Suboxone Talk Zone

I know from my radio show that I will need to talk by myself for awhile... I often get letters from patients that ask specific questions that can be answered in general ways. I will include my responses, blocking any personal information, and maybe others will read my opinions and learn from them. Today I received an e-mail from a patient complaining that she takes one 8 mg dose in the AM, and by noon she thinks it has worn off. She uses the suboxone for pain control; before suboxone she was a bit out of control with narcotic pain pills--we all know how it goes-- running out early and withdrawing, or always needing more, or fearing that her lecturing doc would stop prescribing. Hear is my response:

Dear XXXX,

Yes, I did receive your message. Clarify for me a couple things—when you say ‘by mid day you feel the same’ I’m not sure what you mean. Feel the same to when? To before you took the dose? And what feelings are you talking about—pain? Or withdrawal?

Every day, another study comes out looking at the unique way that buprenorphine acts in the body (buprenorphine is the active substance in suboxone). We now know that the action of buprenorphine at different doses can be plotted out to form a bell-shaped curve. To visualize how this works, picture the liberty bell sitting on the ‘x’ (flat) axis, and the outline of the bell represents the opiate effect of the drug, as the dose is increased going from left to right. To translate what that mean for the patient, the effect increases as the dose goes up to 2 mg, and then levels out for awhile (the bell has a wide, flat top). Then at high doses the drug blocks itself, and the activity decreases again. In a patient, that means that you will get some pain control out of the drug up to about 2 mg per day, but then higher doses have no significantly higher effect. At much higher doses the drug actually blocks its own opiate activity and causes withdrawal.

The other thing we know is that the drug is extremely long acting. A single 8 mg dose will prevent withdrawal for 3-4 days. I can be certain that when you take 4 or 8 mg, the level of drug in your system will be virtually constant for 24 hours. The fact that you feel less after such a short period of time suggests that other factors are at play—the psychological effects of opiates in opiate users is almost as strong sometimes as the effects of the drugs themselves. I have noted that my patients' reactions are consistent with the pharmacodynamics of buprenorphine. For example, people who taper off suboxone find that it is very easy to go from 16 or 24 mg per day down to 4 mg per day—there is no significant withdrawal for that move. But going down that last bit, below 2-4 mg, causes withdrawal.

For you, you will not get any increase in pain control at higher doses. In fact, if you took doses higher than 32 mg you may start to get less pain control as the drug blocks itself. Likewise, increasing the dose from 8 to 16 mg will not make it last any longer, as it is already lasting several days. I can easily prove that to you—just stop taking the drug, and you will find that on day 3 or day 4 you will have withdrawal as it finally leaves your body. The main benefit from raising from 8 to 16 mg is the drop in cravings at the higher dose.

In your case, there is certainly a strong element of relief that is connected to just taking a pill. I would have no problem increasing you to 16 mg per day, but it would cost more, and I doubt it will reduce pain much more effectively. There are some points that are important for you to remember:

Opiate users derive a certain comfort from the drama of taking substances. I don’t know if it is the distraction, the placebo effect, or the feeling of being more in control from taking a medication. This 'comfort' sometimes becomes important enough that the patient thinks it is something they really need. But be aware of the limitations of the medication. For chronic pain, there never is a magic bullet that will do all that we need it to do. We have meds that can take the edge off of discomfort, but most of the improvement in function will come from non-med sources.

Examples of non-med sources include first and foremost, exercise. Low grade exercise, and just as importantly gentle stretching, are the primary healing function for fibromyalgia and other chronic pain conditions. Without exercise and stretching, the patient will not improve, and if on narcotics will likely do worse over time.

Ibuprofen and Tylenol are often helpful adjuncts to narcotics, and are not a problem when taking suboxone.

It is common for patients who have taken higher amounts of opiates to become quite focused on the effects of the drug. A person without addiction will take a pain pill for pain, and the resume activity without a second thought about the medication. At the end of the day he/she is likely hard pressed to remember if or when the med stopped working. People used to taking opiates are hyperaware of when the drug sets in, when it levels out, and when it decreases. They lose the opportunity to find pleasure in whatever it was that they were going to do on that particular day, because the whole day becomes about the medication. Ideally, suboxone will allow the patient to confidently know that the med is working, and that it will last all day—so there is no need to think about it and wait for it to wear off. Try to see the way that opiates grab your attention, and try to distract yourself by taking up some other activity that interest you or that you enjoy. Pain is always at its worst when one is highlighting it with attention.

Anwer my questions when you get a chance. Let me know if you think 16 mg will be helpful, as maybe you are craving opiates a bit. Finally, make sure that you are putting time aside for stretching and exercise—at least an hour or two per day.

JJ

I'm off to watch some football. Go Pack!! Oh-- and please, don't be shy. Add your questions or comments.