I recently accepted a young man as a patient who was addicted to hydrocodone (the opioid in Vicodin), prompting a discussion about treatment options for someone who hasn’t been using very long, and who hasn’t pushed his tolerance all that high. Perhaps it will be informative to share my thought process when recommending or planning treatment in such cases. In part one I’ll provide some background, and in a couple days I’ll follow up with a few more thoughts on the topic.
Most people who have struggled with opioids learn to pay attention to their tolerance level—i.e. the amount of opioid that must be taken each day to avoid withdrawal or to cause euphoria (the latter about 30% more than the former). For someone addicted to opioids, the goal is to have a tolerance of ‘zero’—meaning that there is no withdrawal, even if the person takes nothing. That zero tolerance level serves as a goal, making having a high tolerance a bad thing, and pushing tolerance lower a good thing.
Tolerance is sometimes used as part of the equation when determining the severity of one’s addiction. But looking at tolerance alone can be misleading. Tolerance is a consequence of heavy use of opioids, and also a cause of heavy use of opioids. Tolerance usually goes up over time, so having a high tolerance probably correlates with length of addiction in some—- but not all— cases. Tolerance is also strongly related to drug availability. A person with a severe addiction, who only has access to codeine, will likely have a lower tolerance than a person with a more mild addiction, who has free access to fentanyl, oxycodone, and heroin.
I think it is more appropriate to measure the ‘severity of addiction’ by the degree of mental obsession that the patient has for opioids. Tolerance is one piece of information in determining that obsession, but tolerance alone can be misleading.
To get a sense of the obsession for opioids, I look at many factors. Has the person committed crimes to obtain the substance? Violent crimes? What has the person given up for his addiction? Has he been through treatment? How many times? How long did he stay clean after treatment? Have his parents or spouse thrown him out of the house, and if so, does he still use? Did he choose opioids over his career? Over his kids?
Answers to these questions provide a broad understanding about the addicted person’s relationship with the substance—an understanding that is necessary when considering the likely success or failure of one treatment or another. It is also important to consider the person’s place in the addictive cycle—i.e. early, likely in denial, cocky, with limited insight– or late, after many losses, more desperate—and perhaps more accepting of treatment.
I am a fan of buprenorphine as a long-term treatment for opioid dependence, as readers of this column know. I consider opioid dependence to be a chronic, potentially-fatal illness that deserves chronic, life-sustaining treatment— and buprenorphine, in my experience, is a very effective treatment in motivated patients. But tolerance becomes a factor, when considering buprenorphine for THIS patient.
Buprenorphine has a ‘cap’ or ‘ceiling effect’ that allows the medication to trick the brain out of craving opioids. In short, as the blood or brain concentration of buprenorphine drops between doses, the opioid effect remains constant, as long as the concentration is above the ceiling level. In order to achieve the anti-craving effects of buprenorphine, the dose must be high enough to create ‘ceiling level’ effects. If buprenorphine is prescribed in lower amounts—say microgram doses— the effect is identical to the effects of an agonist, since the dose/response curve is linear at lower levels.
Buprenorphine is a very potent opioid, and the effects of the medication are quite strong at the ceiling level. Comparisons to other opioids will vary in different individuals, but in general, a person on an appropriate dosage of buprenorphine develops a tolerance equivalent to that of a person taking 40 mg of methadone per day, or approximately 60-100 mg of oxycodone per day.
A person taking even a dozen Vicodin per day has a much lower tolerance to opioids. Such a person who starts buprenorphine treatment will obtain a very significant opioid effect from the drug— unless the dose of buprenorphine is raised very slowly over a number of days. And in that case, the person’s tolerance level would be pushed much higher.
So if our current patient starts buprenorphine, he will have a much higher opioid tolerance if/when the buprenorphine is eventually discontinued. I receive emails now and then from patients who are angry at their doctor for starting buprenorphine, feeling trapped by the considerable threat of withdrawal from stopping the drug. But at the same time, taking hydrocodone and acetaminophen in high amounts creates the risk of liver damage from the acetaminophen, as well as the considerable risks from opioid dependence.
And so the dilemma. Should buprenorphine be considered in such a case?
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13 Comments
scruffy2 · July 19, 2012 at 2:00 pm
Perhaps the question is not Bupe— yes or no? But rather, how to use Bupe in this situation. According to the training materials for certification one would immediately prescribe 16 to 24 mg and observe the
situation for 6 to 8 weeks. That is simple – but may not be best for this patient. The training materials are simplistic and do not offer options.
I am not sure if any research has been done- for and approach to induction. But it is common sense and backed b anecdotal material that a closely watched induction starting at .5 mg and going up to the
minium optimum dose that works – perhaps less than 2mg. Maintaing this during the 7-10 days of expected W/D in this case, and the quickly tapering the Bupe. This has been reported to work well in some cases — probably depending on the situation the patient is to return to. If the drugs were all legal prescriptions and the lifestyle of the patient does not involve heavy drug use — this might be what this patient needs.
bunnyman · September 9, 2012 at 6:35 pm
My primary opioid of abuse was hydrocodone. And I have been on 16-24 mgs of Sub for about 3 years. Sound excessive? Maybe it is, but I’ll tell you what: I did almost 4 years in jail over a ten year period for phoning in hydrocodone scripts. My habit required about 400 mgs of hydrocodone a day…..and that also included the APAP found in the Vicodin and Norco I was using. I was taking upwards of 50 grams of acetaminophen a day – that is more than a lethal dose. It’s amazing I am alive.
Suboxone saved my life in more ways than one. I’ve NEVER relapsed on illicit opioids in the 3 years on Sub. I plan to take it forever, even though it completely destroyed my ability to produce testosterone. I just take Androgel and forget about it. Comes with the territory, in my mind.
Bunny
Shane gignac · February 10, 2017 at 10:01 am
Couldn’t ask for a better Dr. To ask questions to and receive answers from. Thanks Dr.junig for all the extra help that you don’t need to do. Shane
La · April 2, 2017 at 2:01 pm
I was addicted to hydrocodone for the better part of 26 years. I’m 40 now. I started suboxone back in 2009 and stayed at an 16mg dose for most of that time. In the past 3 years I’ve been tapering myself, but I’ve had a few setbacks with my health including 9 surgeries. The past year I went from 2mgs down to a 1/4 every morning. It’s been so hard getting my body comfortable at each lower dose. Suboxone saved my life and initially I wanted to stay on it forever. After all these years though, it actually was just a replacement for the narcotics and I hated knowing that I was just chained to it as well. I had to have my gallbladder removed on March 20th. I started kratom about a month before the surgery. I stopped the sub 3 days before the surgery as recommended by my addiction therapist. After the surgery, for 3 days I used about 40 norcos. The first morning after waking up with no more norcos, I felt really good. So I waited to dose back on my 1/4 sub. I kept waiting to feel sick, but it never came. I have issues with restless legs, but that’s it. I’m ecstatic that for the first time in 8 years I am completely clean. I am wondering if anybody has had a related situation and if I’m gonna wake up and Paws will commence.
Jeffrey Junig MD PhD · April 2, 2017 at 5:01 pm
One thing I’m always reminding people here is that opioids are cross-tolerant. So nobody is ‘addicted to hydrocodone’ or ‘addicted to buprenorphine’; the issue is opioid dependence, which includes a tolerance factor and a much larger psychological factor.
If you were down to a quarter (of a milligram?), you were on a very low dose of opioid– equal to 5 mg of hydrocodone a few times per day. It sounds like you got your tolerance lower by tapering, and then used hydrocodone after surgery and stopped. You probably could have stopped the quarter mg of buprenorphine pretty easily, especially since only 30% of a sublingual dose gets absorbed, meaning you were actually on an even lower dose.
Kratom was a dangerous diversion. I’ve seen some serious organ system damage from that drug, from exposure to pesticides or other toxins. Even beyond all of that, Kratom is just another opioid, but in plant form. You may as well use poppies or heroin; they all are just different forms of naturally-occuring opioids.
You may not realize it, but you are the classic buprenorphine patient, and I have many patients similar to you. The idea that bupe is a ‘replacement’ ignores a huge difference between opioid agonists and buprenorphine; the ceiling on the effect of buprenorphine is unique, and allows a person to feel stable on buprenorphine in a way that is impossible on other opioids. If buprenorphine was a ‘replacement’, then you could have simply tapered off your drug of choice! You couldn’t, of course, because nobody can taper off agonists. The unique properties of buprenorphine allow people to become stable on the medication, and in some cases eventually taper off the medication. Those things are not possible using the drugs that buprenorphine ‘replaces’.
There is no reason for you to experience ‘PAWS’, a syndrome blamed for all sorts of symptoms. Many people with PAWS are blaming their history of opioid dependence for symptoms that are totally unrelated. Your challenge is to create a fulfilling life, finding interests in things, engaging in healthy behaviors, becoming productive in the workforce, getting exercise, etc. If you do those things you’ll never have reason to complain about ‘PAWS’.
Good job on tapering, and good luck!
Michele Maguire · May 12, 2017 at 6:28 am
I don’t mean to be curt,but there’s only so much I’m permitted to write;I’m at the end of my rope anyway.Background hx:single mom of 3 boys,left abuser of 12 yrs in 2014.Prior athlete leads to surgeries starting in 2007.Addicted to anything I could get.Horrible custody battle which ex of course parade’s my addiction in courtroom.Fortunately I was never “high” in front of kids/family.No 1 ever knew,until I “outed” myself.Went to CA in 2015.Ignorant but determined-had I done my research on Suboxone,I NEVER would’ve taken it.Went cold turkey off Subs in 10/16.I lasted 5 days;I had to see my Dr.I hoped he would prescribe anything ELSE to get me thru the next few days(Clonidine,Tramadol)ANYTHING ELSE.He put me back on Subs;being that I’m living w/my alcholic mother,who doesn’t understand the physical/mental pain which occurs from jumping @32 mgs,I just had to put “myself back together”.My Dr is not a psych;honestly I feel I know &understand the drug he’s prescribing me better than he does.Last month I ASKED him to taper down from 16 to 12mg.Was shaky but ok.My ex & my oldest son recently got into a physical fight(my ex tried dragging him from the house b/c my son “didn’t want to go to visitation”.The past 2 wks have been extremely stressful-restraining orders,filing court motions&petitions.I went to Dr yesterday explaining I have to be in NY next wk for court.I would like to refill my script 6 days early;so I am prepared,packed,and not worrying about having to drive back to NJ mid wk to fill a prescription.I’ve NEVER had a “dirty” urine screen.Dr knows I HATE being chained to this drug.I travel a lot& this creates a huge burden&stress in planning “according to my refills”.Dr gave me a HUGE attitude & told me I really “need a psych”.No shit – let me see where I can fit that into my “sun tanning,Bon-Bon eating,sitting on my ass watching day time tv schedule”.Point is-I ASKED U TO LOWER MY DOSE.And now U want to give me an attitude b/c I’m asking for a PARTIAL REFILL 6 DAYS EARLY? *U wouldn’t happen to know of a GOOD DR in the NJ/NY area? I’m at the point of hopping on a plane to see u! Some 1 who understands this BEAST OF A DRUG(I had an easier w/drawl from Dilauid!)to please get me OFF THIS THING w/out the depression &lack of energy.I can handle the physical…thanks for listening,Shelley
stephanie · May 18, 2017 at 2:56 am
Dr George Long. Edison Nj
John · July 12, 2017 at 4:54 am
Dr. STEVEN NEUMAN – has an office on east 12th st, brooklyn. Been seeing him for 7 years.
Stephen V Zakrzewski · June 23, 2017 at 11:57 am
For Michele
Dr Gordon Davis, DO Richmond Hill,NY
Dr Alexis Biswanga, M.D. Flushing, NY
Jason · July 20, 2017 at 7:11 pm
I am in a similar situation. A few years ago I was Rx’d hydrocodone for a bulging disc that had been re-injured. After a few months of taking the hydrocodone (one 5/325 tablet twice a day) I knew that from prior experience I would need to wean off.
About a year earlier I had a painful surgery that took months to heal, since I was re-injuring it everyday as part of normal bodily function (I’ll let you guess where the surgery was). I was Rx’d a series of opiate medications that I would step down from as the pain became less and less. About four months later I stopped taking the hydrocodone but noticed I didn’t feel well. It was like I had a mild flu and some restlessness. I mentioned this to my surgeon and he said I was probably physically dependent and needed to wean down. I weaned down over two weeks and had no withdrawal symptoms.
Fast forward to the bulging disc episode. I’m seeing my hospital system’s new “pain management” doctor (the state had implemented new opiate Rx-ing requirements), rather than the original doctor. I gave a urine sample. We discussed my history and current amounts and I was Rx’d Suboxone at 2mg instead. I wasn’t given a taper schedule or anything, just told to take this from now on. I never got high on the hydrocodone, but I did the first time I took a 2mg strip of Suboxone. I was driving to work when I put it in to dissolve and by the time I got to work I was very high. I couldn’t form sentences well and became extremely sleepy. I left saying I didn’t feel well and rested in my car until I felt with it enough to drive home. From that point on I split the strip in two and took 1mg in the AM and 1mg in the PM. Despite being drowsy after the dose, by bedtime I was unable to sleep. My sleep schedule changed to nearly the opposite of what it was. I was now sleeping during the day and working at night (luckily the nature of my job and my boss were accommodating to this). I became unbelievably constipated. My appetite evaporated (making the constipation worse). I started sleeping 10-12 hours and still being tired. I started getting sweats, nausea, and irritability at random times. Now, I was on other medications at the time, so I can’t say these were all side effects of Suboxone, but they were at least side effects of the combination of medications. Some of the symptoms got better with time as well as going to a higher dose (currently on 2mg twice a day). I refuse to go any higher as I’m fearful it will make detox that much worse.
This has all left me wondering why wasn’t I given the option of weaning from the 10mg of hydrocodone? Heck, at this point I’m pretty sure cold turkeying from 10mg/day of hydrocodone is much preferable to the withdrawal I’m looking at being on Suboxone now for a few years. Some of the side effects seem to have lessened, like the constipation, but the sleep problems have not and it’s had a very negative effect on my life. When I asked the pain doctor to help me get off of Suboxone, he said he had very little experience helping people get off the medication. I’m quite fearful of detoxing from Suboxone due to what I’ve read and what the doctors have told me. I understand Suboxone can save lives when applied in the right situation. I wish my close friend’s brother had been on it before he OD’d on heroin earlier this year. However, we shouldn’t be applying it in situations where it will make it harder for the person to ultimately take no opiates at all.
Jeffrey Junig MD PhD · July 24, 2017 at 7:39 pm
I hear you… these are difficult and complicated issues. MOST people who say ‘I’ll just taper off hydrocodone’ are unsuccessful, and end up trying over and over again, as life becomes more and more miserable. But yes– it is much easier, physically, to taper off 10 mg of hydrocodone than to taper off 2-16 mg of buprenorphine. You should have been told this before starting buprenorphine; I certainly would warn such patients several times over, and recommend that they try to stop the hydrocodone if they haven’t tried already. One thought though– don’t believe ALL of the horror stories out there. It is definitely easier to stop buprenorphine than it is to stop heroin or oxycodone, no matter what people write on message boards. I’ve had many patients taper off buprenorphine. The challenge is breaking the dose into consistent, smaller amounts. If you can find a way to reduce your dose by about 5% every 1-2 weeks, the taper is not that hard. I usually recommend people use the film and a plastic template, and cut progressively smaller pieces with a razor or exacto knife.
Jason · August 1, 2017 at 12:09 am
You are very right, they are very complicated. I’ll try not to take the horror stories to heart. Would you recommend a taper vs. an inpatient medically assisted detox? One place seems to recommend I just stop taking it the day before entering so I’m already in withdrawals before I start the five day detox. Another place recommended a fast taper in detox for a total of 10-14 days. For those that do taper, do you find their jump to zero is relatively minor (like they can still work and function relatively well in the days after) and does allowing the brain to slowly re-equalize itself like this help minimize their PAWS?
I never though of using a plastic template before.
Jeffrey Junig MD PhD · August 1, 2017 at 7:21 pm
Jumping to zero will result in significant withdrawal. It won’t be as bad as jumping from heroin or methadone, but it will probably be too severe to allow you to work. I recommend that people taper as low as possible, ideally to less than 0.5 mg per day taken as a sublingual dose, and jumping from there. If you need to stop sooner, you really will need a week or two off work. If the person has been doing well, avoiding opioid agonists for a long time, I might prescribe a benzodiazepine during the detox. A benzo like clonazepam will make the time pass much more quickly. Frankly, THC is probably one of the safest things to use to treat withdrawal symptoms in those people who find comfort in that substance; it does not depress respiration, and as long as the person is not working or driving, it is a fairly safe way to address withdrawal symptoms– at least in the states where use is legal.