Buprenorphine Plus Hydrocodone

I often receive emails with requests for my opinion about various aspects of buprenorphine treatment.  A recent exchange, for what its worth:
Hi Dr. Junig,
I hope you are well.  I know you have written a lot about this, and I have read most of it.  But I still needed to ask your advice on my particular situation.  I will give you all the pertinent details and you can feel free to keep the answer succinct.   I know you do not have a lot of time on your hands. 
I have been successfully using Suboxone for over a year. My current dosage is three 8mg strips of Suboxone a day.  
After a recent traumatic injury I was given an Rx for  20 x 10/325 norcos.  I knew it was tricky to implement this into my Suboxone routine, but I also knew that it WAS possible to do so successfully, and that I really needed to try for purposes of comfort.   
Anyhow, my last doses of Suboxone were yesterday: 1 strip @ 7am, 1 strip @ 1130am.  
I then waited 4 hours and took 2 of the norco, followed by 2,   later, and another 2, 4 hours after that.   I took 2 at 9am this am today, followed by 3 at 1pm today.  And now I am having some serious concerns and reservations about this.  I just feel like shit now. 
And I don’t know if it’s because I am in withdrawal from the Suboxone, or because the Suboxone is still bound and the norco isn’t working?  
My current symptoms are headache, dilated pupils, restlessness, anxiety.  I just don’t feel *right*, and I suspect it’s the opiate situation that is doing this.  I don’t feel comfortable taking more norco at this point, for obvious reasons, but I am also apprehensive about taking any Suboxone right now.  
I appreciate your time and your opinion immensely.  Any guidance (opinion, gut feelings) you can provide me with would be valuable to me.  
Regards,   XXXX
My Response:
My best guess is that you are experiencing early withdrawal from reducing the buprenorphine/Suboxone, and that hydrocodone is not strong enough to replace the buprenorphine you’ve discontinued.  I say that because in the multiple times my patients have had surgeries, I always do the same thing—  continue the buprenorphine at a reduced dose of about 8 mg, once per day, and  add oxycodone, 15 mg every 4 hours, for pain control.  I’ve never seen precipitated withdrawal when starting an agonist when buprenorphine is already established.  Precipitated withdrawal comes when a person is on an agonist, and then takes buprenorphine—not the other way around.
With that in mind, if you were my patient I would cross my fingers, and have you restart Suboxone at a dose of about 12 mg per day— for example 8 mg in the morning, and 4 mg in the evening.  For pain I would give you 15 mg of oxycodone.  If you are like most people, you would get pain relief, without any of the euphoria that you used to get with opioids.
My advice to you would be the same.  I have some concern that you are feeling ‘lousy’ now, when you should still have plenty of buprenorphine in your system after only one day away from it.   But maybe the misery is psychological, or from some other random viral illness.
I have some patients with severe chronic pain, including a firm diagnosis and a solid pain history – i.e. not people with moderate pain, but people who are suffering greatly who other doctors had abandoned.  I start them on 8 mg of buprenorphine per day, and when they are tolerant to buprenorphine I add oxycodone, 10 or 15 mg every 4 hours.  The several people I’ve treated with that approach think I’m a miracle worker because they get pain relief from far lower doses of narcotic than they used before, and never (at least for a year or two that I’ve been doing this) develop tolerance.  Based on those experiences, I would think you would be fine resuming a half dose of buprenorphine, and taking an agonist on top of it.   I don’t know if you can get to an effective dose of hydrocodone and stay safe with the acetaminophen though; hydrocodone may not be potent enough to displace buprenorphine.
Good luck!
Jeff J

Taking Buprenorphine, Having Surgery

Originally Posted 8/12/2013
I will get to ‘Part II’, but today I talked with a patient about something that happens too often, that deserves to be pointed out.  The person was in the ER with an injury that resulted in tib/fib francture.  The ER doc provided no analgesia, in the ER or at discharge, telling the patient “you would get sick if I gave you pain medicine because you are on Suboxone.”
I have a few paragraphs typed up that I send to dentists, surgeons, and other physicians when a patient on buprenorphine has a painful procedure.  I am pasting it below so that it can be copied, printed, and given to physicians to encourage them to do a bit of continuing medical education on the topic.  Those of you who are already enlightened, please leave comments if you see something that you would change.   I have literature to back up this type of approach;  send me an email if you’d like the reference.
Painful Procedures and Buprenorphine Patients
Buprenorphine is a partial opioid agonist that is used for several indications.  In low doses—less than 1 mg/day—buprenorphine is used to treat pain (e.g. Butrans transdermal buprenorphine).  In higher doses i.e. 4 – 24 mg per day, buprenorphine is used as a long-term treatment for opioid dependence and less often for pain management.  At those higher doses, Buprenorphine has a unique ‘ceiling effect’ that reduces cravings and prevents dose escalation.  Patients taking higher dose of buprenorphine, trade name Suboxone or Subutex, become tolerant to the effects of opioids, and require special consideration during surgical procedures or when treated for painful medical conditions.
There are two hurdles to providing effective analgesia for patients taking buprenorphine:  1. the high opioid tolerance of these individuals, and 2. the opioid-blocking actions of buprenorphine.  The first can be overcome by using a sufficient dose of opioid agonist, on the order of 60 mg per day of oxycodone-equivalents or more.  The second can be handled by either stopping the buprenorphine a couple weeks before agonists are required—something that most patients on the medication find very difficult or impossible to do—or by reducing the dose of buprenorphine to 4-8 mg per day, starting the day before surgery and continuing through the post-op period.  Given the long half-life of buprenorphine, it is difficult to know exactly how much remains in the body after ‘holding’ the medication.  That fact, along with the difficulty patients have in stopping the medication, leads some physicians (including myself) to use the latter approach- i.e. to continue 4 mg of buprenorphine per day throughout the postoperative period.  People taking 4-8 mg of daily buprenorphine say that opioid agonists relieve pain if taken in sufficient dosage, but the subjective experience is different, in that there is less ‘euphoria.’
Important points:
Patients on daily maintenance doses of buprenorphine do NOT receive surgical analgesia from buprenorphine alone, as they are tolerant to the mu-opioid effects of buprenorphine.
The naloxone in Suboxone does not reach the bloodstream in significant amounts, and has no relevance to the issue of post-operative pain and Suboxone/buprenorphine.
Discontinuation of high dose buprenorphine/Suboxone results in opioid withdrawal symptoms within 24-48 hours, similar to the discontinuation of methadone 40 mg/day.
Normal amounts of opioid pain medication are NOT sufficient for treating pain in people on buprenorphine maintenance.
Opioid agonists will NOT cause withdrawal in people taking buprenorphine.  Initiating buprenorphine WILL precipitate withdrawal in someone tolerant to opioid agonists, unless the person is in opioid withdrawal before initiating buprenorphine.
Non-narcotic pain relievers CAN and should be used for pain whenever possible in people on buprenorphine to reduce need for opioids. Note that Ultram has opioid and non-opioid effects; the opioid effects are blocked by buprenorphine.
I have had success in people taking 4 mg of buprenorphine/day, using oxycodone, 15-30 mg every 4 hours.  Some patients can control their own intake of oxycodone while on buprenorphine, but some patients CAN’T.  Overdose IS possible, if patients take excessive amounts of the opioid agonist. Consider providing multiple prescriptions with ‘fill after’ dates, each for a very short period of time (e.g. 2 days each) to that patients do not have access to large amounts of opioids at one time.
For longer post-operative periods I have used combinations of long and short-duration agonists, e.g. Oxycontin 20 mg BID plus oxycodone, 15 mg q4 hours PRN.
The risk of death is significant for opioid addicts not on buprenorphine.  Buprenorphine/Suboxone has opioid-blocking effects that reduce risk of overdose and death.  Asking a person to stop or ‘hold’ their Suboxone is introducing significant risk of injury.  Opioid addicts are NOT generally able to stop Suboxone without replacing it with illicit opioids.
J Junig MD PhD

Buprenorphine, Suboxone, and Chronic Pain, Attitudes…

In my last post I mentioned some of the other blogs out there… one such blog is ‘subsux’.  First let me say that I find the name funny– I waste money buying interesting domain names, and that one is certainly catchy.  But beyond that compliment, I don’t agree with anything there– I visited and read through some of the posts, and found a great deal of nonsense, mixed in with some anger and resentment, and sprinkled with ‘holier than thou’ attitudes toward recovery.
Before going off on attitudes I want to correct something I read at that blog.  I read the same thing at a different blog as well, in a comment signed with the name  subsux.  The comment said that ‘it is illegal to prescribe Suboxone for pain in the US’.  This is a perfect example of what I have been griping about lately when I write about ‘misinformation’– the comment is simply wrong!  Not only is it wrong– it isn’t even close!  It has NEVER been ‘illegal’ to use Suboxone for pain, or to use any buprenorphine product for pain, at least in the US– I don’t know about elsewhere, but the writer specifically stated ‘in the US’.  IN FACT, doctors don’t even need the DEA waiver to treat pain with Suboxone!  ANY doctor can treat pain with Suboxone, providing they can prescribe any scheduled narcotic.  If a doctor can write for vicodin, he/she can write for Suboxone!  If the doc is treating opiate dependence, he/she needs a DEA waiver.  He DOESN’T ne ed the waiver for using Suboxone ‘off label’ to treat pain, or even to treat depression!  Unfortunately, many docs do not know this fact, and neither do many pharmacists, so it can be hard to get docs to write it for pain.  But that is a far cry from being ‘illegal!’
The comment was from a person who claims to be ‘from’ the blog– I don’t know if it is from the blog owner, but my guess was that it is from the blog owner.  Why would a person write something like that?  Again, it is very far from the truth on numerous fronts…  any doc reading it would recognize it as a BS comment simply because the medical system doesn’t work that way, where it is ‘illegal’ to prescribe drugs for one thing and not another.  The only case like that I can think of involves agonist opiates;  it IS illegal to prescribe agonists like methadone or oxycodone to treat ‘withdrawal’ without a special license (the one methadone clinics have).  Even then, the use is highly restricted.  There are exceptions, but the exceptions are narrow;  a doctor can DISPENSE a narcotic to treat withdrawal for up to 72 hours.  Note that he/she can’t PRESCRIBE the narcotics– only DISPENSE them.  The blog writer is so wrong that it can’t just be a ‘mistake’.  Instead the comment must be ‘willful BS’.  Why would a person write something, with deliberate intent to deceive the readers?
I don’t know the answer, and I don’t know why is there so much anger about Suboxone out there.  I get some of it– the people who write that their recovery is better than someone elses– because that is just human nature.  Insecurity breeds contempt.  I get the methadone lobby recognizing the destruction of their industry by the introduction of a ‘better mousetrap’.  But I don’t understand most of the silliness out there with Suboxone.  I do caution you to be very, very careful about what you believe.
The good news for pain patients is that soon, buprenorphine will be widely available for the treatment of chronic pain.  There are a number of studies going on right now– in fact, I encourage you to check out clinicaltrials.gov and search under ‘buprenorphine’– studies on pain, buprenorphine patches, buprenorphine implants, combining buprenorphine with SSRIs…  there is a great deal of excitement out there about the use of buprenorphine, and for good reason.  I find it to be a wonderful alternative to opiate agonists in pain patients because it allows the patient to avoid losing his mind to opiates.  The medication just doesn’t get inside the person’s head the way that agonists do.
With all this talk about buprenorphine, and my blog, and my clinical practice, I must really love buprenorphine… right?  Wrong.  I would much rather treat chronic pain with medications that have NO opiate effects, if possible.  I would also MUCH rather have an opiate addict discover AA, NA, or any other 12-step program, and use that to get and stay clean.  After all, that is how I did it.  But I recognize that I had a special situation;  I was being drug tested by the state twice per week;  I had to complete an ‘open-ended’ treatment program in order to have any hope of working as a doctor again (and they kept me for over three months!); and I had to stay in aftercare for at least 5 years in order to work as a doctor (I was in formal aftercare for over 6 years, and I still go to meetings).  Most addicts don’t have the same situation– and most addicts don’t go into residential treatment until they lose virtually everything they own.  Many die before getting there.  And so I am thrilled that Suboxone can help even THOSE people– the people who used to just die, get buried, and get forgotten.  Is Suboxone a perfect, all-in-one solution for opiate addiction?  Of course not.  But wow– what an amazing step forward  it is for many, many people.