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PostPosted: Wed Oct 29, 2014 5:00 pm 
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First a bit of a background: My wife has been a chronic pain patient since the mid 90's following a bad car accident and several neck surgeries. She was also diagnosed with Bipolar disorder and is a sexual abuse survivor (is that the right term?)

My wife has been on Morphine Sulphate and MS Contin for 10 years + and has recently switched to Suboxone because the Morphine no longer was providing satisfactory pain control and she did not want to go up on her dose. She was also having some serious cardiac issues that have diminished greatly since going off the Morphine (but they were already tapering before she started, so....)

The immediate reason I registered to this forum and I am posting today is because since she switched to Suboxone a bit over a week ago she has been on a sustained "manic" high that doesn't seem to go away.

She has had brief manic episodes in the past as well, but never for more than a day or so. The same with her "down" periods, she would struggle with one or the other, but for the most part she managed to keep it under control (often by using other drugs).

What she is experiencing since the switch to Suboxone is different than anything she has experienced in the past 20 years.

I am very tuned into her moods and I am able to recognize both her Manic highs and lows, often far soon than she can. However, I feel I am in uncharted waters.

Part of the problem is that we both want her to go back to being the go getter, extrovert person I married, but I have also learned to be weary of her "highs" both because they invariably are followed by very deep "lows" and because the Highs are just as hard to live with as the "lows" are.

For instance, she is not a shopper. In fact, she hates shopping, but if she goes to Macy's while on a high manic state, it could be very damaging to our finances.
Watching a Movie or the news with her is an exercise in restraint. While I certainly appreciate adult dialog and discussion, it is obvious that anything triggers an avalanche of thoughts and words that cannot be stopped.

Fortunately, she no longer gets terribly offended when I remind her we are watching a movie, not practicing a One Woman show, but I can also see her suffer and being unable to even understand what she is watching because so many thoughts are storming through her mind and the impulse to talk is so strong, she has almost no control over it.

Since never before she went for more than 3 days on such an extreme high, I am very worried about her. If I have to forecast her low from the intensity and length of her high, we are in for something catastrophic.

But each day I brace for all this energy and manic behavior to reduce in intensity or transform into serious depressive episodes and it doesn't.

Of course, both her and I have asked her doctors. However, they don't have the actual experience I have of her "moods". They are concerned, but ultimately, I am the one on the front lines and she is the one ultimately going to suffer the most from whatever is ion store for her.

She does have some medications (unfortunately, I do not remember all their names ATM, but they range from antipsychotic to Xanax) that can help, with some very undesirable side effects, but they don't work all that well and we both hope there is going to be some sort of middle way between a completely pharmacological approach and talk therapy.

The latter has been sorely lacking from the spectrum of available therapies. She has had a few sessions, but the doctors have never said a single thing back to her beside "how are you today" and "goodbye". I would have liked to see some practical advice along with the medicine prescriptions.

Anyway, I already searched this and other resources and I did find that Suboxone can lead to manic episodes, what I am looking for is maybe personal experiences? Advice on what to reasonably expect?

Naturally, I am going to defer to the docs but if there is anything I can do I am willing to try. I have been reading this forum and I know there are a lot of very helpful and knowledgeable people here and I feel I have to try the best I can for my wife.
She has been suffering for way too long. I am hoping Suboxone will both keep her out of pain and mitigate the side effects she suffered from, but this sustained manic behavior is insufferable for both of us.

Thank you for reading this.


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PostPosted: Wed Oct 29, 2014 11:30 pm 
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All opioids are capable of precipitating mania. Your wife's episodes are not long enough to be classified as 'mania', as that requires 7 uninterrupted days of symptoms-- but perhaps the neurochemistry is the same as a manic episode...

My first question is whether the buprenorphine is an increase, or rather a decrease, in opioid effect for your wife-- which would depend on her dose of morphine. It is hard to make dose conversions, but if she was taking less than 100 mg of oral morphine, than going on buprenorphine (at Suboxone-like doses) would result in an increase of mu activity-- which alone could cause mania.

Buprenorphine also has actions at other, non-mu opioid receptors, and those effects may also be responsible for effects on mood. Those effects are thought to be relatively minor, but an individual may have atypical sensitivity to those effects.

If the mu activity is responsible, then the effect will go away as tolerance sets in-- which will be soon. If it is a different receptor, all bets are off-- because the effects at kappa receptors, for example, are not subject to tolerance.

Finally, if she was on a very high dose of morphine-- well over 100 mg per day orally-- then the buprenorphine would be a step down in tolerance, and cause some degree of withdrawal. If that is the case, the 'mania' you are seeing may instead be from irritability caused by the withdrawal. in that case, it should get better over the course of several weeks.

Those are my best guesses!


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PostPosted: Thu Oct 30, 2014 3:58 pm 
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Thank you very much for the kind reply.

I am not sure what her Sub dosage is right now, I know they have been playing with it. Her Morphine dosage was high. At least according to every ER doctor we ever had. If I recall, a combined 180mg + 30mg of Ms Contin and some days 60mg.

I would suspect that if anything she is on a lower comparable dosage of Sub. However, she had been tapering off.

I doubt her mania could be a consequence of a mild w/d. After all, I have had around 20 years to learn her behaviors and I have seen her many times before take a smaller dose over a period of time. She simply was in more pain, but she has never shown "irritability" because of it.

Some of her pain is purely mechanical (she has several fused Vertebrae) and there were days when she needed only 60mg of Morphine the entire day. She has been used to go up and down in dosage.
I guess I should point out she was never a recreational user of optiaters. In fact, she never liked the "high" (she always described this unpleasant "head spinning" feeling which eventually I recognized as the opiate high most people seek. She has always hated it) and her relationship with Morphine was always based on pain. Not on getting high.

The major concerns I have in regard to her mania are the possibility of injury. She tends to be careless when cleaning or doing whatever it is she gets fixated on (As I was writing my OP yesterday, I realized my office bookcases had been covered with lace curtains for no real reason) and she has fallen or otherwise injured herself before and the second thing is the crash.

The first couple of days post "crash" are often a relief for me, having suffered her maniacal behavior, but she can then be in bed for a week or more, and that's not good.

In fact, she has not woken up yet today. The first time since Sub she is not up at 8am with Cappuccino at the ready (there are some benefits to her manic episodes). What I feared, may already have happened.

In any event, thank you so much for the thorough explanation. We'll see what the next few days bring.


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PostPosted: Thu Oct 30, 2014 7:06 pm 
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Well, it appears the "Crash" arrived. She has spent the day in bed.

But there is a big difference from the dynamics I have observed in the past:

Maniacal periods were always followed by big mental and physical crash. meaning that not only her body gave up, but also mentally she went from feeling like wonder woman to feeling like pond slime.

This one so far seems to be strictly physical. She is reasonably upbeat and while she does feel a bit down because she discovered that the medicine the doc gave her yesterday for mania we already had. Bad sign because it means it didn't work the first time around and also induces weight gain. But compared to the dark abyss I have had to get her from after a SINGLE DAY worth of high, this is definitely progress. Great progress.

Frankly, as much as I prefer her "up" moods, they are taxing to both of us. The problem has been that she'd have one day a week where she was normal/hyper and six days she paid for in bed.

If we could reverse that or at least make it 50/50 it would be easier on everyone. I need my quiet time too and when she is revving at 10K RPM I don't get any of that.

Anyhow, it seems we are finally on a downslope, but we are still doing better than pre-suboxone. Frankly, I'd have been worried if some sort of slow down didn't happen.


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Dr. Jeffrey Junig, M.D., Ph.D.

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