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PostPosted: Thu Jul 19, 2012 1:04 am 
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I found this question interesting, and may be worth a discussion.

Is it worth treating people who have a low tolerance to opioids with buprenorphine?

ie if a person is dependent on some of the relatively "weak" opioids, like codeine or hydrocodone, should they be treated with a drug that will inevitably push their tolerance a lot higher? Reason being that buprenorphine's ceiling is somewhere around 8-12mg. If a person only requires a Suboxone starting dose of 1mg, eventually as their tolerance climbs their dose will get raised to the ceiling level. As a result of their Sub treatment, they will therefore end up 8-12x physiologically more dependent on opioids than they were on Vicodin!

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Hydrocodone (Vicodin) Addiction and Buprenorphine
by SUBOXDOC on JULY 16, 2012


I recently accepted a young man as a patient who was addicted to hydrocodone (the opioid in Vicodin), prompting a discussion about treatment options for someone who hasn’t been using very long, and who hasn’t pushed his tolerance all that high. Perhaps it will be informative to share my thought process when recommending or planning treatment in such cases. In part one I’ll provide some background, and in a couple days I’ll follow up with a few more thoughts on the topic.

Most people who have struggled with opioids learn to pay attention to their tolerance level—i.e. the amount of opioid that must be taken each day to avoid withdrawal or to cause euphoria (the latter about 30% more than the former). For someone addicted to opioids, the goal is to have a tolerance of ‘zero’—meaning that there is no withdrawal, even if the person takes nothing. That zero tolerance level serves as a goal, making having a high tolerance a bad thing, and pushing tolerance lower a good thing.

Tolerance is sometimes used as part of the equation when determining the severity of one’s addiction. But looking at tolerance alone can be misleading. Tolerance is a consequence of heavy use of opioids, and also a cause of heavy use of opioids. Tolerance usually goes up over time, so having a high tolerance probably correlates with length of addiction in some—- but not all— cases. Tolerance is also strongly related to drug availability. A person with a severe addiction, who only has access to codeine, will likely have a lower tolerance than a person with a more mild addiction, who has free access to fentanyl, oxycodone, and heroin.

I think it is more appropriate to measure the ‘severity of addiction’ by the degree of mental obsession that the patient has for opioids. Tolerance is one piece of information in determining that obsession, but tolerance alone can be misleading.

To get a sense of the obsession for opioids, I look at many factors. Has the person committed crimes to obtain the substance? Violent crimes? What has the person given up for his addiction? Has he been through treatment? How many times? How long did he stay clean after treatment? Have his parents or spouse thrown him out of the house, and if so, does he still use? Did he choose opioids over his career? Over his kids?

Answers to these questions provide a broad understanding about the addicted person’s relationship with the substance—an understanding that is necessary when considering the likely success or failure of one treatment or another. It is also important to consider the person’s place in the addictive cycle—i.e. early, likely in denial, cocky, with limited insight– or late, after many losses, more desperate—and perhaps more accepting of treatment.

I am a fan of buprenorphine as a long-term treatment for opioid dependence, as readers of this column know. I consider opioid dependence to be a chronic, potentially-fatal illness that deserves chronic, life-sustaining treatment— and buprenorphine, in my experience, is a very effective treatment in motivated patients. But tolerance becomes a factor, when considering buprenorphine for THIS patient.

Buprenorphine has a ‘cap’ or ‘ceiling effect’ that allows the medication to trick the brain out of craving opioids. In short, as the blood or brain concentration of buprenorphine drops between doses, the opioid effect remains constant, as long as the concentration is above the ceiling level. In order to achieve the anti-craving effects of buprenorphine, the dose must be high enough to create ‘ceiling level’ effects. If buprenorphine is prescribed in lower amounts—say microgram doses— the effect is identical to the effects of an agonist, since the dose/response curve is linear at lower levels.

Buprenorphine is a very potent opioid, and the effects of the medication are quite strong at the ceiling level. Comparisons to other opioids will vary in different individuals, but in general, a person on an appropriate dosage of buprenorphine develops a tolerance equivalent to that of a person taking 40 mg of methadone per day, or approximately 60-100 mg of oxycodone per day.

A person taking even a dozen Vicodin per day has a much lower tolerance to opioids. Such a person who starts buprenorphine treatment will obtain a very significant opioid effect from the drug— unless the dose of buprenorphine is raised very slowly over a number of days. And in that case, the person’s tolerance level would be pushed much higher.

So if our current patient starts buprenorphine, he will have a much higher opioid tolerance if/when the buprenorphine is eventually discontinued. I receive emails now and then from patients who are angry at their doctor for starting buprenorphine, feeling trapped by the considerable threat of withdrawal from stopping the drug. But at the same time, taking hydrocodone and acetaminophen in high amounts creates the risk of liver damage from the acetaminophen, as well as the considerable risks from opioid dependence.

And so the dilemma. Should buprenorphine be considered in such a case?


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PostPosted: Thu Jul 19, 2012 1:23 am 
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I think it's a great article and can't wait or part 2. I don't know what to say in a discussion about this... I mean, his point about the level of the patient's obsession with obtaining opioids and The consequences faced by the patient and whether or not they were able to stop in the face of heavy duty consequences. Choosing Vicodin over their kids for example. I think that person would be a great potential sub patient assuming they want to stop using vicodin or whatever.


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PostPosted: Thu Jul 19, 2012 1:31 am 
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I think that once a person falls in love with opioids, whether it's codeine or heroin, they're pretty much destined to go down the road of addiction til they hit a point of severity where they can take no more. So if they're willing to put opioids before all that's good in their life, they're destined to increase their tolerance anyway.

On the flip side. I knew a guy in NA who was on methadone because he was using OTC ibuprofen+codeine pills. He ended up on 110mg methadone. He looked really fucking stoned on that dose of methadone. He woulda probably ended up with 50+ x the level of dependence as a result of being on that dose of methadone. At the time I thought the doctor was hugely irresponsible. If a person isn't that physiologically hooked on opioids, and their addiction is more psychological at that early stage of addiction, then perhaps it would require a psychological intervention over something physiological and potentially damaging like methadone or Suboxone.


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PostPosted: Thu Jul 19, 2012 2:30 am 
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tearj3rker wrote:
I think that once a person falls in love with opioids, whether it's codeine or heroin, they're pretty much destined to go down the road of addiction til they hit a point of severity where they can take no more. So if they're willing to put opioids before all that's good in their life, they're destined to increase their tolerance anyway.

On the flip side. I knew a guy in NA who was on methadone because he was using OTC ibuprofen+codeine pills. He ended up on 110mg methadone. He looked really fucking stoned on that dose of methadone. He woulda probably ended up with 50+ x the level of dependence as a result of being on that dose of methadone. At the time I thought the doctor was hugely irresponsible. If a person isn't that physiologically hooked on opioids, and their addiction is more psychological at that early stage of addiction, then perhaps it would require a psychological intervention over something physiological and potentially damaging like methadone or Suboxone.


This is an excellent point. I fell in love with opiates. The physical withdrawal just reinforced the need to use. Had I had a intervention setting and the right support at the right time, I beleive I could have been swayed to stop and look for other things in my life to fill that void. Though I have no real regrets. I view suboxone as an anti depressant and wish that others could see it in that way also.


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PostPosted: Thu Jul 19, 2012 3:25 am 
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I would view it as an anti-depressant ... if I didn't still get depressed while on Sub.


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PostPosted: Thu Jul 19, 2012 6:58 am 
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Tearjerker wrote:
Quote:
ie if a person is dependent on some of the relatively "weak" opioids, like codeine or hydrocodone, should they be treated with a drug that will inevitably push their tolerance a lot higher? Reason being that buprenorphine's ceiling is somewhere around 8-12mg. If a person only requires a Suboxone starting dose of 1mg, eventually as their tolerance climbs their dose will get raised to the ceiling level. As a result of their Sub treatment, they will therefore end up 8-12x physiologically more dependent on opioids than they were on Vicodin!


That is quite a scary thought for me. My DOC was hydrocodone, though like most addicts, I'd take percs, or anything else, if I couldn't get hydros. I like to think that suboxone has done more for me than just address the hyrocodone addiction. Like this article says, the decision to go on sub for me, was moreso because of the quality of my life. The things that I was putting on the back burner in order to fuel my addiction, were insane. Though my children were never really less important to me than drugs, I certainly allowed them to take a back seat to my using. I lost custody of both of them, and my maternal rights were terminated to one of them. It kills me now. I let my house get forclosed on, let my car get reposessed, and successfully destroyed every single relationship I had.

My tolerance to hydros were through the roof! I would take 5 or 6 10/650 lorcet, every single morning, just to function. I can't even imagine what i was doing to my liver. The amount of money I spent on all those doctors, was just as insane.

So, for me, sub did address both my addiction, quality of life, and as an added bonus....it addresses my pain and depression. I cannot ignore the facts though. The fact that my tolerance is currently higher than it was on hydros, is definately something to think about....

Thanks TJ! Good article!

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PostPosted: Thu Jul 19, 2012 12:11 pm 
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Years ago, when my opiate addiction first started, I was only taking 4 Hydrocodone 7.5's per day (30mg total). I had been on them for over a year and tried to quit. I made it 30 days and I said, "Fuck This Noise." The acute wd had passed, but the frickin' PAWS were killing me. I went right back to the Hydro's. Had I taken Suboxone back then, I believe I'd be years and years ahead of where I'm at now.

At the time, my tolerance may have been low, but my addiction was strong. I had been using weed and cocaine for the previous 13 years, then the Hydro's.

Anyway, Suboxone gave me time enough away from active addiction to help me get where I'm at today. Did it push my tolerance to opiates up? It probably did, but that's a small price to pay to be where I'm at today.

Tolerance shouldn't be the deciding factor in getting on Suboxone. Like the others have said, it's more about the nature and strength of your addiction.

Until better medications come along, I think Suboxone or Methadone are still great choices.....if used properly.

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PostPosted: Fri Jul 20, 2012 5:43 am 
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FYI - this is under the category of Dr. Junig's blog posts (Suboxone TalkZone). We can put those discussions in that category from now on, K?

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PostPosted: Wed Nov 28, 2012 7:45 pm 
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Heres my thoughts. There are two major benefits to subs. Maintaining the physical side of addiction and also healing the mental side. When your taking suboxone as prescribed and staying away from old connects, the mental part of the addiciton is in remission. Obviously the physical part is still there. If someone on vicodin has such a crazy mental addiction that there willing to INCREASE the physical part just to fix the mental part then so be it. Let them do it. Its there choice. The prescribing dr should definitely explain that they will be increasing there physical addiction to opiates.

I mean to that person that said there tolerance was through the roof and they had to take 6 vics just to function. Lets just say that during my heroin use once i took 10 vicodin 7.5s and i was still sick. Even with this crazy tolerance, 8mg of sub is enough to keep me well. So using 8mg would increase your tolerance. If your ok with that then thats fine, its just doctors should be making the patients aware that the sub WILL be making there physical addiction worse.


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