A Question:

I see my urologist, the prescribing doctor on Monday, August 18th and am planning on asking him to write a prescription for Subutex for my pain. This weekend I am trying to collect some useful information to bring to him in support of my request. As I have previously stated it was my physicians’ idea to try this medication. I believe he feels uncomfortable prescribing it as in this country it is being very actively promoted/publicized for addiction. Like may doctors he may be under the impression that he needs a special UIN number to prescribe it.

As can readily be identified in the above DEA letter he does not need any special qualifications. Besides showing him the letter I need to find credible medical information to show him as to the equivalent dose Subutex/Suboxone to the “Avinza” 90mg he currently has me on?

As stated I see no downside to my trying Subutex/Suboxone for pain management, do you?
“long half-life results in a very stable subjective experience” I see this as a benefit.

“Tolerance occurs very rapidly…I would expect tolerance also to the analgesic effects. So theoretically it should not be a good pain drug because the rapid tolerance would eliminate the analgesic effect after a few days.” Should this occur than I would of course not be able to sustain.

“In reality, though, patients will claim relief from suboxone for an indefinite period of time in many cases. I have no explanation…”

“Suboxone certainly has advantages over other opiates, if it is found to be effective. The tolerance with buprenorphine is limited, whereas the tolerance to a pure agonist has not limit—so there is a lower amount of withdrawal if/when the drug is eventually discontinued. The stable blood level prevents the temporary ‘highs’, the miserable lows, and the cravings that can accompany the use of agonists. The patient feels much more clear headed on suboxone compared to opiate agonists. And suboxone can be dosed once per day, which has a couple effects—first, it just is less trouble to take, but more importantly the absence of ‘as needed’ dosing all day long will help prevent the patient from focusing as much on the pain.”

Again I see no down side to trying it, not focusing on my pain or if and when I might start having break through pain, not having my mood go up and down as a medication blood level changes (very important to me is leveling out my mood), possible cravings (I have not had yet),. I would be much relieved to be more clear headed. I have been having cognitive problems for several years now and have had neurological testing for it. Having a clear head and a level mood(good or bad) could potentially provide me with some relief from some of the problems and might provide some answers as to why they are occurring which might enable me to address the cognitive deficits more effectively.

“…many people have told me that suboxone seems to work as a ‘mood stabilizer’…”

As I suffer form treatment resistant depression and have read several accounts where buprenorphine has helped depression I am interested in trying it as for me it has a potential dual purpose.

“Chronic pain is a very difficult issue…I encourage you to avoid opiates as much as possible—there is generally little future in opiate treatment of pain, since tolerance always chips away at the effects of the opiate over time…”

I have a limited understanding here but as buprenorphine is a partial agonist, having this ceiling effect I was thinking it might be helpful to me in the long run as far as building up tolerance to opiate medications? For instance if I am able to obtain adequate pain management with buprenorphine over several years would I not benefit from this over taking morphine or oxycontin, full agonists over the same period of time? My tolerance for the full agonists could potentially increase during this time and if I need to continue with opiate pain management the tolerance will minimize the ability for pain management with full agonist medications if I need to go on them at some later point.

It is not clear to me whether my tolerance for buprenorphine will increase quickly or not. You stated that in theory tolerance occurs rapidly but in practice this is not always the case.

“Suboxone certainly has advantages over other opiates…”

You have in the above statement impressed upon me several advantages to using buprenorphine for pain management if it can be accomplished.

I would appreciate any input or advise you might have for me on this issue. I would also appreciate it if you could provide any relevant links to credible medical information about buprenorphine and pain management and/or suggested equivalent starting doses.

I believe my email is in my profile but to b sure you have it:

Thank you for your consideration,

My Reply:

I agree with everything you wrote– although I recognize that most of the quotes are from things that I have written, so how could I not agree?!  I’m joking– I suppose I should write LOL to clarify that…

As for the question about starting dose– because of the ceiling effect, the Suboxone dose is always going to be in the same general area, regardless of the opiate requirement for pain or the opiate tolerance of the patient on maintenance addiction treatment.  I have disagreed with a couple earlier posts that suggested different Suboxone doses (or using methadone instead of Suboxone) for people who have high opiate tolerance;  I have helped patients go on Suboxone from HUGE doses of methadone or oxycodone, and I do not think that a high tolerance argues for methadone over Suboxone or vice-versa.  I see tolerance as dynamic;  in any one person, tolerance is a function of two things, time and opiate dose, with the latter being most important. 

My own addiction to intravenous fentanyl (anesthesiologists have access to very powerful medications!) resulted in an extremely high tolerance, despite being ‘active’ for only a few months, because I kept pushing the dose higher and higher.

I have come to see withdrawal as the subjective symptoms of lowering one’s tolerance level.  Suboxone has an opiate agonist potency equal to about 30 mg of methadone per day.  Taking Suboxone will make one’s tolerance ‘reset’ at that level, and stay there for as long as the person is on Suboxone.  A person who starts Suboxone from a lower tolerance level will get ‘high’ for a couple days, until his tolerance stabilizes at the higher level;  a person who starts Suboxone from a higher tolerance level will have ‘precipitated withdrawal’ as his tolerance is ‘yanked down’ to the lower level.  That is why we usually ask an addict to stop using for 24 hours or so;  that way his tolerance will come down a bit (and he will experience withdrawal), and starting the Suboxone will not cause an instant surge of withdrawal symptoms. 

People sometimes ask why Suboxone causes withdrawal when one stops taking it; the reason is because there is no free lunch– Suboxone protected the person from needing to go through all of the withdrawal necessary to get tolerance down to zero, and when one stops Suboxone there is still work to be done to bring the tolerance down.

I tend to wander a bit… but as for specifics, the starting dose of Suboxone would be about 4-8 mg.  The usual ‘final’ dose is about 16 mg.  Some pain patients claim more pain relief from higher doses, but I am skeptical of anything more than a placebo effect, as we know that buprenorphine’s effects at mu opiate receptors are subject to the ‘ceiling’ that I have been referring to.  Similarly, dosing once per day will result in complete, constant binding of all of your mu opiate receptors–  dosing twice or three times per day will cost more and be more trouble but probably has no benefit beyond the placebo effects.

You are correct about the requirements for Suboxone prescribing;  any doc can use it for pain.  It may be helpful to write ‘for pain treatment’ on the script; that way the pharmacist may be less likely to question it.  BUT…  that does not mean thats a doctor will prescribe it or that a pharmacist will fill it.  There is a great deal of ignorance about Suboxone, and many docs just don’t want to mess with something that they are not familiar with.  Moreover I have noticed that many pharmacists have become more active in controlling prescriptions; many times I have run up against pharmacists who simply refuse to fill something for reasons that are highly suspect, including ‘I don’t like the looks of the guy’  (I honestly have heard that!). 

Sorry Walgreens, but when I have had problems it almost always has been from one of your pharmacists.  Surprisingly, I have had problems with many different Walgreens locations!  I don’t think this is true, but I sometimes wonder if Walgreens trains their pharmacists to be jerks– patients have told me that they were told ‘your doc is breaking the law’ or ‘your dose should be lower’…  Then I had the Walgreens pharmacist call after cutting all of the controlled-release pills for a patient in half because he didn’t have the lower dose in stock, and asking for me to write a script instructing him to do what he had already done (which, by the way, results in the dangerous, instant release of 12 hours of medication)…

I better stop before I get carried away.  But I don’t like that particular pharmacy chain.

Anyway, as I was saying, your doc or pharmacist may not go along with you, and there is nothing you can do about that.  I do not recommend that you threaten your doc; he is not required to prescribe what you want him to.  And frankly, it is always a bit dangerous for a doc to prescribe meds that he/she is not familiar with.

You asked if there was any ‘downside’; understand that you must not take Suboxone when you have opiate agonists in your system or else you will get VERY sick.  I took naltrexone once in a misguided attempt to get clean back in my using days;  I never want to be that sick again!  The other rules of Suboxone apply as well, the primary issue being to avoid taking benzos or other CNS depressants until you are tolerant to the Suboxone.   The other downside is that while you are on Suboxone, no other opiate agonists will work.  If you need emergency surgery you can be put to sleep OK but it can be difficult or impossible to get good pain control for a day or two afterward.  It takes AT LEAST several days to get the Suboxone out of your system.

I do not have references for use of buprenorphine for pain– I am actually out of town this week and don’t have access to everything I usually have access to.  The references are out there– as are references for use of buprenorphine for depression or other mood problems.  Understand that opiates are not ‘indicated’ for treatment of mood, and it is possible that a doc could get into trouble by using opiates for such an indication.  Given the issues of tolerance and addiction, I consider use of opiates as mood stabilizers or antidepressants to be extremely risky at best.  Yes, they do have the mood ‘side effects’, but that is a completely different issue than using an opiate primarily for mood effects.  I would not be surprised if there were state laws against using opiates for such purposes.

You are accurate with the ‘tolerance’ comments.  Suboxone causes tolerance that will reduce efficacy for pain treatment, but so do all other opiates.

I have to run– good luck with your doc.  Let us know what happens.


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