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PostPosted: Fri Jul 18, 2008 10:38 pm 
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An e-mail that I received yesterday:

Dear Dr. Junig,

Yesterday I visited a pain clinic... that has an excellent reputation for both its medical staff and its interdisciplinary approach. I won't relate to you the entire, long story as to how my pain developed, but the upshot is that they suggested Suboxone treatment. I have not been abusing any drugs, prescription or otherwise. I have, however, developed a very high tolerance to opiates.

I do understand the drug reasonably well, esp. its benefits over long-term nartcotic tx., but also have some significant concerns about it. My main worry is whether Suboxone is likely to render my personality a dial tone. I only know one person on the drug.... I have noticed that her affect has become much more dull since starting Suboxone treatment. I've noticed the same thing... on the Durgesic patch, and have heard similar things about morphine pumps and Oxycontin; in other words, about other extended release analgesics. I asked the nurse practitioner about this, who only said that she could not predict how a person's other medicines might interact with Suboxone, but that such an outcome is possible. Would you mind sharing your opinion on the matter with me?


Respectfully,

(name withheld)


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PostPosted: Fri Jul 18, 2008 10:39 pm 
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Thank you for writing.

I feel that I have a good understanding of suboxone…. With the exception of the pain issue. The reason for my lack of confidence in that area is because first, I have seen less-consistent results in pain patients, and second, some of the claims made by patients just don’t make sense!

Suboxone has several characteristics that make it different from opiate agonists (like oxycodone); the ‘ceiling effect’ combined with the long half-life results in a very stable subjective experience—there is no up and down, but rather there is a constant level of opiate effect over time. Tolerance occurs very rapidly—that is a good thing for addiction treatment, as the person taking suboxone feels ‘normal’ within a few days. But just as the person becomes tolerant to the sedation, respiratory depression, and other side effects of buprenorphine, I would expect tolerance also to the analgesic effects. So theoretically it should not be a good pain drug because the rapid tolerance would eliminate the analgesic effect after a few days.

In reality, though, patients will claim relief from suboxone for an indefinite period of time in many cases. I have no explanation for such an effect; perhaps it is all a placebo response, or perhaps (more likely probably) the pain control system is much more complex than we imagine. The other odd thing is that pain patients will often claim that the analgesic effect of buprenorphine increases linearly with dose, without reaching a ceiling and leveling off. That makes no sense to me either—the analgesic effect of opiates occurs at the mu receptor, which is the site where buprenorphine binds as a partial agonist, and so the ceiling effect should apply to the analgesic actions of buprenorphine. I suspect that in this case the placebo response is the reason for the patients’ perceptions.

Suboxone certainly has advantages over other opiates, if it is found to be effective. The tolerance with buprenorphine is limited, whereas the tolerance to a pure agonist has not limit—so there is a lower amount of withdrawal if/when the drug is eventually discontinued. The stable blood level prevents the temporary ‘highs’, the miserable lows, and the cravings that can accompany the use of agonists. The patient feels much more clear headed on suboxone compared to opiate agonists. And suboxone can be dosed once per day, which has a couple effects—first, it just is less trouble to take, but more importantly the absence of ‘as needed’ dosing all day long will help prevent the patient from focusing as much on the pain.

As far as the personality effects… many people have told me that suboxone seems to work as a ‘mood stabilizer’—they feel less labile, more regular, and generally a bit happier on the drug. There are case reports of opiates treating depression or precipitating mania, but buprenorphine doesn’t seem to push people to euphoria, but instead seems to ‘level’ their mood. Maybe that is what you have seen in your friends. I think that part of the effect relates to cravings; cravings can manifest as mood symptoms, and as suboxone eliminates cravings, it also eliminates some of the mood symptoms. This raises the issue of whether buprenorphine should be used to treat mood disorders… and for that I will leave the readers to do their own research. A couple years ago there was an article in Elle magazine by Lauren Slater, describing her own treatment of depression using suboxone. I do not know of any large clinical studies that support such use at this point.

Chronic pain is a very difficult issue, and I wish you the best. I encourage you to avoid opiates as much as possible—there is generally little future in opiate treatment of pain, since tolerance always chips away at the effects of the opiate over time. I am sure that at some point we will have ways to prevent tolerance, which would be quite a thing for people with chronic pain. On the other hand I can imagine many dangers associated with such a discovery. Thank you very much for your question; I am going to go ahead and post on my blog, http://suboxonetalkzone.com , and on the forum at http://suboxforum.com (without your real name).

J


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 Post subject: suboxone and pain
PostPosted: Sun Aug 10, 2008 5:38 pm 
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i have actually had reasonable results with suboxone and pain, though not total relief from the worst headaches, it has been very helpful with my daily low level chronic pain.

and like what was posted by the doctor, i have decidedly fewer mood issues or titration issues that might cause withdrawal, particularly in the morning when i wake up. this was a daily struggle while on opiates, even with long-acting ones.

if it is psychosomatic, well then great, it helps, but i sure know that i feel much better on the suboxone, than without it. and my depression seems not so bad either! we'll see come next march when the slies are grey.

my issue is now treating the harvey wallbanger migraines.

my pain doctor said that he has had some success with other patients using suboxone for chronic pain relief as well.

seems worth a shot.

i found that the opiate train is a very very unstable one.

-june


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 Post subject: Help: Subutex for pain
PostPosted: Wed Aug 13, 2008 1:32 pm 
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A little background or maybe a lot, I am loquacious ;-)

I have been taking oxycontin for about five years for chronic pain associated with interstitial cystitis. My urologist does not like my use of pain medication. He says I self medicate because I never take the entire amount he prescribes if I do not need it and end up having breakthrough pain. I have for the past 5 years been under the assumption that my need for pain management was going to be temporary, at least my need for opiates. Experience and my doctors’ insistence have convinced me otherwise.

He prescribed oxymorphone for a time but I could not breathe. He wants me to change the opiate I am taking because I am not getting good "pain management". He prescribed "Avinza" two years ago and I finally got up the nerve to try it last month as I was and continue to worry as I seem to finally have started developing a tolerance for these mediations.

I was taking 20mg oxycontin twice a day for two years and beginning around February this year it has not been enough to control my pain.

Several months ago the urologist suggested Subutex and also suggested that I go home and read about it.
I decided it would be a good idea for several reasons including its ceiling effect and its potential use as an anti depressant. (My treatment resistant depression preceded my pain issues by many years).

I told him I was willing to try Subutex and now he says he does not know enough to prescribe it. I cannot seem to find a doctor who is willing to prescribe it for pain management. I am entirely frustrated.

I read the information on this site about the pros and cons of using Suboxone for pain management and have read much on other sites. I see no down side to giving it a trial? If anything I would think if I did get good pain management from it that over the long term it would be a better choice than a pure agonist?

I would appreciate your opinions as to how I should proceed. I live in Pittsburgh, Pa if anyone has any suggestions about doctors who would be willing to help me.


Thank you for reading this,


Tig


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PostPosted: Sat Sep 13, 2008 8:36 am 
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You mentioned about the "dial tone" personality and that you only knew the one person... It is likely that is or was her actual demeanor/personality before the opiates were introduced to her lifestyle. I have "calmed down" considerably, but only due to the lifestyle changes not as a side effect of the Suboxone. Just a thought.


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PostPosted: Tue Apr 28, 2009 5:29 pm 
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Suboxone dosen't work for chronic pain, at least not for me. After being addicted to pain pills/narcotics on and off for over 40 years, yes, I said 40 years of addiction and pain, the best Suboxone does for me is it keeps withdrawls away - but that all by it's self is nothing short of a miracle, as far as I am concerned. To deal with chronic pain and insane withdrawls would most definately be a prelude to suicide for me. I absolutely can't see how any body would ever be able to get pain relief from Suboxone. If I had to go through withdrawls on top of the chronic pain, I don't know what would happen. Even with Suboxone holding the withdrawls at bay, I live in pain and wish for narcotics for even just 1 day of relief! It is funny though, how people think Suboxone is some powerful narcotic, when it is not and how misinformed the general public is about this drug and even some people who take the drug! That will swear they get pain relief. I find that the most questionable statement I have ever heard! Stops horrible withdrawls, doesn't relieve acute or chronic pain. At least not for me.


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PostPosted: Tue Apr 28, 2009 10:30 pm 
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I have chronic pancreatitis. Suboxone really did help my pain. Not 100%, but it helped probably as well as hydrocodone did. Of course, I had a lower tolerance at the time, so maybe that had something to do with it. I was on about 40-50mg hydrocodone/day by the time I started Suboxone. Yeah, I know maybe Suboxone was 'too much' for me but I wanted to try it for the pain because it was recommended to me because of the withdrawal I had every morning. It took all that completely away!

Does it help with pain? I guess thats debatable. In Europe, its used as a pain medication. Its also the #1 abused medication in Sweden (or Finland, don't remember). I think it has been used I.V. in the United States for pain, I vaguely remember SuboxDoc mentioning that in a blog posting a while back.

Suboxone is expensive as many know, but supposedly going generic in the fall. I'm not sure how the generic thing works.. I think someone else has to manufacture it for it to become cheaper, but I'm not an expert in that field.

Oh, about it not being powerful.. Try stopping it for 3 months, then restart it. Its amazing how powerful it really is if you're not tolerant to opiates believe me.


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PostPosted: Wed Apr 29, 2009 7:42 pm 
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Just my two cents...After going off all the opiate pain meds I'm left with Suboxone. It most definitely helps my chronic pain. Does it relieve it 100% - no way. But nothing really ever did - it's chronic pain! I think it's important to remember that medications help different people in various ways - or not at all. Which is why there are so many different medications in the same class. Long-term opiates are just not a good idea; look how many of us on this site alone!
Best of luck!


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 Post subject: pain
PostPosted: Thu May 21, 2009 12:22 am 
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For what its worth I've asked my doctor about this and was told that taking 800 mgs of motrin along with subs was a pretty good pain moderator and should be more than enough to cover moderate pain


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PostPosted: Wed May 27, 2009 10:34 am 
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Kerouackat wrote:
Suboxone dosen't work for chronic pain, at least not for me. After being addicted to pain pills/narcotics on and off for over 40 years, yes, I said 40 years of addiction and pain, the best Suboxone does for me is it keeps withdrawls away - but that all by it's self is nothing short of a miracle, as far as I am concerned. To deal with chronic pain and insane withdrawls would most definately be a prelude to suicide for me. I absolutely can't see how any body would ever be able to get pain relief from Suboxone. If I had to go through withdrawls on top of the chronic pain, I don't know what would happen. Even with Suboxone holding the withdrawls at bay, I live in pain and wish for narcotics for even just 1 day of relief! It is funny though, how people think Suboxone is some powerful narcotic, when it is not and how misinformed the general public is about this drug and even some people who take the drug! That will swear they get pain relief. I find that the most questionable statement I have ever heard! Stops horrible withdrawls, doesn't relieve acute or chronic pain. At least not for me.


Well I for one know without a doubt that my Suboxone has indeed helped me deal with my chronic pain. Of course I still hurt but when I don't take my daily dose I really can feel the pain in it true form. I know that it might not be particularly good narcotic to be used to actually treat pain but it certainly is powerful at doing what it was designed to do with a few extras i guess you could say.. I am thinking that if one wasn't on it for addiction and doesn't have a tolerance then it most likely would have a pain relieving effect even if it wasn't for an indeterminate time. Just my opinion.


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Fond Du Lac Psychiatry
Dr. Jeffrey Junig, M.D., Ph.D.

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