Taking opiates for pain… on Suboxone.

Question:

hi doc,

i am a 35 year old man with a very active career and full life with 10 years recovery from alcoholism.

i struggled with ongoing pain issues including migraines since age 10 and a diagnosis of fibromyalgia.

i have AA sponsees, a very good spiritual life, and in general love my life, with the exception for being knocked down hard from three day headaches. i eat very well, am in great shape physically and otherwise have a good mental outlook. i see an acupuncturist regularly as well as a massage therapist bi-weekly.

in any case, i found myself abusing my pain medication last year and am now on 16 mg suboxone 2x a day. i had a knock down drag out month emotionally and then another injury that put me over the edge. i had strong narcotics at my displosal and then began abusing them to numb myself from physical and emotional pain. fortunately i came clean to my friends and family after only one month of abuse and decided to do treatment. i have way too much to lose in my life.

for the most part, suboxone has been incredibly helpful. i am in an out-patient program and am on half time disability. this past week i was hit with one of my monster migraines, completely debilitated and wanting to put my head through the wall, except that i couldn’t move because of the nerve pain in my face from inflammation.

my addiction doc and my pain doc both said to go to the ER, where it would be ok to use the dilaudid shot that always works for me. i had already taken torodol at home, which was doing nothing.

my question is this, can i intermittantly treat these monsters with narcotics and remain on suboxone?

suboxone has actually been very very helpful for the muscle pain and daily headaches. i feel truly stuck. the pain issues are real, no matter how much mind of matter, prayer and juggling other medications that i have done for the past ten years, i get one of these 72 hour monsters anywhere from no times in a month to once a week. it depends on what is going on in the air with the weather and pollen.

any thoughts?

i have friends who can hold medication for me, i just hate the ER ordeal as it is a waste of time for me and the physicians who probably would rather be treating more critical patients (even though the pain in my head has me wanting to die)

thanks so much,

XXXXX

Answer:

Hi XXXX,

Ouch! The combination of chronic pain and opiate dependence puts a person in a tough spot, as you have learned all too well. There is no great solution, and unfortunately you will quickly find that doctors are uncomfortable when they are at a loss, and they take that discomfort out in ways that sometimes makes patients feel as if they are doing something wrong. So my first comment would be that if you start to feel a bit paranoid and misunderstood, the reason is because your doctors won’t want to really understand what is going on– instead they will try to ‘pigeon-hole’ you into certain categories, particularly into the ‘addict’ category. If you get angry about that, it will only reinforce that opinion. So try to understand ‘how things are’, and do your best to work with the medical system with all of its flaws.

My best answer will probably leave you unsatisfied– but opiates are just a dead end for chronic pain. There are many reasons that I have come to that conclusion over the years… tolerance always takes away the vast majority of the analgesia from opiates; addiction always becomes a problem eventually (despite the oft-heard statement that people taking opiates for real pain will not become addicted); and the emotional and physical withdrawal from opiates makes life a constant struggle. There are other reasons that are just as important but more difficult to understand and accept; when pain patients are using opiates, their pain complaints eventually become very intertwined with psychological factors that are not really pure addiction, but that have addictive components. For example, a patient who is trying to avoid opiates will start thinking about how ‘maybe the pain is so bad that an opiate is justified’… that idea will grow like a weed until the patient is convinced that the opiate is absolutely necessary. I have watched that ‘weed’ grow in people over and over, sometimes over a week, other times over an afternoon– I will get a series of e-mails where one can see it clearly, and watch as it grows– watch as the patient loses more and more insight and perspective, until they have entirely lost sight of the original position they were in. I have considered that perhaps the pain is increasing and that is what causes the insight to disappear, but after enough times I know that there is a different reason– that the ‘addict inside’ gets a foothold and takes over, actually changing the person’s personality. It is a scary and fascinating thing for an intelligent person to be susceptible to something akin to a ‘split personality’… and the only way to avoid it completely is to avoid opiates completely.

But… you probably already know that, and have decided that there is just no way to make it without opiates. I don’t know if that is completely valid because of your degree of pain, or if the ‘addict inside’ is doing the talking. So I will just appeal to the ‘true you’ to really give it some thought– in light of the fact that active opiate addiction will eventually rob a person of everything he/she holds dear. I do think that a person on a sufficient dose of Suboxone, by having the cravings suppressed, is more likely to be ‘running the show’ as far as the ‘split personality’ thing goes… but not in all cases. I also admit that in spite of tolerance some chronic pain patients seem to get a long-term benefit from a small, constant level of a potent opiate. I have no idea why that is the case.

You are talking about something a bit different in that intermittent dosing would avoid some of the tolerance, although just being on Suboxone is going to keep your tolerance constant at a raised level. If you wanted to get pain relief from an opiate it would take a significant dose, even if you waited for the suboxone to leave your system (and that takes a long time). To be more specific, I sometimes need to provide pain relief for a Suboxone patient who is having surgery (I have had three patients deliver babies over the past three months– two by C-section. The moms and babies are fine, by the way). If a person took 8 mg of Suboxone in the morning (I usually maintain people on 16 mg once per day) it is very, very difficult to relieve postoperative pain– it requires going to an ICU and taking 20-50 mg of morphine every 2-3 hours. Stopping Suboxone for three days helps a bit, but still results in the need of large doses of opiates to relieve pain– I have prescribed oxycodone, 30 mg every 4-6 hours with some success at that point. So to answer your question from a practical standpoint, it is a very difficult thing to do– to use opiates for intermittent analgesia while on Suboxone. You mentioned that the headaches can last 72 hours– I suppose in those cases you could stop taking Suboxone and start taking oxycodone at doses of 30 mg or so… and after a day or two they may start working. Not a good solution.

People do not generally get sick from being on Suboxone and adding an opiate agonist. They precipitated withdrawal occurs in the other direction– when a person on opiates goes back to Suboxone. A person with an intermittent need for opiate agonists is not a great candidate for Suboxone– although the key word is ‘need’. Given the destructive power of opiates, how genuine is the ‘need’? Only you can answer that question. I do not want to imply that you are ‘faking’ anything– I have no idea what your pain feels like. But if there is any way for you to tolerate it using relaxation, etc, that is called for here. Finally, a Suboxone patient who may need opiates should probably be on a lower maintenance dose. Suboxone relieves withdrawal at very low doses– down as low as 2 mg per day. Higher doses are usually required to stop cravings. But finding a compromise of 4-8 mg per day may help to get some relief from opiates on rare occasions.

I re-read your message and note that you say you take 16 mg Suboxone per day times 2? If that is right, that is quite a high dose– about double what is used on average and above ‘indicated’ dose.  I recommend talking to your doc about at least getting down to 16 mg, and maybe lower, as there will be no hope for opiates to act with that much blockade going on.  You may even be getting headaches from the high amount of naloxone in such a big dose of Suboxone;  Buprenorphine itself can even have an antagonist effect of its own at high doses.  In my experience, patients get little out of doses above 16 mg (presuming they are taking it correctly).  Patients can, however, get into a misguided dosing schedule where they think they need to dose more than once per day–  in those cases the symptoms they feel late in the day (sweats, etc) are ALWAYS a product of the mind, and not true withdrawal.  One can easily prove that to one’s self because if the person doesn’t happen to have Suboxone to treat the ‘symptoms’, or the person gets distracted, the symptoms are gone 15 minutes later– not the case with real withdrawal.  This is a tangent, but I strongly encourage patients to dose ONCE per day, in the morning.  Use discipline in regard to those late-day feelings, ignore them, and they will go away completely in a few days.  If you feed them by dosing, THEY WILL GROW.

A couple random thoughts…

Some patients with chronic pain will claim that taking an opiate relieves their pain, even while they are on Suboxone. I don’t have an explanation for why that happens– I tend to ascribe it all to a placebo effect that is perhaps ‘jazzed up’ a bit by addiction. But when I discuss it with the affected patients they do not buy a placebo effect– they insist that it is ‘genuine’ pain relief. The thing is… the placebo effect is just as ‘genuine’– patients getting pain relief have the same subjective drop in pain sensation as do patients getting ‘real’ pain relief.

Opiates often cause headaches, and some patients get in a cycle of post-analgesic headaches causing the person to take more opiates, etc…

Some people find that tramadol (Ultram) is helpful. Don’t confuse it with toradol– which is an NSAID– tramadol has several actions including increasing central serotonin and also activating non-mu opiate receptors (which are not blocked by buprenorphine). Two side effects are important– tramadol can cause seizures, and the combination of tramadol and antidepressants can cause ‘serotonin syndrome’, which I will let people look up.

Many times people confuse migraines with sinus headaches– which are treatable using local application of a strong decongestant and a med to break up mucous like guaifenesin. I mention this because of your mention of ‘pollen’ and other ‘air things’. If you are having visual scotomata then you are likely indeed having migraines. Have you tried all of the suppressive therapy– including the newer one, Topiramate (Topomax)? Have you tried the different abortive treatments for migraine? I hate ERs also, and would do anything to avoid them… but if you are there, ask if they have anything else that they use in such situations– I have heard of ERs using nitrous oxide, oxygen, IV toradol…

You mentioned ‘nerve inflammation’ in your face- I wasn’t sure if you were referring to the migraines or to something else. For ‘neuropathic’ pain, anticonvulsants sometimes help (like Neurontin, carbemazepine, etc).

I know I am grasping at straws here, and I wish there were better options.

Take care,

JJ