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 Post subject: My induction problems...
PostPosted: Tue Jul 03, 2012 9:59 pm 
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Hello! I'm new here. I'm a CPP whom has been stabilized on a daily regime of ER/IR opioids for a couple years. I'm also about to graduate from Dental School and going into practice with family whom was strongly against me practicing while on the strong medications. I didn't abuse, but as Im sure many can relate to regardless - my family doesn't understand tolerance to medication, etc etc. So, I was given the ultimatum of quitting those meds, or not having a future job in the family practice.

I actually started pain management on subutex for pain, but did switch to stronger meds when the subutex wasn't controlling the pain any longer and my daily performance was suffering as a result at school. So, after a family meeting with my pain Doc, everyone was on board with me going back onto subutex. There is a little bit more drama to the story, which I won't totally delve into, but basically a very misinformed member of my family called my pain Dr and left a very nasty message about suing their practice for prescribing me strong narcotics. I was a little upset since they chose to not speak with me before leaving such a nasty message for my otherwise great physician. It obviously scared the hell out of them, and I feel lucky to still even be a patient quite frankly.

I digress. One health issue I combat infrequently is acute pancreatitis. I had my first bout with it probably 2.5 years ago. I shortly thereafter had my gall bladder removed. I've continued to have it occur no less than once every 6 months. If you've never experience it, it's awful.

Well, I chose to induce on subutex this past Saturday, June 30th. I knew the routine, and had waited the appropriate amount of time. However, at about 4PM I started to have the early symptoms of AP. I wasn't 100% sure or not, but when I say that, I mean I was HOPING it was withdrawal. So, by 5PM - I was having severe stomach pain and was fighting back the vomit. I wanted to wait a little bit longer before inducing, however I knew it was OK... and by that time, I was feeling SO horrible, I thought that MAYBE either the subutex WILL do it's job as a pain reliever and help with the stomach pain if it is AP, or if it was withdrawal -- i'll be feeling better in no time.

Well. Wrong on both accounts. While I felt the other symptoms of withdrawal subside, the stomach pain and naseau w/ vomiting became incessant and horrendous. I vomited once every 20-30 minutes for the next 12 hours, but never once did I feel like I didn't NEED to throw up for about 36 hours. The stomach pain is finally tolerable as of today - Tues, July 3rd.

This is the first time I haven't gone to the hospital for my AP -- because I knew that they could not have done much for my symptoms due to the subutex. I felt like a damn PRISONER.

Over the course of that Saturday evening, I ended up taking 6mg of subutex in total. Since I had already crossed that path into receptor bondage, taking more was all I could do to try to ease the pain. Luckily, I had 8mg Zofran tabs that I was able to take (albeit which didnt help much until I could keep them down).

I refrained from taking anymore Subutex, and suffered (in every sense of the word) for the first 48 hours until a prescription of Percocet that I had was able to finally provide SOME relief. All attempts prior to that mark were entirely futile, and I felt utterly betrayed by the subutex :(

Now that Im at the 72 hour mark, the Perocet is finally reasonably affective, and I've gotten the upper hand. Unfortunately, I've had to use 2-3x the amount to get the appropriate clinical effect, so will also be faced with possibly running out before I'm totally healed. The Percocet is the only reason I've been able to attend to my life today, and did what I could on Monday. Luckily with the holiday tomorrow, I get to rest.

So, anyway. Hopefully in a couple of days, when I have no other choice quite frankly, I'll be over the worst of it and can re-induce to stave off withdrawal, and pray that it won't flare up in the meantime.

I don't really have much in the way of a direct question, but am open to comments and suggestions. I could have tried to go to the ER, but wow -- what a STORY that would have been for the attending!? THey would have thought I was CRAZY. So, I just chose to not even go there. Such a horrible ordeal. I can handle pain -- but vomiting/naseau -- that was induced by pain moreover -- kill me!

There are no laws or even legal/ethical standards in the Dental community in regards to stabilized chronic pain medication, other than the wishes of my future employers/my family. I'm willing to give the subutex a go, and try alternative therapies in the meantime... however Im scared to death of situations like this one. I also suffer from no less than 1x/year kidney stones which never fail to get lodged and require surgery. I suppose I'll have some of the guidelines for treating acute pain printed out and ready to go in the future for cases like this, but it does suck that the literature is coincident with talk of addiction. (not judging, I know how easy it is, and I go thru the same withdrawal as any addict!!)

/rant end
;-)


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PostPosted: Tue Jul 03, 2012 10:07 pm 
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...oh AND it sucks that I now have to go through the withdrawal process all over again once this is over! BLEK!

I guess ONE question I do have, is if ANY LOW dose of the sub will be LOW enough to allow full agonists to allow breakthrough/acute pain relief in this sort of situation? I plan to maintain on 2mg or hopefully LESS per day. I still am concerned that even MICROgrams of bupe is enough to block full agonists...

any opinions or otherwise?


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PostPosted: Tue Jul 03, 2012 10:38 pm 
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Geez, that just sucks that you suffered like that. I'm so sorry to hear it.

So if I understand you correctly, because of your health needs you're on high doses of pain meds, but you do not abuse or overtake them and you are dependent only. But your family is also going to be your career/job, and they have a hand in things so it's been decided by all involved that sub is your best bet - am I correct? Mainly though, you're not an addict, but do you plan to stay on sub for your pain control needs? If so, am I to understand you want to be at the lowest dose possible to achieve said pain control? I take sub for pain and I've found that although some people do OK with pain relief at lower doses, personally, I need much higher doses to get decent pain relief. I get much better relief at 8 mg than I do at 4 mg. I can't imagine how little I'd get at 2 mg or below, much less in the microgram range. Also, keep in mind that your tolerance to opiates will dictate your dose, not how much you would like to take.

When you induce this time, you'll be in moderate withdrawals. Will you be using the COWS induction aid? I would recommend that you do. Here's that link: http://www.naabt.org/documents/cows_ind ... _sheet.pdf

Usually it's said to be in mild to moderate w/d, but I wouldn't take any chances after going what you went through. When the time comes, you can start out with a very low dose, like two mg. That way, just in case it goes wrong again, it won't be nearly such a violent reaction. (How much did you take last time before you became sick with P/W?)

After about a half hour or so and no reaction occurs, you can take an additional 2 mg. That's still a low dose. Most people start out by taking 4 mg first. But we're starting you out slowly, remember. Take more every 30-60 minutes until you're completely out of withdrawals and feel "normal". That should hold you. If later in the day you start to feel withdrawals or cravings, then take some more, like 2 or 4 mg (depending on the total you took earlier). Then the amount that you took that first day will equal the dose you'll take all at once the next morning. That will be your daily dose. (Ideally.)

Bupe in micrograms shouldn't block other opiates. In those really low doses it's really an agonist and not the partial agonist that it is at high doses. It's the buperenorphine that's been used as a pain med for decades now, in micrograms. So no, at that low of a dose it won't block other opiates. If that's the kind of pain control you want, you might not need subutex. You might want to consider Butrans, the patch. That will depend a lot on where your tolerance turns out to be, which you'll see when you induce. These are all things that you'll need to consider and figure out. Anyway, sorry to be so long-winded.

Good luck.

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-I'm only responsible for what I say, not for what you understand.


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PostPosted: Tue Jul 03, 2012 11:04 pm 
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Hatty:

After having read through many posts and seeing your responses to others, I'm happy to see your arrival into my own! I welcome and appreciate your insight as someone I consider a resident "expert" here. So, first of all: thank you.

You hit the nail on the head with all that you had said. My parents own the Dental practice that I'm about to enter, and have owned it now for 30 years. I depend on it for my success. I've also depended on the pain meds to allow me to not feel the lumbar radiculopathy so that I could focus on treating my own patients. They however are not comfortable with the medication I was on (Opana ER), but seem to be OK with the subutex. Having used it initially for pain relief, and knowing that it will perpetually/indefinitely keep withdrawal at bay -- I'm OK with giving it a go -- I have to be. I'm trying to see the bright side, especially after reading how well so many others "feel" from their maintenance with bupe. I also do welcome the absence of the ups/downs that came along with even regular, prescribed dosing. Waking up in some stage of withdrawal every morning was never fun.

Well, anyhoo. It's good to know that a low dose could allow for an acute pain situation to be made better. It's also interesting to hear that you feel relief from your chronic pain at higher doses than the ceiling. I'll do some playing around and see what works for me. I'd like to stabilize in an area that could allow for full agonist rescue in the event of say a kidney stone, or acute pancreatitis -- but could have the option of taking more to curb a particularly painful flareup of my chronic pain. After I do feel that I am "maintained", I will certainly consider the Bupe patch. Honestly don't know a thing about them. However also was never a big fan of a patch, considering I tried the fent patch (Rx'ed) a couple times in the past.

Do you have any advice on the timing of, or when I would want to possibly try switching to the patch -- after starting with the sublingual subutex?

As far as the COWS induction goes, "the dude abides" ;-)


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PostPosted: Tue Jul 03, 2012 11:41 pm 
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Thanks, you're so sweet!

It all depends upon your tolerance as to what you'll need. If it turns out you need a very low dose of subutex, then Butrans, which is meant as strictly pain control...it's a regular, full agonist (it's just bupe), might be something you could switch over to later. How much Opana are you taking? That's what I used to take before I started sub 3.5 years ago. The thing is with Butrans, it's not for addicts, so it's regular dosing for people with regular tolerances or even opiate-naive. Suboxone and subutex are meant for addicts, therefore the use of high dose bupe. It's got to account not only for our tolerances, but also it needs to be above the ceiling so that we don't get additional effects, including euphoria, ups and downs, and to block other opiates as well as to have a solid blood level so that we always feel normal.

Normal sub addiction dosing is once per day, but when it comes to dosing for pain, it's best to dose every 4-6 hours with sub. So keep that in mind when you find your dose that you'll be splitting that up into 2-3 doses per day, depending on your pain.

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-As I have grown older, I've learned that pleasing everyone is impossible, but pissing everyone off is a piece of cake.

-I'm only responsible for what I say, not for what you understand.


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PostPosted: Thu Jul 05, 2012 11:24 pm 
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I wanted to post a follow-up now (as well as just talk!) that I've recovered from the symptoms of my acute pancreatitis, stopped the Percocet, and successfully switched to my subutex for my "pain management". I was muscled into this treatment, but am keeping an open mind despite the fact I once outgrew the potential of this drug for its pain tolerating effects before switching to full agonists; Hatty: Up until about 10 days ago, I was on Opana ER 15mg TID and 4mg Dilaudid PRN breakthrough, and thanks for your second response :). As I said though, I won't miss ups/down even with regular prescribed dosing - being the nature of full agonist dependence IMO.

Anyway. The pain/vomiting/naseau subsided, my apetite returned (again, all from pancreatitis), and I stopped the Percocet yesterday evening at approx 6PM-ish. I woke up feeling OK, took some loperamide to help with the physical symptoms of withdrawal so I could see my dental patients at school, and headed off. I waited until 12PM noon or roughly 18 hours after my final dose of the FA opioid, and dissolved 2mg subutex sublingual. Over the hour, my symptoms improved and felt ok the remainder of the day. Still not feeling quite "normal", I've taken an additional 2mg split up in 1mg doses over the past 5 hours, and its now 9PM. I feel as good as I expect too, so will stop here for the day. I do have a marked headache though, and I don't get headaches.

I did read that Bupe is administered for pain on an every 6 hr schedule, but that's also with micrograms of the drug, and really for the more opiate-naive (it would seem). Dosing that often, unless I was using the BuTrans patch, Buprenex microgram IV/IM injection or the european Temgesic sublingual .2mg tab, would to me seem to just accumulate blood levels unnecessarily considering the dissociative constant at the mu receptor and half-life elimination. Since I'm more concerned about being able to treat my possible acute pain in the future than I am about my everyday chronic-pain, Im going to live with whatever pain relief I get from the dose I'm shooting for. In the name of pain management, however, I will split my dose up. BuTrans is definitely alluring considering my situation, but Im just too active physically to wear a patch - along with some super sensitive skin.

I plan on trying to initially stabilize on 1mg AM and 1mg PM. I'd likely to shortly thereafter stabilize on .5mg AM, .5mg PM.
I use the word stabilize like someone would who is using it for maintenance therapy because I feel like staving off withdrawal is probably the greater use I will obtain rather than pain relief as I am accustomed.

I spoke with a gentleman who also suffers from chronic kidney stones whom takes bupe everyday -- he is stabilized on 1mg or less perday, and has achieved adequate acute pain relief in times of need at the ER from a full agonist at a reasonable dose that an ER doc could actually be expected to feel comfortable with ordering.

Hatty -- I did want to comment on how you call bupe a full agonist at the low therapuetic pain doses. I understand the point you're trying to make, since in the opiate-naive, it sure "acts" as one. But that said, it is a partial-agonist at the mu-opioid receptor at any and all doses. The amount or dose does not pharmacologically change it's characteristic at the mu-receptor site.

Anyway! Just felt like blabbering. Maybe someone will find this little thread of some use.


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 Post subject: CPP
PostPosted: Fri Jul 06, 2012 2:14 pm 
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That is some informative reading Pulpitis. Is there some kind of dexterity test you could do to prove that the medications you take won't affect your ability to give good dental care? There are lots of CPP'ers out there functioning just fine and causing no harm.

I do hope you can receive adequate pain relief from the Subutex. At least with that medication it shouldn't affect your work in any way, especially if you are taking small doses throughout the day.

Hopefully soon we can call you Dr. Pulpitis!

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PostPosted: Sun Jul 08, 2012 10:29 pm 
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R62:

LoL. That's nice of you, and yea hopefully by this December I will have the ole Dr. title to feel good about ;)

I agree with you, stabilized CPP opioid treatment is something that high-functioning members of society, including professionals, live with everyday and by no means cause harm. I forget if I mentioned it, but there are no legal or ethical stipulations in the Dental profession that restrict or even regulate chronic pain opioids for Dentists. The past two years that I
ve been successfully treating patients in the school's clinic can attest to the fact that none of it has hindered any of my abilities. Unfortunately, my mom & dad have been privy to my treatment being part of my close knit life-support group, and have awarded themselves the ability to look beyond the fact of how un-interfering the treatment has been, and jump to demonize opioids. The fact that they are OK with bupe goes to show by itself that they don't understand opioid treatment considering bupe is one. However, it's been useless for me to push the subject, as supporting narcotics has been an easy battle to lose.
My Dad will retire within 5 years time, and at that time - being my own boss, if I'll need to switch back, I will. If my pain became debilitating in the mean time, Id either have to sit them down... or pursue practice outside of my Dad's practice. Id hate to need to consider that, but Im not letting chronic pain get in the way of doing what I love. I am fortunate enough to love practicing Dentistry, but its not the easiest profession on a lower back problem :(

Subutex has continued to provide some relief, enough to take the edge off. However Im scared that I'll grow tolerant to it like I did before.

I do have a question for anybody reading.

I'm on day 4 of the subutex, and despite the fact that I didn't abuse my old pain meds, Im still having this persistant depression that I didnt have before. I assume it's just because of the absence of full agonists, but can anyone relate? How long did that take someone else to get over?


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