Needing, Wanting, and Taking Narcotics: Do opiate addicts need more or less?

Today I received a call from a patient who has been taking Suboxone for about six months, asking for help with a pain issue.  Before getting into the specific details I’ll mention something that I have mentioned many times before; some people do very well on Suboxone maintenance for opiate dependence, and others do less well.  Some people take their daily morning dose of Suboxone and then live life almost as non-addicts, rarely even thinking about opiates as they go about the business of life.  But others will remain in an addictive relationship with opiates.  The Suboxone bails them out of jams, or even prevents the jams from happening in the first place.  They don’t spend all of their money on oxycodone or heroin, and in most cases they will manage to avoid taking opiate agonists most of the time.  But they clearly think about opiates much more than would be ideal.   They dose Suboxone more than once per day, even while admitting that they are probably only getting a ‘placebo effect’ when they take that second dose late in the day.  Some are even worse off, taking little chunks of Suboxone at times because they think it gives them a ‘lift’ of energy or mood.  This type of behavior doesn’t necessarily end in disaster (although it sometimes does), but people stuck in this pattern don’t seem to benefit near as much as do those who dose once and forget opiate for the rest of the day.
The patient who called today wanted something ‘i.e. something narcotic’ for ‘severe throat pain that felt like a hole in his throat’—or as my kids would call it, a sore throat.  He didn’t have a diagnosis, but playing the odds he probably has a virus, or perhaps strep throat.  I’ve had strep throat many times, as have most people, including all of my kids.  I’m a pretty compassionate guy as far as my kids go, and I can’t think of a single time I considered treating their sore throats with a narcotic.  I did not provide narcotic for this patient either; doing so would have been unprofessional for multiple reasons, including the fact that he first needed to know what was using the sore throat, before simply masking the pain with narcotics.  But even after a diagnosis has been made, it is not appropriate to treat a sore throat with narcotics even in a person without addiction, let alone in a person with an addiction to opiates.
I have had a number of similar cases; people on Suboxone requesting narcotics for back pain, hand pain, carpal tunnel pain, fibromyalgia, a sore tooth, a sebaceous cyst… things that ‘normal’ people would never seek narcotics for!  I usually get into a discussion, and sometimes an argument, where I try to make the point that most people go through their entire life without taking a schedule II narcotic.  If they did have a schedule II narcotic prescribed it was almost always for severe pain from kidney stones, major surgery, or perhaps from an acute spinal disc herniation; NOT for a sore throat.
There are several issues at stake here and I’ll try to avoid getting them confused with each other.  First, people with opiate dependence who take or don’t take Suboxone must remember that they cannot control their use of opiates.  In the days before Suboxone, opiate addicts were scared to death about needing to take narcotics for surgery.  I remember cases I had as an anesthesiologist where addicts made me promise to withhold narcotics even if they begged for them during the post-op period.  I usually tried to convince those people that they simply HAD to take narcotic in some cases, as there are risks associated with untreated severe pain such as pneumonia from failure to expand the lungs after gallbladder surgery or heart attack from hypertension after abdominal aneurysm surgery.  To summarize, addicts could take their fear too far and avoid narcotics that were necessary to their surgical recovery, but the bottom line was that the smart addict avoided narcotics whenever possible, and was quick to recognize and admit the thought all addicts have after stumbling on a sidewalk crack:  ‘good- maybe I’ll break my leg and need some Percocet!’
Suboxone allows some degree of carelessness because taking Suboxone prevents a free-fall into compulsive opiate use.  But I see too much complacency, and it is important for addicts to realize that not everybody on Suboxone does well.  I have seen cases where an addict on Suboxone believes he/she is safe lightening the dose of Suboxone now and then and taking a couple ‘80s’ for a weekend of pain relief, only to end up back on oxycodone ‘full-time’, no longer able to benefit from buprenorphine. Opiate addiction is a ‘crafty MF’ to borrow a phrase.  We are lucky to have a tool to help some escape the misery of addiction.  But those who take sobriety for granted and abuse the opportunity provided by Suboxone are asking for a heap of misery, and there may be no respite the next time around.
A separate issue is whether opiate addicts DESERVE pain treatment, and I don’t want to be misunderstood on this issue because of my comments above.  There are times in life where a person may need potent schedule II narcotics to treat pain, and in these situations an opiate addict is as deserving of pain relief as any other patient.  I have seen MANY times over the years where a doctor will take note of an addict’s high opiate tolerance, and instead of prescribing a higher dose of narcotic will prescribe a lower-than-normal dose or none at all!  I have heard doctors say ‘out loud’ things like ‘I’m sick of these people, and I’m not giving him anything!’  When a person with a high opiate tolerance (often because of a carelessly- prescribing physician) goes to the local pain clinic for relief of genuine pain, the pain docs will look for a lucrative injection that can be performed, and in the absence of an injection they will look at the patient with a blank expression and say ‘I’m sorry but I can’t help you—I’m not giving you anything.’  They don’t want to do the hard work, and don’t want to take on the trouble of a person who has been damaged by other narcotic prescribers.  Why bother trying to help that person when the next guy has insurance that pays $700 for the 20 minutes of time it takes to do an epidural steroid injection?  If you have a high opiate tolerance and you are refused adequate pain treatment, you have rights.  If you are in that position, send me an e-mail and I will hook you up with a group that advocates for such patients– a group with many lawyers!
I hope that you can differentiate between the two situations described above.  There will always be a gray area between the two types of situations, but the ideas behind each of the two extremes are clearly different.  Opiate addicts learn to see every pain as deserving of treatment with narcotics regardless of whether the pain is coming from a viral cold, a migraine headache, or major surgery.  Addicts who do well are those who recognize that narcotics are rarely necessary and rarely if ever taken by non-addicts.  On the other hand, in the rare cases where narcotics are clearly indicated, addicts have as much right to pain treatment as does anyone else.
JJ

Runny Nose, Back Pain, Withdrawal in New Patient

This new patient has been on suboxone for two weeks, and reports having low back pain and a runny nose. He also feels that the 16 mg dose of Suboxone that he takes in the morning wears off by the end of the day. You can read my answer, and feel free to add your own experiences or suggestions:
Hi XXXXXXX,
I received your message.A couple thoughts…As far as pain goes, the suboxone has the analgesic potency of about 30 mg of methadone or about 50-60 mg of oxycodone.Your best bet, with or without Suboxone, is to avoid treating back pain with opiates– that is a dead end street with a pile of messed up lives at the end of it.It may be that you were treating aches and pains that you didn’t know that you had– often people on opiates will hurt their backs, knees, whatever, without knowing it, and continue to do more and more damage without the usual warning that our bodies give us (as pain).If you try to treat back pain with opiates long term, the tolerance requires higher and higher doses of meds, and the patients gets more and more messed up by the obsession for opiates.
Treatment for your back should include 1) rehabilitation either through physical therapy or by your own exercise and stretching routine, 2) anti-inflammatory medication like ibuprofen or naprosyn (over the counter as aleve), 3) avoid re-injury by learning correct lifting technique and avoiding certain things that you know will aggravate it, 4)ice after over-use, heat to loosen muscles at night, 5) getting enough sleep, and avoiding things that cause muscle spasm like caffeine, opiates, and alcohol.
Runny nose… that is sometimes a symptom of withdrawal. That along with your other questions suggests that your tolerance is higher than the opiate effect of suboxone. Give it time, and it will go away– if it is still there after a couple weeks I would start to think it is something else, like a virus.As far as the meds ‘wearing off’, I have had the benefit of seeing the pharmacologic data on the drug buprenorphine when I was doing my ‘treatment advocate’ training with the company. The drug lasts forever in us humans– when a person stops taking subox the ‘real withdrawal’ doesn’t hit for 3-5 days.In your case, you are likely feeling a combination of things. First, as I said in the prior paragraph, you are having mild withdrawal from ‘mismatch’ between your tolerance and the Suboxone– this will resolve soon. Second, it is not uncommon for people to have full- blown withdrawal symptoms that come from our brains ‘replaying’ our earlier withdrawals. Usually the more we focus on them, the worse they become. They will fade away as your tolerance adjusts– by the time I see you again they should be gone. In the meantime try to keep busy and distract yourself as soon as you sense them coming, or if they come at a certain time each day try to keep busy at that time. More Suboxone will not help, because of the ceiling effect of the drug– your receptors are all bound up at 8-16 mg/day.
J