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PostPosted: Sat Mar 18, 2017 12:23 pm 
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I'll try to be brief. In 2009, I began seeing a pain management group after my GP referred me for the treatment of bulging and herniated discs from L3/L4 - S1/S2. I was put on Norco 10/325 initially, and then the interventional pain doc in the same practice placed me on Avinza 30mg. At the time, my pain group became sold on the idea that Long acting pain medications were the only treatment (this is pre-opioid epidimic) options that were feasible, and they had mentioned that Methadone and Duragesic would be the next logical step. My problem is that I do not like the way pure agonist opioid medications make me feel. That being said, I never had an addiction issue, or medication misuse issue. I noticed that I began seeing a bunch of fliers at the dr office for Suboxone, and could hear other patients talking about how their pain was, or wasn't, under control with Suboxone. So, in mid-2011, I began to look up Suboxone, specifically for pain, and could not find a lot of info or research regarding its application solely as a pain medication. That being said, I also noted that people did not seem to have the ups and downs associated with opioid medications, so I became intrigued. After only 3 months on Avinza, I asked my nurse practitioner if their office was really prescribing suboxone for pain, or if they were beginning a process of weaning patients on high dose opiods off, and replacing their medication with a form of "alternative to opioids". The NP assured me that they were using Suboxone for pain, and I had no reason to doubt her, aside from the fact there was no, and still is no approval for Suboxone for pain management.
I explained to her that, even though I had been on Norco since 2009, I never truly felt better. I explained that the reason I did not care for opioids was because I knew the medication was effecting my mood, and I did not want my mood being extremely well, or extremely low. I told her how Norco seemed to work for the pain, yet make me miserable in between doses, as it never worked more than 4 hours, and Avinza would just make me very tired for a very long time. I asked if she thought I could try Suboxone, because I was not going to allow myself to be placed on Methadone or Duragesic. She was absolutely thrilled that I had "voluntarily came to them to try Suboxone" because "most patients fight tooth and nail against trying new medications."
So, I sat up an appointment with the Dr to begin Suboxone. I went to the office, with my Suboxone that was called in that day, and they gave me my first doses of 2/0.5 mg Suboxone. After about 45 min, and 2 doses, I felt the same as when I went in, minus the pain. Over the course of 2 years, I was bumped up to 8/2mg three times a day, for pain management. Every single one of my prescriptions read "for pain management", and was a hassle with insurance. However, I felt great, and sang Suboxone's praises to anyone who would listen. BTW, I normally only took 16mg/day, but was always rxd 3 per day, with the understanding to only take 2 daily, and a 3rd would be okay if the pain warranted taking it.
For the next four years, I felt better than I ever had. I was able to work again, and never felt the need to carry medication on me for fear my dose would wear off, something that I always had to do on Norco. Then, out of the blue, I was kicked from the practice in 2015 for being on Klonopin- which I had been on, with their knowledge, the entire time I was seeing them. I know that, now, when a patient is on a benzodiazepine, the dr is hesitant to rx pain meds, but this was not the case with my pain group. The only time it was ever brought up was when the Dr at my pain group had asked me to talk to my psychiatrist about a non-benzodiazepine control for my panic disorder because benzodiazepines and opioids were "a bad mix", as he put it.
Since being discharged, and re-enrolled with a new pain dr at a different pain group, I have been miserable. When they see that I was on Suboxone, I (somewhat understandably) get questioned about why they chose that drug, and they tell me Suboxone is a poor pain drug that has no evidence it works for pain (and they then assume that, perhaps, I was a patient who wanted more opioids, and nothing is further from the truth.) The closest to Suboxone the dr would get was Butrans, and it just did not work for me, even @ 20mcg/hr. My GP, who agrees that suboxone is a safer medication for pain, but who will not rx it, has told me to find a dr who prescribes Suboxone for pain, and he would refer me. However, it appears that most of the drs who advertise, or even acknowledge prescribing suboxone for pain, also deal with a huge addict population, which is fine. However, most of the reviews for doctors like this all have the same tone: "I saw dr XYZ for chronic pain in my (insert body area here), and I explained to him/her my past issues with opioid abuse, and they started me on Suboxone." That is great, and I am happy that former drug abusers are finding drs who will treat their pain with Suboxone, but I am not a former or current opioid abuser. I actually feel like the fact I have never been addicted to opioids is a hindrance in finding a dr willing to prescribe it for pain. The last time my pain doc did the mandatory 4mo patient med review, where I am encouraged to talk openly with him about possible dosage adjustments, I brought up Suboxone, again. While I have finally gained the drs trust via monthly drug tests, never needing anything filled early (gabapentin and norco), and being with them for two years, he changed the reason his office does not rx suboxone from "it doesn't show any reason why it would work" to "we can't prescribe it because of the opioid epidimic and it's value on the illicit market."
My problem with this is that there are so many ways they can ensure that the patient (me) is taking the meds. Call me in to show you my films, drug test me once a week, only rx a week at a time, etc. Yet, because of the "stigma" this drug has thanks to people misusing it, and the media portraying this (locally, anyhow) as nothing more than a way for addicts to avoid withdrawal symptoms, I can not find a dr willing to prescribe suboxone solely for pain. I feel kind of "screwed" by the system, despite always conforming with its ways. I have never tested positive for any illegal drugs or prescription drugs that were not prescribed to me, while always testing positive for my prescribed drug, and always in the expected nanogram range. Full agonist opioids, despite working, effects my mood, which is why I don't like them. Because I do not like them, I tend to not take them as often, and consequently, have had poor relief the past 2 years. If I do take my pills 3 times per day, I end up feeling spaced out at the end of the day.
I am sorry this post became disjointed, and long, but my frustrations grow every time I talk about this. Is there any way to approach my pain dr to better show him that the reason I want back on Suboxone is its long life which, despite its claims to only provide analgesia for a few hours, worked for me for the entire day? I have no clue how to continue trying to find a pain dr who utilizes Suboxone for pain management, but I am also unwilling to give up.
For the record, I have already looked at the database of prescribers of Suboxone, but did not want to reference that site here. Aside from the dr who kicked me for beING on klonopin, and his partner, the the majority of the drs are either addiction specialists, or psychiatrists. I should note that my previous pain dr, who prescribed Suboxone for chronic pain, was a psychiatrist, but not a pain psychiatrist, or an addiction specialist.


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PostPosted: Sat Mar 18, 2017 12:32 pm 
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Realizing my initial post is too long for most people to bother with, I shortened it to the following, leaving out specifics:
I voluntarily asked to try Suboxone when I realized my pain management group was using it for pain because I do not like side effects of full agonist opioids. I had great pain relief for 5 years before they kicked me from the practice after I tested positive for klonopin, even though they were well aware that I was on Klonopin. Subsequent pain drs say there is no reason suboxone would work for pain, and are un willing to prescribe it for pain. I have never had an addiction issue, or ever tested positive for illegal drugs. I have only tested positive for my prescription meds, and always within the expected nanogram amounts.
I am becoming increasingly pessimistic at the chance of finding a pain dr willing to prescribe suboxone to non-substance abusers, but will never stop trying to find a pain dr who does understand Suboxone can, and does, work for some people to diminish pain. Is there a way to get my pain dr to see that the reason I want to be back on Suboxone is because of its long duration of relief, as opposed to Norco?

Edit to include: I've had countless steroid injections in the facets of L3-S2, physical therapy, and even a TENS unit.


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PostPosted: Sat Mar 18, 2017 1:14 pm 
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Well some people who are no longer opiate naive like yourself do get some pain relief from Buprenorphine. How high it your tolerance? How did you fare when you lost your opiate supply?
Did you have withdrawal issues?

Bupe is most effective for pain in lower doses. The reason this is so is theres a "ceiling" which begins to kick in at 4mg/s which limits further opiate effects even if increasing dosage, People who are opiate naive
usually get small, micro doses and do get substantial pain reduction.

So one important question is where are you in terms of tolerance right now

I'm not a doctor, and not an expert by any means. Others will chime in I'm sure..

Welcome to the forum!


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PostPosted: Sat Mar 18, 2017 4:08 pm 
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Thanks for the reply, and the welcome, Godfrey. In terms of my tolerance and how I fared when my pain group kicked me: my tolerance has probably built up over the past two years, as I am on Norco 7.5/325 three times a day, and gabapentin 600mg three times a day. I can't say that I have a mega tolerance, because I am kind of unsure. The Norco does not knock me out, but it still helps with the pain despite being on the same dose for 2 years. In terms of how I fared when I was kicked, I guess I am lucky. My GP saw the certified letter when I saw him, one day after being kicked, and he prescribed Norco to last me until I could get in to the new pain group. Do I have withdrawal? I'd have to say yes, to some extent. I do not crave the medicine, but 4 hours or so after my last dose, I have noticed that I get kind of lethargic and, in general, just feel lousy. Part of that is the pain, but another part of it is probably the tolerance I have built over the last two years.
I don't know if having been on Suboxone for pain in the past is in any way related to why Butrans did not work for me, but it definitely did not seem to help the pain like I thought it would. I know Belbuca is also available, but where I live in the US, doctors seem to want to steer clear of anything buprenorphine related.


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PostPosted: Sat Mar 18, 2017 7:36 pm 
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Hey my game...

So you must have mentioned your previous experience with bupe in the longer version of your post. I'm sorry I just didn't have time to read it. I think you were smart to put up the second one. Maybe a mod will come by and delete your first so people don't get discouraged and miss the second one.

You have to understand that bupe is a very effective pain medication in small doses, less so as the dosage increases as a function of ceiling effect and individual tolerance. Not sure if I put that very well, but I believe it's generally correct.

In fact in higher doses there's some disagreement as to why some people get halfway decent pain relief with higher doses. One thing you could try is splitting your dose when you find a doctor who'll prescribe it for you...

Honestly, I think if you have severe chronic pain you might be better off with the opiates (Likley a controversial statement) as you don't sound like an addict to me in the usual sense. The fact that you're not craving a fix when in mild WD seems to indicate
you're not a true addict.

Also, the opiates are still working for you...Eventuallly though, they'll likely stop working and you'll begin the climb to every increasing doses that are the norm.

I'd guess the reason the bupe you tried didn't work very well was because of your tolerance, not because
you'd used it in the past. But again, I', missing some details. Tomorrow morning when I have more energy I'll take a stab at your longer post...

One thing I'm not clear on, you have one opiates now from you GP to tide you over But not enough for pain relief, just enougn to keep you out of severe withdrawal? Do I have that right?

P.S.I just looked at your post again and I see you don't like the opiate side effects. They're too unpleasant to manage? Can I ask what they are? Just don't like the way they make you feel?

I guess whether subs are appropriate for you now, is how severe your pain is. You know, you could always go to a clinic, tell them you're an addict which is technically true and that you want subs as a shortish term bridge to sobriety. Then see if it works for you. Again, some do get pain relief for chronic pain, but some don't and it's not for severe pain generally when used in the higher doses we usually talk about here.


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PostPosted: Sat Mar 18, 2017 9:40 pm 
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Lol! Godfrey and I have been having this debate for a little while. We are good friends, so my disagreement with him is not personal.

From my understanding, the analgesic properties of buprenorphine are time limited. They last 4 to 6 hours, no matter what dose you are on. So I believe that if you are on a total of 16mg, for example, that you should split your dose into 4 equal parts and take a dose every 6 hours. If you are on a total of 4mg, you should split your dose into 4 equal parts and take a dose every 6 hours. I don't believe that the ceiling limit affects the analgesic properties of buprenorphine. You can get pain relief at 4 doses of .25mg, 1mg, or 4mg every 6 hours.

I have to admit that I did not read your initial post, so that is just a general response on my part.

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PostPosted: Sun Mar 19, 2017 5:42 am 
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Sorry to hear you had/are having so much trouble getting suboxone for pain. I'm one of those recovering opiate addicts with pain conditions who use the med for both. Unfortunately, the medication gives US a bad rap, too. We go to emergency rooms and doctors there see us as active addicts and not recovering addicts. So, yes, there is a stigma surrounding a life-saving medication, which is dreadfully important.

Recently I was off suboxone for a couple of years and then returned to it when I started relapsing. Because I had used so little, I went back on a very low dose (i was practically opiate naive still). I'm taking just over 2 mg/day. Every person taking it for pain will take what THEY need and dose as they need. Everyone is different. Because my tolerance was low, I'm OK on this low dose.

I hope you can find some help soon. Keep trying. There are some (about 4 I think) online suboxone doctor locators you can go through to try to find them. Oh and you likely had trouble with insurance because suboxone isn't FDA approved for pain (damn them!).

Good luck!

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PostPosted: Sun Mar 19, 2017 4:24 pm 
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Yo hatmaker!

A couple thoughts... the situation is just so frustrating... buprenorphine is so much safer than opioid agonists. About 40 people die each year, in the US, with buprenorphine in their bloodstream, compared to 30,000 deaths in people NOT on buprenorphine. It clearly PREVENTS death, not only doesn't cause it.

I get the insurance problem with pain, and see the same all the time. If a patient takes buprenorphine for pain, insurers say 'just take oxycodone'. I don't know if they are ignorant, and just don't realize how often taking oxycodone leads to addiction, or if they are just pretendding to be ignorant to avoid paying a bit more. But they would clearly save money in the long run by choosing buprenorphine.

About using lower-dose formulations for pain... it isn't that the lower doses work any better for pain; it's just that because of the ceiling effect, there isn't a lot of value in taking 24 mg, say compared to 8 mg. I could see where a person would feel better on the higher dose, just because there would be less likelihood of the blood level dropping below the ceiling threshold, in between doses.

The highest dose of Butrans, 20 mics/hr, is only 0.5 mg per day-- and so a person will get more pain relief on 8 mg or 24 mg of buprenorphine sublingual, compared to Butrans.

Amy, I have heard what you've heard. i don't know, though, how much data supports the idea that analgesia only lasts 6 hours. If all of the analgesia from buprenorphine comes from the mu receptor, then people should be fine treating pain by dosing every 12 or 24 hours. But maybe there are other receptors involved that we don't fully understand-- the nociceptin receptor, or other opioid receptors for example-- that require higher blood levels of buprenorphine, and so benefit from more-frequent dosing.

I've wondered if the main reason people like to dose more frequently, when in pain, is because of the placebo effect. Maybe the buprenorphine is providing pain relief, but those extra doses add that extra benefit.

And maybe some type of pain, or pain in some individuals, responds better to buprenorphine than other types of pain, in other individuals. We make the mistake of assuming it works the same in every patient, but pain is a very complicated sensation.

As for the original question, I don't know!! I think there are regional differences in approach; I do know of doctors around my area that prescribe buprenorphine ONLY for pain. But your area sounds different....

Finally, you should know that ANY doctor or nurse practioner with a DEA license-- anyone who can prescribe a med like Norco of Vicodin-- can legally and ethically prescribe buprenorphine or Suboxone for pain. NO waiver is needed. Many doctors just don't understand the rules. The waiver is ONLY necessary to treat addiction; NOT to prescribe buprenorphine medications!! So if you can find any doctor out there who is intelligent enough to actually look at the rules, and beyond his/her misunderstanding, you will be fine!

Again, your general practice doc CAN prescribe buprenorphine for pain. He apparently doesn't realize that he can, and he is convinced that the rules prevent it. You are welcome to have him contact me; he can find me on LinkedIN, or if you want my email just send me a message here on the forum.


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PostPosted: Sat Apr 22, 2017 7:10 pm 
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I have fibromyalgia and my Dr. Recommended suboxone. I take 8mg a day after years of trying every kind of opiate. I go to a pain management Dr. In Michigan . You need a good , not shady pain doctor and the will understand how to use suboxone for pain only. Good luck


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