October 9, 2009 the FDA approved a generic version of Subutex. In 2011 Subutex (brand name) was discontinued, in 2012 Suboxone (brand name) tablets were discontinued and replaced with Suboxone Film.
Some advice– double check your information before writing ‘you do not know WTF ur talking about’. This is an easy topic to verify.
Sam · March 19, 2017 at 11:27 pm
Actually, subutex does exist because I take it daily. It is made by Roxane. It is true other manufacturers stopped making it years ago, but it is widely prescribed for opiate addiction and withdrawal with pregnant women, and people allergic to or sensitive to side effects of the additives (namely the sweetener) in suboxone. Roxane makes the generic version, so there are other manufacturers as well. In fact I used to take the name brand version of subutex, until my insurance stopped covering it once the generic became available. Been on it for over a year.
Jeffrey Junig MD PhD · March 20, 2017 at 10:00 am
No, Subutex does not exist. Subutex was a brand made by Reckitt-Benckiser (now buprenorphine products were spun off and are made by Indivior). Subutex was discontinued at the same time the company eliminated Suboxone tablets, and changed to Film.
Plain buprenorphine is manufactured by several companies, including Roxane. People often talk about ‘Subutex’, but they are mis-speaking, and the proper term is just ‘buprenorphine’. It doesn’t make a whole lot of difference, but if you ask your insurer if they cover ‘Subutex’ the answer will always be ‘no’— since that product hasn’t been made for about 5 years.
We are arguing semantics, but ‘semantics’ is the nature of this discussion. Subutex is no longer made, but there are other products that are almost exactly the same as what used to be called Subutex.
Katie · April 30, 2017 at 9:22 pm
Subutex is not off the market. I take it everyday after becoming pregnant.
Jeffrey Junig MD PhD · May 1, 2017 at 6:26 am
You take a generic drug that USED to be called Subutex. Subutex is a discontinued brand name, but the drug itself– buprenorphine– is still available.
Grant kegley · May 27, 2017 at 6:13 am
No subtexts any more sub u tecs i cant spell. But u say people r just callin gen bup this but genric bup wit no nalox is subutexts just with outnfanxy name. Am i wrongl. So there for there just isnt any name brand subutext or bup.
Jeffrey Junig MD PhD · May 27, 2017 at 2:33 pm
Doctors usually communicate about medications by referring to the chemical name, not the brand name. We do that because there may be several brand names for any one chemical, and brand names tend to come and go over time (but the chemical name remains the same).
Buprenorphine is used to treat addiction, either alone, or combined with naloxone. Reckitt Benckiser developed the brand ‘Subutex’ for plain buprenorphine. That brand name was eventually discontinued, but plain buprenorphine is stil available, without a brand name attacted to itt.
Likewise, buprenorphine/naloxone is used to treat addiction. One company, Reckitt Benckiser, developed a branded form of that medication called ‘Suboxone.’ Other brands are Zubsolv and Bunavail. There are also a number of generic companies making the same medication. Many people incorrectly refer to it as ‘Suboxone’, but in reality it is buprenorphine/naloxone, without a brand name.
Aaron · June 23, 2017 at 7:50 am
There is a such thing as subutex. I’m currently prescribed it. It has not been removed from the market
Jeffrey Junig MD PhD · June 27, 2017 at 6:34 am
See the prior comments. Subutex is a discontinued brand. You are taking generic buprenorphine.
Charles Anthony Foutch · June 27, 2017 at 6:24 pm
Dr Junig I think you just need to give up and agree with them. lol I still use the name Subutex because it is easier to spell than Buprenorphine. lol I do remember reading years ago Subutex was discontinued.
Jeffrey Junig MD PhD · July 1, 2017 at 10:34 pm
Yes, you’re probably right. It is not a big issue… but it feels like some principle is at stake!
Ray · July 9, 2017 at 4:57 am
Hi, I just started taking subs and came across your posts. You have answered alot of my questions. And am enjoying reading the posts. Just want to say thanks Dr.
Jeffrey Junig MD PhD · July 9, 2017 at 6:07 pm
Thanks!
Charles Anthony Foutch · June 27, 2017 at 6:29 pm
I do have one question since someone brought up Clonidine a drug i was given several times for WD. I thought I read somewhere Clonidine can actually cause high blood pressure. I know it can mess with your blood sugar but can it cause high blood pressure. I went from having low BP to high BP in just a month.
Jeffrey Junig MD PhD · July 1, 2017 at 10:29 pm
Clonidine is used to lower blood pressure. I cannot imagine a way it would RAISE blood pressure. It lowers sympathetic activity in the brain– i.e. reduces the increase in blood pressure and heart rate when people are excited, afraid, or anxious.
If a person is on clonidine constantly for weeks, the person will have ‘rebound’ hypertension of the drug is suddently stopped.
The Dude · June 30, 2017 at 8:58 pm
Not true
Somaniferum · July 31, 2017 at 10:12 pm
Subutex is still available in the European Union. It is produced by Indivior UK Limited. So THERE IS brand name SUBUTEX still made. Not all people reading this are from US. Please be a little more humble doc. Thank you.
http://www.medicines.ie/medicine/1658/SPC/Subutex+0.4mg%2C+2mg+and+8mg+Sublingual+Tablets/#PRODUCTINFO
Jeffrey Junig MD PhD · August 1, 2017 at 7:33 pm
I appreciate the information. About 95% of the visitors to this blog are from the US, so yes, I make certain assumptions. As for humility, I do my best. Understand that I respond to people who have a range of attitudes. For example, one person wrote that I was full of S@#$ on the Subutex issue, and that she would send a picture of her medication bottle to prove that I was wrong. She was from the US, BTW… and when I responded that I was waiting for her to send the image she wrote about, she responded with a string of obsenities directed at me. And yes, that irritated me– as I’m only human. I answer questions on this blog for no reason other than to try to get the facts straight. This isn’t my ‘job’; I don’t get paid to do it, other than literally about $15 per month in adsense revenue. The cost of hosting is much more than the ad revenue.
I’ll assume that the info you provided is accurate in 2017. In the US, Subutex was discontinued about 5 years ago. The arguments on this blog have not been about other countries; they have been from people in the US, who don’t seem to understand the difference between generic names of molecules, vs. trade names. I’ve been trying to correct those misunderstandings, but for whatever reason some people decide that instead of learning the difference between generic and trade names, they will cling to incorrect information and spew profanities. I usually delete those emails, and I almost always delete the profanities– so you aren’t getting the true picture or the messages I deal with on a daily basis.
But again- I always appreciate information, especially when it isn’t provided in the middle of F-words!
Somaniferum · August 1, 2017 at 8:49 pm
No problem I know how it is like when somebody pushes your buttons. I appreciate information I get from you.
Indivior UK Limited is still producing it and delivering it to many countries around the world, where I live. The company was established as the Buprenorphine division of Reckitt Benckiser in 1994. In December 2014, Reckitt Benckiser spun off its specialty pharmaceuticals business into a separate company named Indivior. By February 2015 the company was capitalised at £2.3 billion on the London Stock Exchange.
By the way, I get Subutex brand name and it is available in doses of 8, 6 and 0.4mg (0.4mg is great addition for the tapering off the medication).
Here is rough table that shows availability of their product – http://www.indivior.com/products/
Thank you for all the information again doc. All the best!
Jeffrey Junig MD PhD · August 2, 2017 at 5:49 am
Thank you! Wow- 0.4 mg? That would be very helpful… Hopefully some generic manufacturer will provide that here at some point.
Jeffrey Junig MD PhD · August 2, 2017 at 5:53 am
BTW… I always wondered if the spin-off of Indivior was done to protect the stock for Reckitt Benckiser– i.e. they worried about sales of Suboxone, and assigned it to a different company to protect the larger business empire. I assume I was wrong in those thoughts, as sales of Suboxone are stronger than ever. Do you have an opinion on that issues? Check this out: https://seekingalpha.com/article/3296625-stock-in-focus-indivior
Somaniferum · August 1, 2017 at 9:47 pm
Sorry 6mg was typo. Subutex is available across Europe in doses of 8, 2 and 0.4mg. Thank you.
Somaniferum · August 3, 2017 at 12:34 am
No, I do not have any hard info about that, but my thoughts go into protecting “the larger business empire” as well. Just from another point of view – protection from lawsuit. As of 2015 Reckitt Benckiser is no longer in danger of any potential lawsuit like the one Purdue Pharma faced (and settled). I think this is why they moved away from Subutex in the US – people thought it has greater abuse potential than Suboxone (which is not the case because buprenorphine out competes naloxone in binding contest even with IV use – simply buprenorphine has greater affinity at the receptor site than naloxone). In the time of large problems with opioid abuse in the US escape goats will be pulled out of the pact. Perdue is first, and maybe Reckitt Benckiser wanted to get as far away from that. Remember, they also gave wrong information about their products. Suboxone is just as abusable as old Oxycontin (OC). It is not so recreational, and opioid abusers generally do not like it as oxycodone or oxymorphone, but it is abusable much more than Reckitt Benckiser claimed (they gave impression that it is bulletproof because of naloxone). In fact, in micrograms doses, people compare buprenorphine IV shot to small dose IV heroin shot. So for the people with no or low tolerance it is quite abusable and enjoyable. Second thing that is was marketed and pushed in the wrong way was – the need for the large doses of the medication. That is now being semi normalized. But the power of the medication is still not fully appreciated in the US.
Case example (imagined):
Tom is 17 years old. He teares his knee ligaments and is given hydrocodone for his pain. Tom likes thee high that 20mg hydrocodone gives him so he abuses it lightly. Next year Tom tears same knee but this time he says hydrocodone (Vicodin) is not helping enough and is given oxycodone (Percocet). Tom likes the oxycodone high even more and gets hooked. Tom is now buying Percocet or even Roxycodone on the street. One day his parents find about his abuse and they confront him. He is given 2 chances: get off (oxycodone) or get out (from parents house). Tom says ok, but he is afraid of the withdrawal. He is taking 60mg of oxycodone to get high but could stave off dope sickness with just 30mg. Methadone is off the table, but there is this “new” medication “that has minimal withdrawal with no apparent abuse potential for someone like Tom who is opioid tolerant”. Tom gets on Suboxone. First he is over prescribed and gets different but just as intense high as he got from 30mg oxycodone. Than Tom googles a bit and finds out about this micron filtering. Tom graduates to IV use. Tom is careful so he uses only 1mg of Suboxone, but to potentiate the high he takes 2mg Xanax that he bought of the street. Tom does not have benzodiazepine tolerance. Tom takes 2mg Xanax and then IVs 1mg Suboxone. Tom is found dead in his room morning after. Parents are shocked. More so because they were told that this is a safe medication that can not be abused intravenously. Toms parents find out that they were lied to and they sue doctor. More people with similar cases are brought together because Toms parents create Facebook page, and now Reckitt Benckiser is in trouble. Not because of Toms case but because they miss presented level of danger that buprenorphine carries.
Sorry for the long post but this is not just possible answer to why Reckitt Benckiser created Indivior ( I may be dead wrong here), it is warning to anybody reading this and thinking of abusing buprenorphine “because it is so safe”.
Sorry for the rant. But people – DO NOT UNDERESTIMATE THE POWER OF THE BUPRENORPHINE!
Peace.
Jeffrey Junig MD PhD · August 14, 2017 at 6:01 pm
The problem with your case, though, is that it would never happen. There are about 40 deaths each year in the US in people who have traces of buprenorphine in their system (40 compared to 40,000 overdose deaths WITHOUT buprenorphine in the bloodstream). Those numbers are verifiable by looking at CDC data, since all overdose deaths are autopsied and drug levels almost always obtained.
Of those 40 deaths, almost all were caused not by the buprenorphine, but by heroin, fentanyl, or oxycodone. In almost all cases, death would have been avoided if MORE buprenorphine was present. I have testified in two buprenorphine deaths. In both cases, the person who died had zero opioid tolerance– one who never took an opioid, and the other who was released from jail the day he died. In both cases, death was caused by buprenorphine plus a second respiratory depressant, which is the only way an adult can die from buprenorphine– i.e. 1. have very low or no opioid tolerance PLUS 2. a second respiratory depressant.
Anyone taking 60 mg, or even 30 mg of oxycodone each day for a week or more would have a very low risk of death from buprenorphine, even if benzos were taken too. Buprenorphine is extremely hard to die from. About 400 people die each year from tylenol; ten times more than from all buprenorphine meds combined. When you look at the people taking buprenorphine, those numbers are even more impressive. Buprenorphine is incredibly safe, no matter how you measure safety.
A couple other things… and understand I’m not fan of Indivior, although I have to give their parent company credit for the tens of thousands of lives they saved. The number should be higher, but that’s for another day…
The naloxone is irrelevant. Not sure what you mean about the ‘micron filter’; people don’t need that to inject Suboxone! But injecting buprenorphine or Suboxone is not like heroin. If a person used heroin in the last 12 hours, injecting plain buprenorphine, or Suboxone, will precipitate SEVERE withdrawal. That’s NOTHING like heroin! If buprenorphine is injected anytime later, the max effect is capped far below the potency of a full agonist like heroin. Anyone tolerant to 60 mg of oxycodone per day would, at best, ‘break even’ injecting buprenorphine. The effect at the brain cannot go higher than the effect of 60 mg of oxycodone, period– even if injected in a huge amount into the carotid artery. That’s the amazing thing about partial agonists– the brain doesn’t care where or how they got there, and they only have so much effect.
Finally… buprenorphine is hardly a ‘new drug’. It was patented 17 years ago, and has been used in the US for over 14 YEARS. Millions of prescriptions have been written during that time. And while a half million people in the US died from opioids during that time, about 300 had buprenorphine in the bloodstream– but death was caused by other drugs.
Those are facts, not opinions. Is buprenorphine ‘safe’? No, if compared to bananas (although I wonder if more people died from choking on bananas?) But for a medication that treats a life-threatening illness, the safety is pretty impressive. It is FAR safe than chemotherapy, and far safer than drugs that lower cholesterol
Charles Anthony Foutch · August 15, 2017 at 12:24 pm
What do you think of Kratom. I am sorry but it is very hard to figure out your site and comment section. especially for an old man like me. lol Anyone else having a problem or is it just me?
Rycee02 · March 5, 2017 at 5:04 pm
Subutex does not have naloxone in it. Suboxone has naloxone in it. The naloxone is what makes you go into immediate withdrawal. My wife was just given Subutex because she was not off opiates long enough and her doctor said if he have her Suboxone it would send her into withdrawal
Jeffrey Junig MD PhD · March 6, 2017 at 8:02 pm
Sorry, but you are mistaken. Naloxone will block heroin or oxycodone for about 20 minutes after it is injected, but naloxone has nothing to do with the withdrawal precipitated by taking Suboxone. Your mistake is a common one. Buprenorphine is what causes precipitated withdrawal, by displacing opioid agonists from the mu opioid receptor. There is no such things as ‘Subutex’; that drug was removed from the market by Reckitt Benckiser about 5 years ago, and now people use that term to refer to generic buprenorphine. Both generic buprenorphine and Suboxone (and also Zubsolv and Bunavail) will equally cause immediate, precipitated withdrawal if taken by a person who recently took opioid agonists.
James P. Buttery · June 4, 2017 at 12:59 pm
I don’t care what anyone says. Naloxone does cause precipitated withdrawal. I was on 80 mg of methadone for a month…went into rehab and after 36 hours was put on Subutex with no I’ll effects. About 4-5 months later I was on 80mg of methadone for about a month and wanted to get off and waited 50 hours and then took Suboxone and was immediately sent into Precipitated Withdrawl and had to be hospitalized for it. It’s clear the naloxone in the SUBOXONE caused the PWD syndrome. Now, maybe some people will experience a PWD from buprenorphine, but, the chances are MUCH MORE LIKELY while taking Suboxone rather than just buprenorphine. I’m living proof..
Jeffrey Junig MD PhD · June 17, 2017 at 8:10 am
I realize that you consider your memories to be ‘proof’, and maybe that’s enough proof for you. But your conclusion is at odds with known neurochemistry. I’m not going to change your mind, obviously- but if you intend to get the world to believe you, you will have to explain why the tiny fraction of naloxone that is absorbed sublingually– 3% of less– had such an effect, especially when naloxone is metabolized in about 20 minutes.
Not sure whether it is productive to point this out, but something being ‘clear’ to an individual does not create ‘living proof’. That’s why, in fact, no journal would ever accept as ‘proof’ a finding if not double blinded– i.e. where neither the subject nor the experimenter know which drug is being applied.
Derrick · April 10, 2017 at 8:02 am
Look I’ve been on suboxone 8mg 2mg for the last 4yrs, everything affects people differently. It’s been my experience that if while on 3 suboxone per day if I take 4 percocet 10mg I will feel every single bit of it and get a usual buzz, it just doesn’t last as long and I feel depressed because I relapsed! Ultram will work while on suboxone I’m living walking talking proof,as well as Lortab and all other opiates! I’ve even come clean with my suboxone dr when I relapsed and she seemed amazed that I was able to feel the opiates but she also said that all drugs affect everyone in a different way. If I’m to have a surgery,I will have my suboxone dr ok it and get the opiate pain meds for said surgery because no one should ever have to suffer!
Jeffrey Junig MD PhD · April 11, 2017 at 6:12 am
I agree that people respond to some medications uniquely. But all opioid receptors are the same molecule, and they respond identically across the mammalian genome. The most likely explanation for your situation is that you have a lower blood level of buprenorphine, either because of reduced absorption or increased metabolism of buprenorphine. The enzyme that breaks down buprenorphine varies between individuals, and it can also be induced (made stronger) from taking certain medications (wikipedia.com lists inducers and inhibitors of the enzyme, called cyp3A4).
Norco contains relatively small amounts of hydrocodone, a weak opioid. Tramadol has mu receptor effects with a similar potency. If you ‘felt’ regular doses of those medications, then you do not have much buprenorphine on board, for whatever reason.
40 mg of oxycodone, on the other hand, is a high dose of a potent opioid. That amount of oxycodone would treat post-op pain, as it out-competes buprenorphine at the mu receptor (although the ‘high’ experienced would be greatly reduced or eliminated). BUT- understand that it is highly unlikely you will ever find a surgeon or other doc to provide that amount of oxycodone every 4 hours (the time for oxycodone to wear off). Your suboxone doctor may ‘ok it’, but that does not mean anyone will actually prescribe it.
As I’ve written before, I generally treat post-op pain with doses of oxycodone less than half of what you described. People usually get adequate pain relief from that amount of oxycodone.
Casey W · May 21, 2017 at 6:05 am
Dr. Jeffrey,
you’re getting nowhere with your abundantly clear explanation to these people! they may be taking Suboxone/ Subutex, but their brains are still very much in “addict-mode”.
Just left them have their sugar pill !!!
because we are given prescriptions and have learned from our own experiences, we all think we’re doctors here. but in reality, Jeffrey is the doctor and he’s trying to help educate us.
instead of arguing with Jeffrey, go find your cop neighbor and explain to him how you’re all detectives because you watch CSI.
side note: it took me two minutes to google and read the press release from the manufacturer of Subutex saying it’s been discontinued.
Jeffrey Junig MD PhD · May 23, 2017 at 6:37 pm
Thanks, Casey. I sometimes wonder the same thing.. I don’t claim to know everything about everything, but the issues I write about here are things that I’ve read about, and studied, for years. I would never try to contradict an electician or plumber about those topics! But so many times I’ll write a long explanation about something, explaining the known facts such as the absorption rate of naloxone or the maximal opioid effects of buprenorphine, and then someone will post comments that ignore everything I’ve written!
I try to differentiate between the things we KNOW, vs. the things that are controversial. As you mentioned, the Subutex issue is pretty straightforward– but I continue to get comments telling me that I’m wrong.
The best trait any person can have is an open mind– a mind open to the possibility that their opinions are incorrect. There are so many things out there that we know so little about… yet everyone seems more certain than ever before. I’m digressing, I know… but the situation on this blog seems to be emblematic of society these days.
Cindy · May 4, 2017 at 3:18 pm
I was told the same thing but I think they say that hoping we won’t find out just to help keep us from taking opiates. None of us want to withdraw anymore than we have to.
SusieQ · June 28, 2017 at 8:21 pm
No it will not cause precipitated withdrawal. When I had to have surgery my doctor moved me to oxycodone while on suboxone. I took a 4 mg that morning, my last dose before surgery, and he had me go ahead an start taking the oxycodone anyway so I’d have pain coverage and not withdrawal while coming off the sub. He had me continue taking the oxycodone until the sub was out of my system, for one week before my surgery. So no it doesn’t cause any type of withdrawal what so ever- you just don’t feel the oxycodone until the sub is out of your system (about 16 hours for a 4 mg). I think rehab personnel just tell people that to scare them so they don’t take an opiates. But even though it doesn’t cause withdrawal, there’s no point in taking an opiate while sub is in your system because it won’t have the same effect for pain management.
Jeffrey Junig MD PhD · July 1, 2017 at 10:35 pm
Mostly agree… but if enough oxycodone is prescribed, patients will experience pain relief without any of the other feelings you get from opioids.
Simone P · November 20, 2017 at 12:17 am
I had always thought the same with everything I read online as well. For years now I have been reading and asking similar questions which seem to quite often show the same answers as well. Although as the Doctor on here has explained quite eloquently I might add and say thank you as well, you will not get sick in the Suboxone before opioid direction it is the other order which will send you into wd.
Thank you for being careful with your life.
Melissa · February 26, 2017 at 11:22 pm
Hi jeffery, I havea question im fixen to go in for surgery historectommy im getting. Im on aby where between 2 and 4 mg of suboxen a day. What wil be the best for me to do before surgery? Im so scared, i had a colonoscopy done not too long ago and i told the doctor about me being on suboxin he told me not take any the day of and half my
dose down from what i normally the day before. Should i stop 3 days before the suboxin?
Jeffrey Junig MD PhD · March 2, 2017 at 5:39 pm
You really need to follow the instructions of your doctor. You are welcome to reference my site, if you want to convince that doctor of how best to treat you. My general approach is to reduce the buprenorphine dose to about 4 mg per day, and then I give higher doses of oxycodone for pain control post-op. It usually takes 15 mg of oxycodone or so to provide pain relief for a person who is on buprenorphine– and the person will get pain relief, but will not feel any of the other usual sensations caused by opioids (none of that fuzzy, warm feeling for example). Good luck– I hope they take good care of you.
Miranda · March 7, 2017 at 3:15 am
All doctors need to better educate themselves on suboxone.I was pregnant and was switched to the one with out naloxone. I had to have a C-section and once the epidural wore off. I have to say I have never been in so much pain. The pain medication the hospital was giving me was such a low dose it wasn’t working at all. Then they were trying to give me both medications together. I don’t get any pain relief until I refused the subutex and made them switch me from dilation to percocet.but they treated me like a drug seeker because I was telling them the medication wasn’t working when it really was not. It was a horrible experience. I couldn’t even hold my baby the first day because of the pain! Because the doctors and nurses where uneducated about subutex.
Jeffrey Junig MD PhD · March 7, 2017 at 8:57 pm
Yes, you are absolutely right. I have posts in this blog describing how I like to treat post-op pain; I usually continue buprenorphine, and treat pain with a high dose of oxycodone, on the order of 3-5 times higher dose than used in people NOT on buprenorphine. But may docs will simply increase the pain medication by 10% or so– which does nothing to treat pain. The other problem I see often is when doctors use one pain med, get frustrated, and move to a different pain med. They use sub-clinical doses of opioid after opioid, when they would have done fine if they just stuck with ONE opioid and pushed it to an effective dose!
Morphine is the one opioid I don’t recommend, as it releases histamine and is not potent enough to out-compete buprenorphine… but oxycodone, fentanyl, or dilaudid work fine.
Tommy · March 15, 2017 at 5:50 pm
I have a question im on 8mg/2mg suboxone i take two films at one time but i get kidney stones alot and worry that pain meds wont help if i have to go er im allergic to morphine dulida codeine before they give me demeral before i got on films so would the demeral still work if they gave me higher dosage
Jeffrey Junig MD PhD · March 16, 2017 at 5:22 pm
If you get another kidney stone and you are on buprenorphine, you will need higher doses of narcotic to get pain relief. Demerol would not be a good option. Is Demerol still available? I know there was talk about removing it from use because of the neurotoxicity of normeperidine– which is why it would not be a good drug in someone on buprenorphine, as high doses would be required (meaning higher amounts of normeperidine). I have a patient who gets occasional kidney stones; I usually have to give 15-20 mg of oxycodone every few hours to get effective pain relief.
L.A. · April 18, 2017 at 3:15 am
I’ve read some of your replies…Where can I find your blog site…You’ve answered many of my questions with your replies…I’ve have 22 I&d’s on my hip from a reaccuring abscess which developed to necrotizing phasheitous…I sure I’m spelling it wrong…flesh eating bacteria…I got on subs few months ago…I also will say I battle kidney stones from having alkaptauria.. Again sorry about the spelling…Aka black urine disease… Currently I’m passing a stone and want to know more what my pain relief options are…Since I’m allergic to nsaids and morphine…I find so many Dr aren’t properly educated on Suboxone as many pharmacist as well…I had one pharmacist call my Dr when I was prescribed pain killers saying I was a drug addict? Originally I got on subs to get off of 1000mg a day habit of tramadol…Long story…I was living in middle East when I had the flesh eating bacteria and 22 I&d’s and they don’t have hydrocodone or oxycodone…So tramadol for years…Anyway what are me options. Thank you for all your responses. It’s really educated me.
Jeffrey Junig MD PhD · April 18, 2017 at 6:09 am
Thanks for stopping by! This is my blog; I also have a forum at http://www.suboxforum.com , and we would welcome your input there. It’s free, and you are welcome to register with a face name or whatever you need to do to maintain your privacy.
One aside– many people who are told they are allergic to morphine are not truly ‘allergic’. Morphine causes histamine release from a type of blood cell called ‘mast cells’. That histamine causes an immediate reaction, including flushing, itching, and hives, and a mild drop in blood pressure. It is a normal reaction to morphine; when I worked as an anesthesiologist I would see it every time I gave morphine IV. Nurses often wanted to put morphine allergy in the chart, but we would try to prevent that– because it isn’t correct, and it removes access to a medication that may be helpful some day. I don’t know what your reaction was, but if it was hives and itching that lasted less than an hour after the dose, it probably wasn’t true allergy.
But morphine is not a great option for your current problem, even without allergy issues. You would do best with a potent opioid– oxycodone or hydromorphone (which is Dilaudid). Some docs will stop buprenorphine, but for reasons I’ve spelled out on the blog, I prefer to keep the buprenorphine or Suboxone going, and use a higher dose of oxycodone for pain relief.
You CAN get pain relief, but you need a higher dose of oxycodone– usually 15-30 mg every 4 hours. Don’t take anything without your doctor’s approval, of course.
Hope to see you on the forum– and also, check out http://www.suboxsearch.com , where you can search either the forum or the blog, using Google’s search algorithm.
Cindy · May 4, 2017 at 3:57 pm
Wow at one time my pain Doc had me on 80 mg of oxycodone and hydromorphone not to mention the Soma, Lyrica and a sleeping pill I can’t remember the name oh yeah zolpidem. I always thought the hydromorphone was morphine because it kinda sounds like it. So I was on dilaided and didn’t even know.
Thomas mosey · May 24, 2017 at 2:06 pm
Hi I’m just wondering if doctors can give u morphine n subitex thanks
Jeffrey Junig MD PhD · May 26, 2017 at 1:55 pm
Yes, but it doesn’t work very well. If a person is taking buprenorphine in a typical amount– 2 mg per day or more– the effects of morphine at the opioid receptor will be blocked. If someone needs relief from severe pain and morphine is the only drug available, you could get some relief from very high doses of morphine. But morphine has other effects including releasing histamine, which would cause blood pressure to drop and also make the patient break out in hives.
For those reasons, other opioids work better for pain relief in patients on buprenorphine, such as oxycodone, fentanyl, or hydromorphone (Dilaudid). All will provide pain relief in high doses, and for obvious reasons they should be used only under close care by a doctor.
James · July 8, 2017 at 10:30 pm
Hi Dr. Junig I have a quick question. I am prescribed suboxone and have been for three years. I take 32 mg daily. Every once in a while I try to only take 16mg a day as I feel 32 is just overkill. But 30 hours ago I consumed an opana 10mg IR. I’m just wanting to know, if I was to take 16 mg of sub would I be OK? I’ve read horror stories about precipitated withdrawal and I in no way want to experience that. Again I do not take opiates regularly, this was the first opiate I’ve done in three years other than my subs. I just wanna make sure 30+ hours is long enough for me to not experience PWD… thanks!
Jeffrey Junig MD PhD · July 9, 2017 at 6:11 pm
There is no significant chance you will have precipitated withdrawal. If a person is on buprenorphine and takes an agonist, the agonist is blocked– and the person can continue taking daily buprenorphine without any problem. The only problem would be if the person stayed off buprenorphine for a few days, long enough for the buprenorphine to be mostly gone from receptors. At that point, if a person takes agonists, he/she should do a formal induction to restart buprenorphine. But given your high dose of buprenorphine, you’ll be fine!
Charles Anthony Foutch · March 1, 2017 at 6:14 pm
I had a bad experience in 2007 I was in a house fire and had to jump out a window crushing my heel. I was on 16 mg of Suboxone a day. The doctors at Vanderbilt (a reputable hospital) had no idea what Suboxone was. I was sedated 3 days on a respirator. When I woke up they were giving me Morphine for 3 days and then they gave me suboxone. I did not have my glasses and swallowed it. My Suboxone doctor sent instructions but they ignored them. I went through hell because they treated me like a normal patient. Early on my Suboxone treatment a counselor told me the same thing I would go in WDs if I took an opiate. I told him he was an idiot and he needed to go back to school. lol Well I did not call him an idiot but inferred it. Today I just take 6mg a day of the generic which is weaker than the name brand films
Jeffrey Junig MD PhD · March 2, 2017 at 5:36 pm
No– they ARE idiots. I get so frustrated by the nonsense that I hear from doctors who should know better. The facts about buprenorphine are not all that complicated; certainly easier than learning about recent medical advances in genetics for example. The lack of knowledge is due to one thing– a noncaring attitude toward people struggling with addictions. Given that many, perhaps most cases of opioid dependence are CAUSED by doctors, those attitudes are indefensible.
carl · March 24, 2017 at 11:08 pm
Totally agree Dr’s are not educated enough on what to do! 1 told me “if” I would need pain relief I would be given torodol (sp.?) But uh it’s worthless plus I’m allergic I would be screwed! I was at er time for cat attack /bites on hand extremely painful they said can’t give you anything sorry take apap or ibup.omg I was in severe pain which suboxone helped tiny bit but it was just a nightmare! !! Dr’s need to be more educated more on suboxone/buprenorphine and way more compassionate!! Too many r in it for $! Used to be Dr’s actually cared!! I know not all are careless but majority rules on this 1 in my opinion! I honestly don’t know what I would do if I was seriously injured and it scares the hell outta me! 🙁
Jeffrey Junig MD PhD · March 25, 2017 at 7:38 am
I agree about the lack of knowledge, and about the lack of empathy for people on buprenorphine. I recommend that people try to have a plan in case of injury; educate a close relative to be your advocate in those cases, or see if your primary care doctor is willing to understand the issue. There ARE solutions, if the doctor treating you makes the effort to use those solutions.
Charles Anthony Foutch · March 25, 2017 at 1:37 pm
I have found when a person on Suboxone or Methadone is in pain and needs relief both healthcare people think a drug seeking junkie. I was in intensive care in severe pain but people working there see so much pain they are immune to it and most don’t care. This among other reasons is why i don’t like most healthcare people.
April Wolfe · March 28, 2017 at 5:37 pm
Are you a actual doctor? Just wondering with all the knowledge you have on Suboxone. What is the best way to know if a doctor is educated in the subject properly?
Jeffrey Junig MD PhD · March 28, 2017 at 7:25 pm
Yes, I’m an actual doctor. I hear you, though– there is so much misinformation out there and it is hard to know who to believe. I try my best, on my forum (www.suboxforum.com) to point out when I’m writing something that is clearly supported by studies, and when I’m providing an opinion.
As for my own credentials, after college I went to grad school at the Center for Brain Research, University of Rochester in Rochester NY. I received my Masters and PhD in neuroscience, specializing in neurochemistry. I entered the Medical Scientist Training Program and attended medical school at the U. of Rochester School of Medicine and Dentistry. I did an internship in the internal medicine program at Strong Memorial Hospital, then went to Penn for residency in anesthesiology. After that I became Board Certified in Anesthesiology and worked as an anesthesiologist for about ten years, until developing an addiction to opioids that started with cough medicine and progressed, very rapidly, to fentanyl.
I went through residential treatment for over 3 months, and and was monitored by the Board for 6 years. I decided to leave anesthesiology to do a residency in psychiatry. I became Board Certified in Psychiatry a few years later and started working with opioid addiction in about 2006. Since then I’ve treated over 1500 patients addicted to opioids, first as medical director of residential treatment programs. After tiring of reading obituaries of patients I knew, I started working with buprenorphine, and most recently also with methadone. I’ve treated over 800 people with buprenorphine over the past 11-12 years.
I don’t know if there is any great way to know who to trust. I’ve sat through heroin summits, listening as ‘experts’ said very silly things– like ‘the only thing keeping them stuck is the withdrawal, and if they could detox, they could be free from heroin’… or ‘buprenorphine works just like heroin because it doesn’t have the blocker that is in Suboxone.’ Both are so, so wrong… and many of the ‘task forces’ in various states are enacting laws based on the same lack of knowledge.
Government agencies keep track of the drugs that cause overdose; that information is reported and can be looked up. I’ve said this so many times– but over 30,000 people die from overdose each year in the US, and only about 40 of those people each year, on average, have any buprenorphine in the bloodstream. That number alone tells you that buprenorphine prevents death very effectively. Yet many states are passing regulations that make it harder to prescribe Suboxone or buprenorphine, saying it is a ‘dangerous drug’. That one error is so large, and so easy to see, that it should serve as an obvious indicator that something is wrong out there.
Charles Anthony Foutch · March 28, 2017 at 9:07 pm
I live in Tennessee and only pregnant patients and hospitalized people can receive Buprenorphine. I was on it for a couple years and it really saved me money but thankfully now there is generic Suboxone. I went to the Veterans Hospital to try and get treatment but the doctor wanted me to jump through hoops and be off Suboxone within 1 year. So now 25% of my income goes to Suboxone treatment but I have not used illegal drugs (except trying pot twice for my Neuropathy) since 1993.
Jeffrey Junig MD PhD · March 29, 2017 at 7:19 am
In Wisconsin, buprenorphine is available and even covered by some insurers. But medicaid only covers it for pregnant women, and will not even allow people on medicaid to purchase it for cash.
In Tennessee, can someone pay out of pocket for buprenorphine if a doc prescribes it? Or is it actually banned for all but pregnant patients?
Charles Anthony Foutch · March 29, 2017 at 4:58 pm
No you can not get it unless you are pregnant or hospitalized.
Tiarra Rice · April 16, 2017 at 7:26 am
okay so if you have an injury or just experiencing bad pain somewhere and you have to go to the er, but let’s just say, the er doctor have admitted you. Okay at home you take 4mg/1or2mg suboxone, 2 times a day. But now that you are admitted in the hospital, what do you do about your suboxone and what do you do about the pain agonist the doctor got ordered every 3 to 4 hours, how would you do this without you going into withdrawal Doc? Another question, if you go to er,do you think its best to let that er doctor know that you are taking suboxone , thats how they would know you need larger dosage of meds for pain??
Jeffrey Junig MD PhD · April 16, 2017 at 9:36 am
Those should be easy questions, don’t you think?! How crazy that they aren’t– that instead, people have to figure out how to handle the situation, because of the fear of being treated poorly if they are honest!
When my patients have gone to the hospital, they usually are allowed to take buprenorphine each day per their normal routine. Hospitals don’t generally dispense buprenorphine, but they should– just as they dispense lipitor to patients admitted on THAT medication. Communication is the most important thing, so that there is some PLAN in place. Right now, communication is a big problem. Sometimes I won’t even know that a patient is in the hospital until after the patient is released, and calls to tell me! I would encourage anyone on buprenorphine to make sure there is communication in place between the doctor treating you in the hospital and the doctor prescribing buprenorphine.
As you probably know, when you tell the ER doc you are taking buprenorphine, that doc will likely say ‘then I can’t treat your pain.’ Understand, that comment is a lie. Your pain CAN be treated. Don’t expect all of your pain to go away, but doctors should make efforts to reduce your pain. The ‘gold standard’ would be to send you to a monitored bed, such as in the ICU, where you have a pulse oximeter and oxygen, and respiratory rate is monitored closely. If that was the practice, then you could get excellent pain relief. But since insurers won’t pay to make you that comfortable, hospitals won’t generally provide that type of service. So it comes down to a doctor deciding ‘how much pain can this person tolerate?’ or worse: ‘I won’t get in any trouble for NOT providing pain relief, so I won’t.’
All of these issues, I understand, make it tempting to just keep your buprenorphine use to yourself. But if you do that, you certainly won’t get the analgesia that you need, because the doc will use codeine or hydrocodone, that will do almost nothing for your pain. So you have to be honest– and cross your fingers that you found one of the rare docs out there who does the little bit of extra work necessary to reduce your pain.
Jeffrey Junig MD PhD · April 26, 2017 at 4:06 pm
I’m not sure if I answered this question. If I didn’t, stop by the forum, or search for the answer on http://www.suboxsearch.com . There is tons of info about dealing with acute pain there.
Charles Anthony Foutch · March 3, 2017 at 4:46 pm
Now a days i use the Veterans hospital and when I have colonoscopy or when they went through the artery in my arm with dye to check my heart i just skipped the opiates. I was told I need to skip 3 days of my Subs and I knew i would be miserable the 3rd day so I did the heart thing i skipped the opiates. It hurt a lot and my BP went up. For the colonoscopy when i told doctor i was on suboxone he said i need to get off it and go to 12 step or faith. I told him i was an atheist and tried 12 step 13 years and it did not work for me. Then I told him I was not their for addiction treatment. I was in withdrawals and did not feel like listening to him. He said he would only give me Versed because the Fentny would not work. It was hell and I will never have this done again.
Samuel · March 5, 2017 at 9:49 am
I’m currently taking Suboxone 4mgs per day in an orange chewable pill version. I have four Butrans 10mg patches that really helped me a lot while wringing off methadone to get to Suboxone, which is my clinics protocol to get off methadone. I walked away from that at 6mgs and feel stupid for not using the patches to walk vs their protocol. My question is, can I use these as a crutch to wein off these Subs as well seeing that it’s the same drug without the blocker? Seems like it would be fine but I’m getting conflicting information and really just need a good answer. Not a follow your doctors recommendation because I’m not going there, I apologize I just can’t in my current situation without putting myself in jeopardy. Any and all advice would be very greatly appreciated! Thank you!
Jeffrey Junig MD PhD · March 5, 2017 at 12:45 pm
Consider coming to suboxforum.com with the question. But briefly: the ‘blocker’ is not relevant to this discussion at all. Naloxone ONLY deters injecting– nothing else. Frankly it doesn’t even deter injecting very well, as naloxone is metabolized within 20 minutes and gone. Naloxone does NOTHING to buprenorphine that is not injected.
The Butrans patches deliver buprenorphine, the same molecule as delivered by your ‘generic Suboxone’ tablets. But the dose of the patches is MUCH lower. The patches are dosed in micrograms, which is thousand times lower than a milligram. Patches are also dosed ‘per hour’, whereas buprenorphine tabs are a dose given at one moment in time.
The largest Butrans patch provides just less than 0.5 mg of buprenorphine per day– less than half of a milligram. I’ll allow you to make all of the other conversions– but you also want to take into account that the Butrans patch tells the amount of buprenorphine that enters the body, whereas the tab tells the amount put in the mouth. Of the dose placed under the tongue, only about 30% gets into the bloodstream. With that taken into account, 1.5 mg of sublingual Suboxone delivers ABOUT the same amount of buprenorphine into the bloodstream as the largest Butrans patch. The smallest Butrans patch releases, I believe, about 0.1 mg of buprenorphine– a very low dose– so the patches can be a helpful way to taper for some people.
Samuel · March 6, 2017 at 2:18 am
Thank you very much for the response. I truly appreciate the answers given and I will adjust my dosage accordingly. I just didn’t want to put a patch on and it worsen the way I currently feel. I have legitimate pain issues mainly in my back from Scoliosis w/Twisted Spine and my sternum was cracked, so pain there as well. My left knee is shot to pieces also! I was extremely tired of the Methadone and going down 5mg’s every two weeks like clockwork was not easy, but I did it with assistance of these patches. I was told the Patch would essentially be blocked by the I guess generic Suboxone they give me. I went from 6mg’s a day to 4mg’s a few weeks ago and I just can’t sleep well and feel bad all the time. I imagined that it would be an easy taper and an easier way off Methadone than cold turkey, and it was. I mean I didn’t get sick sick the days I wasn’t supposed to use anything because of the Butrans. I’ve been up science 1:30am tossing and turning so I’m going to slap one on and pray that it helps. Again, thank you very very much!
Brian Reid · April 8, 2017 at 6:27 am
You need to speak with your doctor but the same are supposed to be dissolved under your tounge. Not chewed. I don’t belive you are getting the full benefits of the drug.
JEFF · March 7, 2017 at 11:38 am
Dr. Jeffery — we share the same first name. Hey, just writing to tell you thank you so much for this information. I am NOT one to give complements often and seldom do, But> you appear to be very educated regarding Buprenorphine. I would say I am as well as I have been studying this for years being on Methadone for chronic pain and now am making the transaction and have been documenting my experience. I believe I was inducted on too high of dose (16mg). I was inducted six days ago (March 1st, 2017). I am also very concerned about if I were to have an emergency surgery and I want off of this stuff – although I did notice very significant pain relief from this at 10 – 12mg. I took 6mg yesterday and was fine. Have taken 4mg so far today. Anyway: Thank You Very Much for sharing your Knowledge as I did learn something knew today regarding buprenorphine about you can overcome the receptor affinities with higher doses of morphine – I was informed this would not work, so thank you – will take your word since you have practiced it.
Jeffrey Junig MD PhD · March 7, 2017 at 9:05 pm
Hey, thanks Jeff! One thing– I do not recommend trying to out-compete buprenorphine with morphine. Not sure if I mis-typed that somewhere or if you misread it- but morphine is about the worst drug for this situation for two reasons… it is not very potent, and it releases histamine from mast cells. if you give enough morphine to out-compete buprenorphine you will likey cause a great deal of ‘itching’ and a drop in blood pressure from the histamine.
I prefer oxycodone in outpatients, and in monitored inpatients, fentanyl (by PCA, or patient controlled analgesia). Those drugs will out-compete buprenorphine in high-enough doses; the challenge is getting the physician to focus on the patient’s respiratory rate, rather than on the dose. We all were taught, somewhere along the line, to treat the patient instead of the numbers… but in practice that doesn’t happen.
Feel free to send me a note if you do need surgery; I’m always happy to share my two cent’s worth!
Burton Pitts · March 8, 2017 at 10:27 am
I take 32mg of buprenorphine daily been on it for 2 years it has saved my life I just broke my heel I dont tell the doctors of the bupe because they dont care you are right its my addiction but they prescribed me over 3200 pills yearly can I take oxy and bupe together
Jeffrey Junig MD PhD · March 8, 2017 at 12:03 pm
A person on buprenorphine or Suboxone can take opioid agonists, including oxycodone. Doing so will not cause withdrawal– but the oxycodone will have only a minimal effect, if anything. That is one of the beneficial aspects of buprenorphine; you would not be able to get ‘high’, even if you wanted to. But that causes problems after surgery.
The usual approach for emergencies is to reduce the dose of buprenorphine, and then ‘out-compete’ the buprenorphine with oxycodone, using a dose that is higher than usual.
An item of frequent confusion– a person on oxycodone will have withdrawal symptoms if he starts buprenorphine. But if you are on buprenorphine FIRST, then oxycodone won’t cause withdrawal, and you can continue taking buprenorphine without having withdrawal as long as you never go for more than a day or two without buprenorphine.
Feel free to stop by suboxforum.com– people will have advice there as well.
Burton Pitts · March 8, 2017 at 12:13 pm
Thank you for the information its not easy to get a honest and good no bs answer on buprenorphine there needs to be more education on this medicine which has saved my life thanks again to bad your not in my area
Crystal Brooks · March 13, 2017 at 3:42 pm
Thank you for all your information I had a lot of questions about how Suboxone and pain medication works if you absolutely have to have it. You’ve been a huge help.
Jeffrey Junig MD PhD · March 13, 2017 at 4:38 pm
No problem. Feel free to go to http://www.suboxforum.com and send me a message if you have questions; I’ll do my best to answer them!
Miranda · April 26, 2017 at 5:48 pm
I have a question about different dosages of the naloxone.I was on subutex while I was pregnant it worked great! 6 months After I had my son I was switched back to suboxone. The suboxone makes me very nauseous. I am assuming its the naloxone.I have to take nausea medication to be able to take suboxone.my doctor absolutely will not put me back on subutex even though I have never failed a pee test or taken any pain medication in 7 years.is there a suboxone that has a lower dose of naloxone I am currently taking 8mg/4mg I hate feeling sick and having to take more medications.
Andrea W · March 10, 2017 at 9:49 am
I am supposed to go in for a cholecystectomy on Monday the 13th. I have been taking 2- 5.7mg zubsolv every morning for the past few months. When I started having gallbladder pain I reduced my dose to only 1 half of a 5.7, and that has been for a little over 3 weeks. I did this because of my fear of ending up in the ER with them unable to do anything for me. I met with the surgeon on the 2nd and told him that I was on buprenorphine. His response was that he is not going to write me any prescriptions for pain meds. I explained all of this to my suboxone clinic drs and counselors. They came up with a plan and reassured me that my post-op pain will be controlled and that they will talk to me about it at my next visit. When I went in on Wednesday, they told me that they will be giving me the highest dose of Norco possible. I know that is 10 mgs. They also told me to continue with the bupe until 24hs prior to surgery. At this point, I am scared to death of even going in for the procedure. I am a single mother of 3 and I need to be able to take care of my kids. Hopefully the pain isn’t bad, but if it is, I know that 10mgs of hydrocodone is not going to touch it. My question is, how do I get my drs to realize that this will not be enough without looking like a drug seeker? I really don’t want to have to resort to buying oxys off of the street and reconnecting all of those connections that I have severed. But at this point, I feel like that is what is going to have to happen. I just wish there were a way to get them to understand that 10mg hydros is not a higher than usual dose. I feel like they are setting me up for failure.
Any insight would be greatly appreciated,
-Andrea
Jeffrey Junig MD PhD · March 10, 2017 at 9:53 pm
You are correct– norco (hydrocodone) will not be enough to provide analgesia. I don’t know how to get doctors to listen, but feel free to use the form that I provide to my patients, to give to their surgeons- you can find it here: http://suboxonetalkzone.com/surgery.pdf
There are two problems. First, you have a high opioid tolerance, and second, buprenorphine blocks opioids. Just stopping buprenorphine doesn’t fix the problem because it takes a week or two to get it out of your system, and then you STILL have a high tolerance. So I keep people on half their dose of buprenorphine (half your dose of Zubsolv) and treat pain with a high dose of oxycodone. It generally takes about 3 times more oxycodone to treat pain in a patient on buprenorphine than in a regular patient. Hydrocodone is just not potent enough to out-compete buprenorphine.
The NIH put out a consensus statement about the situation a few years ago; I don’t have a copy at home, but you can find it if you search the forum– try the search function and look for nih consensus statement, or search for ‘post-op analgesia on buprenorphine’. You will also find help at http://www.suboxforum.com. Good luck!
Andrea W. · March 11, 2017 at 10:13 am
Thank you. I actually found out at the end of the day yesterday that my prescription is going to be for 15- 5/325 Norco which is supposed to last me until Wednesday and then I am supposed to go back on zubsolv. I am beyond scared, but because I found out at the end of the day yesterday, it is too late to cancel surgery. The lack of compassion with my current situation has caused me to no longer trust the medical system. My hands are tied. I went onto suboxone from methadone to try to avoid the stigma related with OAT, but I am really regretting it now. I feel like I would be in a lot better of a place if I would have stayed on methadone. I have no choice but to go through with the procedure and just not have any pain relief.
Jeffrey Junig MD PhD · March 11, 2017 at 12:54 pm
It is a tough call. I work in methadone treatment too, and I see the same things– surgeons who says ‘The methadone will cover your pain so I won’t give you anything.’ The stigma is a huge problem.
If they are using a laparascope, you will get some relief from 800 mg of ibuprofen every 8 hours. If the pain is severe, go to the ER; go with a friend and refuse to leave until your pain is addressed. If you have pain that is not addressed you should contact the medical board in your state and file a complaint. That is the one thing that gets a doctor’s attention– and hopefully someone on the board will understand the issue.
Andrea W. · March 11, 2017 at 1:50 pm
I will do that. It is not fair that because I was honest, I will just have to suffer. Every other person who goes through this procedure is entitled to pain relief. I should be as well. Thanks for all of your help. I really do appreciate it.
Charles Anthony Foutch · March 10, 2017 at 10:21 pm
I sometimes use the term Subs because I am a lazy typist. lol
Greg · March 18, 2017 at 2:19 pm
Dr Jeff,
I am a chronic pain patient that had an intrathecal pain pump explanted due to an infection. Yesterday I suffered through a Colonoscopy wide awake as the fentanyl did nothing. I tried explaining to the fellow (Dr) performing this procedure he told me that they gave me as much fentanyl allowed without an anesthesiologist in the room. Here is my dilemma/query I was put on 16 mg of buprenorphin until another pump can be placed. Now the question I am having rotator cuff surgery on March 20 and the Dr. Prescribed 10 mg Percocet for post op pain. He gave me the prescription on March 13 and I still have not filled it. What do I tell the surgeon and anesthesiologist about my concern that this will in now way keep me comfortable? My nurse case manager is going to call me at 8:30 the day of surgery and I am going to have her explain my case to those that listen. BTW my pump setting was .537 mg and after explantation 30 mg MSContin bid with 20 mg roxicet for breakthrough pain. After discharge they gave me 45 days of medication then the pain medicine doctor from A World Class Hospital dramatically titrated me down by 90% I knew I didn’t need the roxicet anymore but cutting me so quickly put me in physical withdrawal.
Jeffrey Junig MD PhD · March 18, 2017 at 5:56 pm
I’m a little confused why they started buprenorphine, knowing you have rotator cuff surgery coming up. But 10 mg of oxycodone is not enough opioid to compete against 16 mg of buprenorphine. Not for post-op pain, anyway. I usually have patients decrease their dose of buprenorphine to 8 mg per day, and then I use about 15 mg of oxycodone every 3-4 hours for most surgeries. But for shoulder surgery patients usually need more narcotic, and they need it longer than patiensts having other surgeries. I often end up using 30 mg of oxycodone every 3-4 hours, and patient usually need significant opioid analgesia for several weeks during physical therapy. There are more risks related to inadequate analgesia after shoulder surgery than after other operations; patients can end up with adhesions and ‘frozen shoulders’ if they can’t participate in PT because of pain.
The analgesia issue is frustrating when viewed from a scientific perspective, rather than from a perspective of fear and stigma. Opioid agonists are cheap, safe, and effective. The actions of mu agonists at the mu receptor come down to simple competition. Doctors fear that if they provide a high dose of opioid, they will be blamed for overdose… but the only way overdose can occur is if the patient stops the buprenorphine and then takes a very large amount of narcotic. If patients take the medications properly, analgesia can be provided very easily and safely.
Doctors also fear that they will be criticised for prescribing too liberally if they use the necessary amount of opioids. Patients end up in significant pain after surgery…. when it would be SO easy to eliminate that pain.
A hospital being ‘world class’ doesn’t protect patients from pain, because the present ‘standard of care’ is to UNDERTREAT pain!! Is that messed up or what? Patients probably get better pain control in small community hospitals, where doctors are more likely to give in to pressure from suffering patients. In the ‘elite’ programs, doctors are more-likely to feel the support of their peers, and less likely to succumb to the pleas of their patients. If someone disagrees, feel free to share you thoughts!
Charles Anthony Foutch · March 18, 2017 at 6:40 pm
In most cases doctors no longer control pain management the DEA does. I had a colonoscopy and when the doctor found out I was on Suboxone (that i had stopped for 3 days) he refused to give me any fentanyl. It was barbaric. Doctor are there any new pain drugs on the horizon that are not opiate based?
Roni · July 21, 2017 at 8:43 am
I understand the frustration with not getting enough pain relief. I have had a neck fusion in 2000 and my trust in hospitals changed when I had back surgery in 2003. The nurses took the catheter out before my organs were awake and sat me on a bed pan. When my sister yelled at them saying that I wasn’t supposed to sit upright, they told me that they were unaware that I had back surgery.
Isn’t it procedure to read the patient’s chart? Then I asked them to put the catheter back in and they refused at first. I had to beg before they finally did and I filled the bag. The clenched was the change in pain medication two days later. I was doing really well after getting the nurses on board but the assistant Surgeon chandelier my meds from Demoral to Delautid. I threw up profusely and then felt like I was falling into a dark hole and couldn’t speak. It followed with wild jerking in my legs and arms and my chest felt like someone had clawed my chest. It was on fire and no one could touch me. I can’t say for sure which episode caused what, but I ended up with chronic pain, permanent numbness in my right leg, severe depression and high anxiety. One day in the hospital changed me from an active woman with a wonderful corporate job who played the keyboard at every church service and was physically active to a disabled person who suffers from Chronic pain. I have taken several pain meds over the years.The main one was Methadone. I was also taking Lorazepam until my doctor stopped me cold turkey while visiting my mother in another state. By the time I got home I was going through withdrawals so I admitted myself into a facility. They put me on Subutex,as they called it, but when I left they referred me to a Suboxone physician. I have reduced myself from 8mg /2mg 4x daily to 1mg 2x daily or less. I just can’t get myself any lower and I can’t tolerate the pain at any lower dosage. I also have Fibro myalgia and degenerative joint disease and really need to find some brand of pain relief to take over where the Suboxone ends. Is there any help for me? Doctors also consider me an addict but they were the ones that prescribed all these meds without any explanation as to what it was going to do to me. How dare they judge! Is the any pain medication the is effective enough to dull the level of pain I am in every day?
Jeffrey Junig MD PhD · July 24, 2017 at 7:48 pm
It sounds like you’ve done all the right things, and yes– doctors should have a better understanding of their patients when treating them for ANY condition. Unfortunately, though, the state of the science is that pain relief is limited by tolerance at this point. Some degree of pain relief can be obtained from ‘NSAIDS’– drugs like ibuprofen – but that degree of analgesia is not strong enough for the pain you’re experiencing, or the pain from surgery. THAT type of pain requires opioid analgesia, and at this point there is no way to get that pain relief without triggering tolerance. Tolerance, in turn, limits the length of time that you’ll get that pain relief.
Some day, I’m certain there will be other options. But for now this is where we are, and what we have… i.e. either partial pain relief for long-term, or better pain relief for a short period of time.
MelissaS · March 19, 2017 at 8:51 am
I have a procedure coming up on Wed March 22. I am currently on a taper of suboxone and am currently at .25 mg/day for the last 6 days. Am already feeling a bit of withdrawal. I do not meet with the surgeon until the morning of my procedure. I have had this procedure before and it can be quite painful. What is a possible medication they can give me that won’t make the WD worse? What can they give me that will actually help with pain. I told the nurse who scheduled this procedure that I am on Suboxone. I know I will have a local freezing of the site but honestly that’s not enough. What is done in a situation like mine? I don’t want any medication to go home with I will just use naproxen for that, just something during the procedure.
Jeffrey Junig MD PhD · March 19, 2017 at 2:37 pm
That dose– 0.25 mg of Suboxone — is extremely small. People typically absorb less than a third of a dose, so you are getting less than 0.1 mg per day– which would be like taking a vicodin tablet once or twice per day. Understand that past withdrawal experiences are remembered and ‘played back’, making the experience feel even worse… so as you finish your taper you’ll do much better by staying busy and distracted. You’re almost done!
At your dose of buprenorphine, you will respond to pain medication in a normal fashion for the most part. Understand that NO narcotic pain medication will cause you to have MORE withdrawal; that only occurs when a person is on pain pills and then takes buprenorphine, not the other way around.
When local anesthetic is used, opioids typically are not used. The local is given to block pain fibers, and a sedative, like midazolam, is given to reduce anxiety and perhaps reduce the memory of the experience. Yes, some docs or dentists will give a bit of opioid, but I think it is given as much to provide a ‘feeling of well being’ as it is to reduce pain. Again, many docs wouldn’t give it if they can get a good block, because opioids greatly increase side effects, such as the incidence of urinary retention (causing hospital stays), nausea and vomiting, and prolonged sedation.
Good luck!
A better life · March 23, 2017 at 4:42 pm
Dr. Jeff,
I have been taking suboxone 2mg/0.5 twice daily since 2010 and it has absolutely saved my life after a 10 year battle with substance abuse. On Monday I was in a car accident and fractured my patella. I had surgery on Wednesday and I was very honest about my medications. After reading some of the previous comments I’m certain the orthopedic and anthesixologist have very little understanding of Suboxone. I was given Morphine in the ER, and Percocet 7.5mg when I left the ER and after surgery. The Percocets have not seemed to have much affect and I am feeling like I’m going through suboxone withdrawal. Can I take the Suboxone and the Percocets. Thank you!
Jeffrey Junig MD PhD · March 23, 2017 at 8:29 pm
As long as you stay on buprenorphine every day, you will be fine adding oxycodone (Percocet). I usually keep patients on 8 mg of buprenorphine per day and add oxycodone; your dose of buprenorphine is lower, so I would expect a better response to oxycodone (because you have less blocking from buprenorphine). You shouldn’t get precipitated withdrawal (PW); PW is caused by agonists like oxycodone pulling your tolerance higher and then buprenorphine suddenly pulling tolerance down, causing withdrawal symptoms. If you were to go off buprenorphine for a few days, there WOULD be risk of PW, because there would no longer be buprenorphine around to hold your tolerance down. So if you go off buprenorphine for more than a day or two, you may want to ‘reinduce’– i.e. stop ALL opioids for 24 hours, and THEN restart buprenorphine, followed by oxycodone.
Morphine is not a good choice for post-op pain in buprenorphine patients. It is not very potent, and if you give enough morphine to compete with buprenorphine you will get many other side effects, including histamine release, flushing, abdominal cramping and diarrhea, and itching.
I would typically treat someone in your situation by having them stay on buprenorphine, 2 mg per day, and adding oxycodone about 15 mg every 4 hours. Don’t take that without clearing it with your doctors, but that would be enough oxycodone to cut through the buprenorphine and reduce your pain.
Good luck!
kenneth self · May 28, 2017 at 11:14 am
I’m 61 years old. I road bulls for 7 yrs when I was young and indestructible.needless to say that didn’t work out. I have a lot of pain and I’m on 12mg suboxone a day and it’s just not working I was on hydrocodone for years same problem Dr’s would only give me 4 10/325 a day. Even with all my MRIs, xrays and scars. How do I find a Dr to help I live in small town in Texas. Every day the pain gets worse. I would rather have and addiction than the pain.every Dr thinks I’m only wanting pills and he is right if they will help. I’m thinking about going online pharmacy and trying oxycodone can I do that. I live in a very small town in Texas and on disability. We have two Dr’s.
Jeffrey Junig MD PhD · May 28, 2017 at 5:29 pm
I wish I had a better response. Unfortunately, pain relief from any opioid will eventually fade away from tolerance. The only way to get pain relief over time would be to keep raising the dose. That’s not an issue for cancer patients, where life expectancy is limited to a year or less. But if you are going to live another 5 or more years, there is no way to provide opioid analgesia during that time. You might find a mail order site that will ship narcotics to you, illegally, from overseas. But you will have to find a way to take an ever-increasing amount of that medication. During that time you’ll be at constant risk of losing control of the medication, getting arrested, or having the supplier disappear, causing you to go into miserable withdrawal.
Some people with chronic pain choose to go on methadone through a methadone clinic. Those clinics are intended to treat addiction, not pain– but pain relief is often a ‘side effect’ of treatment. But I doubt you have access to that type of program given your description of your town.
Some people get by with a combination of buprenorphine, NSAIDS, tylenol, and physical therapy/exercise. I suspect you’ve already tried that approach…
The future holds promise for a couple new options… one would be a solution to the tolerance issue; the other is the development of drugs that act at the nociceptin receptor, which may provide opioid-level analgesia, without tolerance. I’m suspicious of those claims, though, as they sound too good to be entirely true.
I had a patient a few years back who said ‘I would rather live one year with good pain relief and then die, rather than live for 30 years like this.’ I responded ‘I know– but at this point, society will not let you make that decision. That’s why these medications must be prescribed by a doctor.’
The point was that even with the pain, trading 30 years away is not a good decision. I usually go all in for patient autonomy, but I worry that some of the people who would make that decision would make it without truly accepting the danger down the line. Addiction to high doses of opioids doesn’t always lead to an easy death; people addicted to high doses of opioid generally suffer years of desperation before their exit.
I wish I had better news. At this point, buprenorphine is about the best option we have.
tata0404 · June 7, 2017 at 3:06 pm
Hello I have a question that I’m hoping someone can answer rather quickly. I have been on suboxone for a couple years now never missed a dose never have done another pain medicine while on my suboxone, I just recently went to the emergency room for severe vomiting and some pain, they ended up giving me 0.5mg of dilaudid around 10:32pm from what my papers state which if i would have known they were giving it I would have said no and I would have figured they saw my meds list and knew i was on my suboxone. I’m terrified now to take my suboxone which its been almost 20 hours since them giving me the dilaudid, I don’t want to have severe withdraws from taking my suboxone now and since I still fell pretty crappy from puking a million times in a matter of hours I’m not sure if I just still feel yucky from that or im I’m having wd symptoms. Please someone help I don’t feel horrible horrible but would like to know when I can start back on my daily suboxone, but also don’t want to get to the point of severe wd’s due to me not knowing since I haven’t went through wd’s in years. I really hope someone can answer this question soon. Thank you
Jeffrey Junig MD PhD · June 14, 2017 at 8:53 pm
If you stay on daily suboxone, there is no problem taking an agonist like Dilaudid and then taking Suboxone the next day. If you STOP suboxone for a few days, though, then you will need to re-induce after taking an agonist. Avoid agonists for 24 hours and you’ll be fine taking Suboxone at that point.
James Buttery · June 15, 2017 at 6:23 pm
You have to be very careful here…if a person if on a full agonist for say 4-7 days or so and their body becomes accustom to that full agonist you do not want to be telling them they are fine to go right back on suboxone…that could send them into Precip withdrawl. Really what this comes down to is, how long are you going to be taking the full agonist for..?
Jeffrey Junig MD PhD · June 17, 2017 at 7:59 am
I appreciate your commments. What I’ve found many times over is that if a person STAYS on a dose of buprenorphine every day, there is no risk of precipitated withdrawal from agonists, no matter how long the agonist is used. I’ve had many patients on the combination for prolonged times, usually after shoulder surgery or knee replacement when prolonged physical therapy is necessary, and the surgeon supports the use of agonists for a month or more. In those cases I have patients take 4 or 8 mg of buprenorphine once per day, and use 10-15 mg of oxycodone for analgesia. The combination works great; they get pain relief but they don’t ‘feel’ the opioid, they usually have no problem controlling the use of the agonist (these are generally patients who have been stable on buprenorphine), and their apparent tolerance doesn’t increase. I’ve used this approach dozens of times over the past 10 years, and I’ve never seen a case or precipitated withdrawal. From a receptor standpoint, there never SHOULD be precipitated withdrawal, because the constant presence of a high-affinity partial agonist prevents the downregulation that makes PW possible.
There is probably a better way of explaining my thoughts, but this will have to do on a Saturday morning….
James Buttery · June 17, 2017 at 4:23 pm
I appreciate your reply and would agree with you. Thank you for educating me more on this subject. I just have strong feelings about the PWD subject because I have been through it before…worst night of my life LOL. If you ever have a patient going through it I would recommend 2 mg IV ativan and 0.4 mg clonodine. It sedated me well and got me through the situation. Thank you again.
Jeffrey Junig MD PhD · June 18, 2017 at 3:31 pm
I don’t blame you for those feelings! I haven’t gone through that exactly, but years ago I thought I could cure my own addiction by starting myself on naltrexone, an oral form of naloxone. I was very sick that night!
Thanks for commenting James!
James Buttery · June 15, 2017 at 6:25 pm
I take back my comment..I didnt read the full comment of the first user about 1 times fentanyl dose…carry on.
Jered · June 27, 2017 at 9:57 pm
I’m currently on 6 mg subutex and I need to see the dentist. I have anxiety pretty bad. Is there anything I can take to calm me down before hand, while on subutex?
Jeffrey Junig MD PhD · July 1, 2017 at 10:25 pm
You are taking a generic form of buprenorphine. It will NOT interact with the local anesthestic that the dentist will give you. Some dentists will provide sedation for their patients, such as a benzo like xanax or lorazepam. They are very safe medications when taken as directed, by a person who is tolerant to his dose of buprenorphine.
Jered · July 2, 2017 at 9:08 am
I greatly appreciate you responding to my post and for the information!
Jeffrey Junig MD PhD · July 2, 2017 at 2:46 pm
No problem– good luck!
Mark Vassar · July 8, 2017 at 10:59 am
Getting off opiates using Suboxone how to treat my chronic back pain. I’m Scared after 10 years of masking it with pain medications. Pain in sciatica… lower back pain L4 L5 not sure where I go from here but what could I take other than suboxone to treat my pain because I don’t want to lose my job or better yet my mind. Thank you in advance Dr.Junig
Jeffrey Junig MD PhD · July 9, 2017 at 7:18 pm
At this point there isn’t any way to obtain opioid-level pain relief, without using opioids. And opioids, at this point, always come with the bad things– tolerance, dependence, and eventual misery. But I’ve had many patients over the years who found relief from pain just from getting off opioid agonists and staying on buprenorphine or Suboxone. I’m not sure why they did so much better; maybe from getting away fron the cycle of opioid use/withdrawal, or maybe, in part, from the effects of buprenorphine. So don’t give up hope yet… you may find that things are better once you’re fully used to the Suboxone. And of course all of the other things are very important, like weight loss if you’re overweight, increasing flexibility, etc. Opioids are incredible tools for the short term– but not yet useful for long term pain.
Katie · July 12, 2017 at 4:48 am
Hi Dr Junig, im currently on 16mg of suboxone once a day. I am having major bowel surgery in august 2017 where they are going to cut out some of my small intestine and fix some of the strictures. I have told all my surgeons and everyone else involved that i am on suboxone and they have told me they will work around it. I am just very concerened at how they will manage my pain after surgery, my sister had a similar op because she has chrones and she was out of it on pain relief for 3 days after her surgery. I am worried that because im on suboxone they wont give me adequate pain relief, i will be in hospital for 5-7 days following my surgery so i will have the medical assistance i need but how can i be sure they know what pain relief i will need and how do they work out pain relief for someone on suboxone? I really am worried and second guessing havinh my surgery until im of suboxone however i am in constant pain and really do not want to put my surgery off any longer – many thanks in advance – Katie
Jeffrey Junig MD PhD · July 18, 2017 at 6:28 am
The problem can be dealt with if the doctors involved do their jobs. Just like bowel surgery is more complicated in a person with strictures; pain treatment post-op is more complicated on buprenorphine– and it is time for doctors to start treating the WHOLE patient. I’ll say to anyone reading this– if your pain is not addressed appropriately, make sure to take action afterward to protect the next person. Complain to the hospital, or to newspapers if necessary. It is ridiculous that in 2017, 14 years since buprenorphine hit the US market, that some docs still don’t know how to treat patients on the medication!
That’s off my chest… they have a number of options to help you. One would be to place an epidural, and use a low dose of local anesthetic post-op to reduce pain. The main problem with that, though, would be it may interfere with getting you walking after a day or two. Also I would worry that the epidural would make them less responsive to your complaints of pain, and allow them to think that you ‘shouldn’t have pain’. Telling a patient they ‘shouldn’t hurt’ is not a treatment plan.
The best approach with pain medication is to ignore the dose of medication and treat to the desired effect. If you are like most people on buprenorphine, you will get pain relief with less sedation than normal, but it will take a much higher dose of narcotic to get there. The best approach is IV PCA (where the patient has partial control), using a continuous infusion of fentanyl with extra doses as needed. They could put you in a monitored bed, e.g. the ICU, and use respiratory rate to determine your need for medication.
They could use alternative potent opioids; Dilaudid is a good option. Morphine is not as effective or appropriate because you will need high doses, and IV or IM morphine releases histamine when injected, which would cause you to itch and break out in hives.
The biggest mistake made post-op is to try one narcotic, push the dose to some point, then get nervous and change to a different opioid. In that way, the patient never gets to a sufficient blood level of pain medication to compete with buprenorphine. Instead, the medication should be chosen, and then used in high-enough dosage to provide pain relief. That dose will be 3-4 times higher than for patients who are not on buprenorphine. The same receptors mediate respiratory depression and pain relief, so they can provide safe analgesia by monitoring respiration, especially when you are sleeping– when rate of breathing is a very reliable tool.
I’m not a fan of adding ketamine, a drug with effects at non-mu opioid receptors. Some people benefit, but it also increases nausea, agitation, nightmares, and other CNS effects.
Good luck– I hope they take good care of you.
Stephanie Emiliano · July 18, 2017 at 7:02 am
Thank you so so much. I completely agree with you about doctors not understanding about buprenorphine. I think every single doctor should be trained in regards to this. When I finished rehab 6 years ago, I was told to see my doctor and he can prescribe buprenorphine. When I saw him, he was completely clueless to what it was, so I educated him. His response was “well I can’t prescribe that to you, but I can give you a script for Vicodin until you find a doctor”. If I knew I wouldn’t get into trouble for slapping him, I would of. I started crying, and called him incompetent. Then stormed out of his office. I was beyond furious. He could of cared less about me. Another time I went to the ER with back pain. I told them I was on Subutex. Immediately I was being mistreated. I told them I was sure it was a kidney stone because I suffer with them. They treated me as an addict. Did a scan, and sure enough I had three stones. They said since I am an addict, they couldn’t give me pain medication. At this point I felt like fainting from the pain. My husband was livid, and told the doctor and nurse “my wife worked her butt off to get off pain meds. But she nor anyone else should have to suffer either. What you are doing to her is pretty much torturing her.” They didn’t care at all. So he called my Nephrologist and, he came up to the hospital. Had me admitted until I passed the stones. For the first 24 hours, it was hell. Dilaudid didn’t do much but make me sleepy. Slowly it started to work, and I went home after I passed them. I filed a complaint against that hospital, and agreed that I would contact my doctor first before going to ER. I once was given Ketamine. It was horrific. I had non-stop panic attack for hours. Sorry for the long story. I did have one more thing to add. I think that they need to create a medication that can kick buprenorphine out of your system in case of an emergency,where the patient will require pain medication. I’m having the feeling that will never happen. 🙁
Jeffrey Junig MD PhD · July 18, 2017 at 5:13 pm
Probably not… it is very hard to remove something once it is in the body. We’re left with trying to ‘out-compete’ whatever was put in last.
Thanks for sharing your story; those things happen often I know, and the only way to change things is to try to point them out!
James Buttery · July 18, 2017 at 5:37 pm
I always worried about emergency situations and needing pain medications too while on Suboxone Stephanie. That would be nice if there were a medication to remove buprenorphine from the receptors, my fear would be that, that would send the patient into Precipitated Withdrawal similar to how being dependent on a opioid and taking Suboxone too soon.
Steph E · July 16, 2017 at 7:03 pm
I’ve been reading your articles for several years. I figured if anyone could answer my question, it would be you. I am currently on 8mg/2mg Subutex 3x daily. I feel that is high, but I trust my doctor. I was addicted to Norco following a major surgery. Anyways, I talked to my doctor about having a procedure done and that I will need to take pain medication for about a week or so. He tells me to stop taking Subutex about 48 hours before the surgery, and that I will have no problem with the pain meds working. I think that with the large dose, 48 hours is nowhere near enough time. What do you think? I appreciate your time. -Steph
Jeffrey Junig MD PhD · July 18, 2017 at 6:55 am
Ugh… I hate these types of questions because you’re exactly right! Even on 8 mg, 48 hours is not nearly long enough to sufficiently remove the blocking effects of buprenorphine. In my experience, you will need much larger amounts of narcotic than a ‘normal’ patient. I don’t have a way, though, to change your doc’s mind on the issue. Maybe really stress your fears, and ask the doc to have a ‘what if’ plan in place, if the pain is not covered by regular pain pill dosages.
Stephanie Emiliano · July 18, 2017 at 7:07 am
I agree. Thank you for taking the time to read and respond. I really appreciate it.
Steph E · July 24, 2017 at 5:15 pm
I have another question for the expert. So my doctor told me to drop from 32mg to8mg for a few days. Then 8mg to 4mg for a few days. Wait 24-48 hours and start taking the Norco a few days before surgery. Why? Is the Norco supposed to help with the withdrawal from the Subutex? I should of asked him, but I was in a hurry. I figured instead of waiting several days to hear back from him, I have a better chance with you ?.
Jeffrey Junig MD PhD · July 24, 2017 at 7:14 pm
Gosh, I’m not sure what his thoughts were. My issue with his suggestions are that first, buprenorphine leaves the body slowly, so you don’t gain much from decreasing each day in that way. If you need to stop it just stop it, and it will leave over a week or two. Yes, I assume the doc is suggesting you take the norco for withdrawal symptoms… but that isn’t usually done, because it isn’t considered ‘legal’ or treat withdrawal symptoms with opioids. So you may do better asking that doc about the plan. Good luck!
Farmer Ted · July 28, 2017 at 3:44 pm
Dr. Junig,
First thank you for your advice. I have a question I had a TBI traumatic brain injury that left me with chronic pain I take Dilaudid and duragesic patches 25 micrograms and the Dilaudid is 4 milligrams of the four times a day when my pain gets too bad I have to go to the emergency room to receive an injection. I’m afraid that I might be coming addicted to the narcotic Dilaudid and the duragesic so I have started taking when I’m not in excruciating pain I have withdrawals so I have to take the pain pills in order to be sick but instead I’ve been taking one to two milligrams of Suboxone instead. Is this a bad thing to do also if I had to go to the emergency room for an injection will be Suboxone I’ve been taking counter effect or stop the medication for the pain from working. Thank you for your help and reply in advance. sincerely,
Farmer Ted
Jeffrey Junig MD PhD · July 30, 2017 at 7:59 pm
Yes– the buprenorphine will stay in your system for at least a few days, and during that time it will prevent other pain meds like Dilaudid or duragesis from working. BUT– many people find that because of tolerance, they weren’t getting all that much pain relief anyway from agonists. Some people find that they feel better on buprenorphine meds, because they no longer have to experience withdrawal. You may want to consider seeing if your doc, or a different one, will treat your pain with buprenorphine instead of Dilaudid or duragesic. Be careful though– because once you give up those prescriptions it will probably be hard to get them prescribed again, especially in the current climate with opioids.
Allison · August 19, 2017 at 2:26 pm
I’m a 23 yr old female with agonizing jaw, teeth, and ear pain. I’m prescribe subutex at 16mg a day. The pain is debilitating and nothing is helping. I’m not sleeping, not eating, and no one is able to figure the cause completely out other than it being possible nerve damage and I’m waiting for that Dr. Appointment to confirm that. I work in the operating rooms, which no one knows I take this medication, but I hear and see them mistreat and allow patients to be miserable due to their prescription. I’m terrified to be that patient. But currently I can’t get the pain to stop and would greatly appreciate any advice. This is ruining my life right now.
Jeffrey Junig MD PhD · August 20, 2017 at 7:29 pm
I can’t determine the cause of your pain, and you deserve a good work-up by a doctor who knows the anatomy of those parts of the body. It usually makes sense in medicine to find the common denominator for a group of symptoms. In your case, the 5th cranial nerve provides sensation for those areas, so I assume that’s the cause. Have you read about trigeminal neuralgia, also known as ‘tic douloureux’? Look it up and see if the symptoms fit– that is one cause of facial pain if it is only on one side. The treatment for that type of pain is not narcotic, but rather an anticonvulsant. Tegretol (carbemazepine) is often used.
I hear you about the mistreatment issues. Those attitudes have no place in medicine, and if you can make anonymous complaints, you should consider reporting them. I’ve worked in the operating room environment too, and I know how surgeons and anesthesiologists can talk when the patients are asleep– probably some of the most primitive areas of modern medicine in many ways.
John · September 1, 2017 at 9:16 am
You have no clue what you are talking about. After contacting both Suboxone and speaking to the Pharmacy rep I was advised that Subutex is called Buprenorphine (The Generic) and a person will not have withdrawal from Buprenorphine by it self… now you take Suboxone or Anything with the blocker in it Zubsolv is another example that is when you can experience withdrawal. In fact buprenorphine is given in Injection for pain management or 2mg or 8MG for both pain management and addiction medicine. It’s blogs like this that confuses people. If you want the real 411 just call the Pharmacy Lab your medicine is made in. Viewing uneducated people’s posts is not only wrong its criminal!
Jeffrey Junig MD PhD · October 4, 2017 at 1:44 pm
Sorry John, you’re simply wrong. I assume whoever you spoke to is not an idiot, which means you must have misunderstood that person.
Precipitated withdrawal is caused by buprenorphine, not by naloxone. Every doctor who has treated patients with buprenorphine knows that. I’ve treated over 1000 patients over the past 12 years, so I certainly know it– although it is written in every scientific article or ‘best practices’ article about buprenorphine, so it doesn’t take any experience to understand the situation. You have several bizarre ideas; buprenorphine is NEVER injected in a dose of 2 mg, ever. For the past 30 years, buprenorphine has been used for pain in the brand ‘Temgesic’, but typical injected doses max out at a couple hundred MICROGRAMS. There are two general uses for buprenorphine; for pain in doses of up to 500 micrograms per day (which is the largest Butrans patch), or for addiction in doses of 8-16 MG per day. Yes, people use 8 mg for pain, just because 8 mg of generic buprenorphine is cheaper than 500 micrograms of Butrans. But that 8 mg generic dose would NEVER by injected, for many reasons– firstly because grinding up a pill and injecting it is never a good idea.
I’m always amazed when someone is so, so wrong about something, yet insults the person who is trying to help people learn.
BTW- when you call a pharmaceutical company (I presume that’s what you mean by ‘pharmacy lab’) you get a salesperson. Those people have no science education; they are trained in sales, and then go to a week-long seminar by the company to try to learn how the drugs work. I’ve taught those people. I have a PhD in neurochemistry, went to med school, and did residencies in psychiatry and in anesthesiology– and worked in each field for 10 years or more. Don’t mean to boast, but the ‘criminal’ comment is silly.
troy d hudson · October 7, 2017 at 12:04 am
dont you bleave the BS/ lies ,i my self have seen what happens with my own eyes,futher more this will prove out to be a very bad drug very soon [just wate] also its being given as a addict drug not a pain releave drug ,becuse it dose non work for people with cronic pain ,90% on it are doing heron or other street drugs ,over seas ther give one opiote with it ,that seems to be working a little ,ps when you sighn paperwork as a drug addict you give up your 2nd amend wrights check in to it ,,LAST WORD BAD DRUG NOT COST EFFECTIVE ,now in oregon thanks to gov brown no traning now needed to give out ,will be giving out like free candy /crack ,, and can only sue for mishaps for max $1000 big scam ,and kids now using just check ERS, wake up please tell the TRUTH..
Jeffrey Junig MD PhD · March 19, 2018 at 7:22 pm
You have some interesting ideas….
troy · March 20, 2018 at 2:35 am
not only dose it not work for cronic pain its the new street drug for young people ,and wallstreet is using drug funds to gamble on stock market FACT they dont want you to know,futher more you have the wright to treat pain with opiates ,and in oregon gov little kate brown will give your first fix on suboxone for free after your hooked you will have to come up with over $1000 a mo for your fix,there are DRS fighting you will have to look across your state to find but you can do it,thy lie n say every one is a drug addict thats BS,ps the 60000 drug farce scenario is a big lie ,90% of the statistics dont have a RX for meds the are drug users ,most on HERION,AS THE SONG GOS YOU HAVE TO FIGHT/STAND UP FOR YOUR WRIGHTS BEFOR THERE ALL GONE ,im doing great got all my meds back its a herd fight but if you have the guts to stand up you can win the war on cronic ill senors/disabled/n metal ill.good luck
Jeffrey Junig MD PhD · March 20, 2018 at 4:25 pm
Thanks! Good luck to you too.
Kristin · August 31, 2017 at 2:06 pm
Hello. I have to have a major surgery in 5 days time and Take 12mg suboxone everyday. I WILL need to use the Norco pain meds prescribed for pain for a little while but have not yet been told how to go about doing this safely and im VERY VERY worried. How long do I need to stop taking my suboxone before then for the pain medication to work post op?? Im so very afraid.. Thank You..
Jeffrey Junig MD PhD · October 4, 2017 at 1:31 pm
Kristin, I discuss your question here: http://suboxonetalkzone.com/surgery.pdf
and also in posts after ‘missing the point of buprenorphine treatment’.
Niko · November 29, 2017 at 2:12 pm
Jeffrey on behalf of me and most others here I would like to thank you for your time, patience, information and advice. You really do help answer people’s questions and there are not many forums you can ask these sort of questions and get an honest and informative answer, especially from a DR! It’s usually just public people answering with no knowledge at all. So thank you very much! And please don’t leave and not inform people anymore just because of a few ignorant know it all ppl that heard it from their heroin addict junkie friends and dont know for a fact like you do, please just try and make them look a fool and ignore their stupid comment as they are probably high on heroin lol. So thank you very much doc really appreciate it. I was actyally on this thread because I’m on 12mg dose of suboxone and have torn a muscle in my shoulder and really need something for pain but if I go hospital they will not really give me anything other then like lyrica lol nah probably tramadol but that won’t do nothing! What can they give me that will help? Anything that’s not an opiate? This is Australia so they very strict and tight about giving pain meds and they will probably think I’m just making it up to get some free morphine which fkn sucks. Should I not tell them and just say hmm morphine is not working I need more n if they ask if I take anything I say no? That’s the only way without a fuck around n waiting years for the dr to come and interview me to see if I just wanna get a free high or if im in real pain ! Sucks here in Oz, does anyone else feel like that sometimes? That they think your not even in pain and just want hard opiates to get a free high? How can I prove I’m in real pain? Omg I’m getting so anxious about them judging me ?
troy d hudson · September 16, 2017 at 8:55 pm
troy in oregon every one i know on subxon over 50 gets no NO pain releafe ,and 2 have died,rest now mixing street drugs for pain futher more i was given 30 days of pain meds on 6/12/2017 called 42 clinics wont see me , only 6 so far none will manage my extreem pain care,and now we are all addicads /bad apples even if you jumped through all hoops for 20 years, ins/OHP OREGON HEALTH PLAN GOV BROWN CAMREIA HOG,WILL NOT HELP US,I HAVE LETTERS FROM GOVS/ CHRIST CRISTYi\/BROWN SENT WIDDEN/ N MORE NO HELP/ hurt 24/7 ,i would end it but god says no n have family,but if i dont get in to clinic soon will do heron as ins/ohp stated to me then will help me with methdone ,[but failed methdone 15 years ago puffed up ended in hospital ,, if no one will help sooon will seek in news paper 4 unithize me put me to sleep like a dog ,can any one help??
Jessi jo adair · October 24, 2017 at 4:42 am
Good morning,
I am having surgery on 11/1; haitial hernia repair along w a VSG to bypass revision for severe GERD. I do not want to take any narcotics. My doctor & I have discussed using a block and just continuing my normal suboxone dose (16mg daily) for pain control. In your experience will this control my pain sufficiently? I’m getting a little nervous. I have been on Suboxone for 15 months. Suboxone therapy has worked wonderfully for my opiate addiction and I don’t want to do anything that will jeopardize my success. Also, it is very difficult to find accurate info re: Suboxone…I am glad I stumbled across this site.
Thank you,
Jessi
Joel A · November 14, 2017 at 4:58 am
Dr. Junig, your concern and compassion for people along with an obvious non-judging attitude and approach makes you a very special physician to say the least. While reading the comments on here, it does not take long to separate those with clean motives from those who desire to stay high. I just wanted to say thank you for who you are and what you are doing here. Each of us has our own story. I long to tell you my circumstances and how I have been wronged by the system, given my life to help others with my job, been looked down on, judged, ending up where I am now. But eventually one gets to the point it doesn’t matter anymore. I am content with myself and although I hate the word used by the youth of today, it fits my description, whatever. Thank you again Sir for all you, be blessed in your work !
troy · March 21, 2018 at 12:40 am
as far as pain mang you must do what you have to do DEA/FEDS/WALLSTREET just care about money not you,dont kid your self this is just more pop controll ,thinning the baby booomers,after all they dont want to pay out ssi/or disabilty,heavens no also most goverment people are on pain meds ill bet your gov/sen are on meds ,they only want to make us the good apples suffer ,again stand up call them out on there BS.look up the wallstreet angle how there are using drug funds to gamble.FACT..after you or your loved ones suffer in pain you will have to act ..ps soon MORE cancer people will and are being targeted ,, read between the lines resurch on line DONT BLEAVE what you see/here on tv news ,99% fake news, good luck god is on our side..
Jeff L · March 22, 2018 at 1:28 pm
I can attest that Suboxone does very little for severe chronic pain – I know because I have been taking it for a year once I was Cold Turkeyed from Methadone, Hydrocodone, Flexeril, Neurontin and Klonopin. To me it is a bad drug as I have never felt right on it — whether that be from the other drugs I was on or if it’s just me, I don’t know. Makes no sense to me giving me a drug in place of Methadone in which I was taking for Pain and to put me on Suboxone which has very little effect on pain has destroyed my ability to perform simple tasks as I just experience to much pain (neck, lower back, hip and sacral joints). I now live in misery just trying to find a somewhat comfortable position. Also: they give this drug for addiction – but I notice that I am physically dependent on it — makes absolutely NO Freaking Sense whatsoever. This country is throwing pain patients off the bus and kicking them to the curb…therefor creating more addicts. Gosh, we need some true advocates here.
Jeffrey Junig MD PhD · March 22, 2018 at 6:04 pm
There are no easy answers. I’ve advocated for pain patients in my posts here, and more (in the case of pain) on psych central. If you google my name, ‘pain’, and psych central you’ll find a series of posts about the issue. As for ‘attestation’, I have many patients who would disagree with you. Pain is complicated; the nature of injury alone varies so widely, and then you throw in differences in individual pain tolerance, emotional impacts, pain traces in memory circuits, the differences in our endogenous analgesic pathways…
Saying ‘this medication never works’, and ignoring the experiences of patients who benefit, isn’t all that different from a doctor telling you that ‘you don’t really have pain’– something I suspect you would find very annoying.
After watching how over 500 people with chronic pain responded to buprenorphine over the past 12 years I have seen a range of responses. With most patients, their pain relief is MORE than I expected– and more than I truly even agree with. I find little or no value in treating SEVERE chronic pain with buprenorphine. I think the medication provides a very slight degree of opioid effect after tolerance sets in. That effect is insignificant in severe pain from my perspective.
But without doubt, many, even most patients I’ve treated who were taking opioid agonists for mild or moderate chronic pain feel better, with less pain and mobility problems, after changing to buprenorphine. The transition is difficult, of course, as it is with any medication. Many of the people going on buprenorphine are detoxed against their will by their doctors, so they have gone through tough times. But when things stabilize on buprenorphine they almost always say, for years afterward, that they feel much better on buprenorphine.
I’ll say sometimes– tolerance removes the mu receptor effect, so I don’t know why you would have less pain. The patient usually says ‘all I know is that it works’. I suspect that much of the improvement is just from getting out of the cycle of ‘on and off’, where the opioid effect is up and down, over and over.
Addiction and dependence are entirely different things, as you know.
Clearly you were happier on opioids. But to be frank, doctors are not going to be prescribing the combination of methadone, hydrocodone, Flexeril, Neurontin, and Klonopin for chronic pain any more. I think most doctors would have disagreed with that combination even 10 years ago! There are problems with that mix that I won’t get into now… but I hear you about advocacy.
This is a National issue, though– so that’s where I’d suggest you focus your anger. Your Senator or Congressman might benefit from hearing your story. That’s where to advocate. But it takes you, and other readers, to take that action.
Jeff L · March 22, 2018 at 6:55 pm
Dr. Jeffrey — I know all about you and praise you for your unbelievable Courage! No offense to you whatsoever sir — that was more of a rant – Yes, I was on a bunch of crap. Methadone made me feel like a zombie along with Klonopin. Then being cold turkeyed after over 16 years on Klonopin really has messed me up and I was taken off on March 1, 2017. For some reason Suboxone doesn’t agree with me as just a little bit makes me feel High for some reason – I have no clue why. I can tolerate about 1mg and that’s it. I hate pain killers but damn it I would sure like to have just one Hydrocodone to try to go to a movie with my Fiance (who by the grace of God hasn’t left me through this). I just cannot exercise and receive the appropriate dopamine response. I really don’t know how to get this body moving. Thank You for representing people who honestly suffer.
Jeffrey Junig MD PhD · March 23, 2018 at 5:03 pm
Thank you, Jeff– that’s kind of you. I get so used to defending things that I’m quick on the draw sometimes! In the psych central posts I tried to write about what is faced by people with severe chronic pain, and the best I could describe it was to say that those people are in a very bad spot. There are many people out there with failed back, with inflammatory arthritis, with severe nerve or nerve root compression, with thoracic outlet syndrome…. conditions that create huge amounts of suffering. The most-quoted experts these days are saying that opioids are not necessary or even helpful for chronic pain… and I understand the concept of opioid-induced hyperalgesia, but the studies of that putative phenomenon are way too preliminary to make clinical conclusions in humans. Yet we get media-hyped stories about studies with a dozen people who responded to NSAIDS and Tylenol or other non-opioid treatment, adding to anti-opioid bias out there.
Patients who have severe chronic pain should at least be allowed to participate in the decision-making process. Addiction to heroin and other opioids has devastated many parts of the country, but the problems of people with addictions should not prohibit the relief of suffering in people who benefit from opioids.
I agree with you, Jeff, that buprenorphine won’t cut it for severe pain. I’m not sure why it makes you feel high; maybe something about the specificity of the drug at mu receptors, or maybe a difference in how you metabolize the drug. But when you mention the trouble getting a good dopamine response I thought about how testosterone levels are lowered after chronic opioid use. Have you had levels checked? Of course then you would face the problem of whether to supplement your testosterone or not… but some people really feel better when a low testosterone level is addressed. Just a thought…
troy · April 2, 2018 at 12:17 am
we live in america,we have the right to deside what health care works and DOSE NOT,i urge any/every one who was doing well on pain meds to stay with pain meds /fight fight fight,wallstreet is making off govment dollars given for pain meds/your state n some DR are making money wile you suffer n some of you will die in pain,but they dont care,stand up fight,make calls,protest befor you n others DIE OR SUFFER MORE,TROY, YOU DO HAVE RIGHTS,
David White · May 29, 2018 at 2:03 am
I saw the post back last March about the state of Tennessee and that they would only give suboxone to pregnant women and people that are in the hospital and that is just not true. I have been on it for almost a year there are even a few places that will accept medicade/medicare for suboxone therapy. So do some research there out there. You need to look up suboxone and come to this site to educate yourself about it because a lot of the doctors here that prescribe it don’t know a lot about the drug.
David White · May 29, 2018 at 2:13 am
I also agree with the statements you guys wrote. It is getting impossible now for people who really need opiates to even get them. Its horrible! I had a compound fracture once and there is no way that tylenol or nsaids would have even touched my pain. i have been to the er since i have been on suboxone and i get treated as if i had ebola virus. It is awful. I went to the er in the small town i lived in where i had very painful cdiff and the doctor flat told me it’s my job to make sure you do not have a life threatening illness not to get you out of pain. It was hurtful and frightening.
David
Jennyt777 · July 14, 2018 at 10:23 am
So very informative.
Thank you for your advice.
Jeffrey Junig MD PhD · July 26, 2018 at 5:08 pm
Thanks!!
troy d hudson · July 27, 2018 at 12:47 am
dont bleave any thing being told people now dieing from from this drug and many more will to ,beware,,also kids using as gateway drug to heron ,,fact
Jeffrey Junig MD PhD · July 28, 2018 at 9:07 am
Each year in the US there are around 40,000 deaths by overdose, most to opioids. Each year about 40 people die who have buprenorphine in their bloodstream. That is the same number of people as the number killed by lightning. Of those 40 deaths, most are from heroin or fentanyl. The buprenorphine in most cases was present from prior use, and death was caused by other opioids. Death would have been prevented in many of those cases if buprenorphine had been present in higher amounts.
That’s the fact. Death from buprenorphine is extremely rare. To die from buprenorphine, people must 1. have a very low or no opioid tolerance, and 2. take a second respiratory depressant that they also lack tolerance to.
Those are the facts. Look them up at the CDC web site. If you don’t like buprenorphine don’t take it. But saying ‘people are dying’ is silly. Less than one one-thousandth of overdose deaths occur in people with buprenorphine in their bloodstream. If a person is taking buprenorphine daily, death by overdose is almost impossible. Fact.
Gateway to heroin? There is no evidence of that occurring. And it makes little sense. Heroin is much less expensive than buprenorphine, and much easier to fine. The long half-life of buprenorphine makes it a lousy ‘drug of abuse’, because if a person is using heroin, oxycodone, or other opioids, buprenorphine precipitates withdrawal. If buprenorphine is their ‘first opioid’, taking it one time causes an effect that lasts several days. Because of the ceiling effect, that person will feel absolutely nothing if doses of buprenorphine are repeated. So to use buprenorphine to get high, a person has to take only buprenorphine- no other opioids– wait a few days for it to wear off, and then take it again. The addictiveness of drugs is correlated with speed of onset and the inverse of half-life, and buprenorphine has a very long half life and an onset time of 3-4 hours.
I don’t know why you’re a bupe troll, but if you plan on continuing in that role you should at least get the true facts right.
brent kelso · July 19, 2018 at 9:52 am
hey doc remember when talking to anyone in or from u.k. they the uk gov dont talk recovery they talk of harm reduction in u.k. if 3 million pound is in profit from alcohol sales and only 1 million is lost due to alcohol related issues hung over ,dui,etc..then the 2 million dollar profit proves there is no problem as it was explained to me. THe reason to contact you is i am now on a generic film and dont think it works as well as the other brand name but part could be in my thinking too the placebo effect
Jeffrey Junig MD PhD · July 26, 2018 at 4:40 pm
There is surely a huge mental aspect to withdrawal symptoms. With both methadone and buprenorphine, if a person THINKS he will have withdrawal, he’ll have withdrawal. I can’t say there is no difference with generics, but we typically ‘over-dose’ buprenorphine to a large extent to saturate the receptors, so people probably wouldn’t be able to detect a small reduction in dose. BTW- where are you that you have generic film available?
Popcicle · August 19, 2018 at 2:37 am
This is the worst response to a simple question about Suboxone and what happens when you need major pain relief while on this drug. I did NOT read the entire damn explanation. I was wanting answers, not a lecture on how the opioid receptors work and what kind of drug does what to whom. Damn – none of this information answers the question.
Jeffrey Junig MD PhD · August 20, 2018 at 4:02 pm
Some people want just the facts. Some people want to know a little more about the Universe. Guess you found the wrong site.
Virginia Elkins · December 11, 2018 at 10:45 am
Hello, I’m loving your blog, but I do have some questions pertaining to procedures I’m having done in 4 months or so. I’m on suboxone or buprenorphine and naloxone since 2017, June and am taking 8mg once a day in the AM. I’m having a gi procedure done in March of 2019, a colonoscopy and Endoscopy, I was informed that I’m going to be given versed and fentanyl as sedatives for these procedures. I’m in a treatment court situation where I’m given random urinalysis, I’m trying to cover my own but by getting a form filled out by the physician that is performing the procedure, so I got that part covered. I guess my question is how long before this procedure should I stop taking my suboxone so I don’t have any issues during or after this procedure? I’m making every step I have to, to advocate for myself since I’m in recovery. I just don’t want to run the risk of going into precipitated withdrawals or “feeling” the pain or anything else associated with these procedures. When I do stop taking it, how long after should I pick it back up? Thank you, I look forward to hearing from you. V
Jeffrey Junig MD PhD · December 31, 2018 at 1:32 pm
I’m sorry if this is too late… I recommend my patients take their normal dose of buprenorphine medication when having endoscopy or colonoscopy. It will block the fentanyl to some extent, but the Versed is the main part of the sedation. If you take benzos, you may need a higher dose of Versed (midazolam). But otherwise, just take your buprenorphine medication as usual. It takes weeks to leave your system, so you can’t get rid of it for the procedure – and it shouldn’t get in the way of what they’re doing.
Charles Anthony Foutch · December 31, 2018 at 10:21 pm
When I told doctor I was on Suboxone he refused to give me Fentanyl during colonoscopy. He gave me such a low dose of Versed felt and remembered everything. I had been off my Suboxone 4 days per doctor’s orders so I was miserable. While I got you my doctor’s P. A tells me that if I need surgery they will put me on Beuprenorphine only and it won’t block pain meds effect. I thought he was wrong. Was I right?
Angel · January 10, 2019 at 6:14 pm
I have a question I really need your help with this one. I am in agonizing pain at this point. Usually I can deal with it. This time I can’t. I haven’t slept for days, I have been suffering from a severe infection in my tooth lower left toward the back (not my molar) I am on suboxone bid. Amoxicillin 500 mg tid now for the infection. And taking tons of ibuprofen and Tylenol. Which has caused serious medical problems for me. And my GI told me I’m not allowed to take them. But I do, I have no choice. I know I will have another episode of gastrointestinal pain and possibly hospitalized like all the other times. I have surgery with an oral surgeon because the tooth has an extra root and the nerves are horribly exposed. It’s cracked in half and the entire half of the tooth is just sitting out exposed down to the gumline. They know I’m in terrible pain I’m crying. I can’t function at all. I asked the Dr today can i have anything stronger? This was at 4 pm and they said they would call me back. I had to know what they could do since my pharmacy closes at 7 pm. I called back at 7:30 since I heard nothing and she just told me I can’t call in any thing and I’m busy! Go call the surgeon. Or go get morphine if you’re in pain from the ER. I don’t understand any of it. I have never asked any doctor for any meds for pain ever since I’ve been on suboxone. I have stuck it out. This time I can’t it is the worst pain. I’m not scheduled for the surgeon till Tuesday for sx and their office said she should have written me something. It is Thursday I will not be seen for almost 6 days. I don’t know what to do? No one will treat me for the pain it seems bc I’m on suboxone and I don’t know what to do? I feel like I’m a terrible person asking for genuine help because of the pain. I feel crazy to go to the ER but I’m scared that’s what is going to happen. My question is are there any doctors that do treat someone who’s on suboxone while in severe pain. Instead of feeling ashamed to ask for help. I just feel so stupid. Please help i don’t know which doctor should be treating the horrible pain.
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