Children Deserve Pain Treatment Too

I hope that people recognize the tongue-in-cheek nature of the title. After working as a physician in various roles over a period of 20 years, I can state with absolute confidence that the answer to the question is ‘yes’.
I’ve written numerous times about the writer/activist for the Salem-News.com web site, Marianne Skolek. I don’t know if she writes for the print edition as well, but at any rate I somehow was planted on a mailing list that provides constant updates on what she calls the battle against Purdue and ‘big pharma’.
People with a stake in the outcome of this battle may want to stay current, and even see if their Senators are involved in the process. The investigation was launched in early may, by the Senate Committee on Finance, and at this point has asked for documents from several pharmaceutical companies, including Purdue, the manufacturer of oxycontin– a medication that has become the focus for most of the wrath of those affected by opioid dependence. The investigation will include a number of groups whose missions are (or in some cases, were) to advocate for pain relief, including the American Pain Foundation, the American Pain Society, the American Academy of Pain Medicine, the Federation of State Medical Boards, the University of Wisconsin Pain and Policy Studies Group and the Joint Commission.
I consider it part of the human condition, the way we push in one direction for some period of time, and then realize (with surprise!) that we pushed too far, and need to push back. Years ago a  Newsweek article warned that an emerging ice age doomed the Earth. Suggestions for saving the planet included covering the polar ice caps with soot, in order to absorb more of the sun’s precious heat– although the article pointed out that growing seasons had already been severely limited in most parts of the world, and famine was just around the corner.
We all know what happened to THAT disaster. And then last week, Dr. James Lovelock, a leading doomsayer of the global warming movement, pointed out that many of the disastrous outcomes predicted by himself, featured in Al Gore’s movie, um…. haven’t happened… and to the chagrin of many, he wrote that most of the disasters that were predicted are unlikely to occur. Read for yourself. Never before were so many people so disappointed by good news.
I’m running off topic, I know, but it is hard to observe the dramatic swing on pain relief without recognizing the broader pattern. For those confused about the pain isssue, you have reason to be confused. About 15 years ago I worked as an anesthesiologist, when the Joint Commission on Accreditation of Hospitals made their 3-year site visit to our hospital. Hospital administrators hired consultants to find out what THAT year’s big issue was— e.g. hospital acquired infections, patient privacy, rights of those with disabilities…. and found that the hot-button issue was ‘undertreatment of pain.’ Little diagrams were dispensed to every patient room, showing the smiley-face guy with an expression ranging from happy to miserable, in case a person was experiencing pain but unable to speak– allowing the person to point to the appropriate picture instead. Key personnel were told to make it abundantly clear that we all take pain VERY seriously, and we do all in our power to avoid undertreatng because of, for example, fear of addiction. Studies were widely cited that claimed that only 7% of people with true pain become addicted to opioids.
One or two textbooks became the authority on opioid prescribing, introducing a new term– pseudoaddiction– which refers to a condition of drug-seeking behavior caused by under-treating pain, rather than by true addiction.
I know that I have to pull all of this together at some point. The easiest way for me to do that is by directing people to the latest article by Ms. Skolek, where she suggests that doctors have been influenced to promote narcotics because of grants from the pharmaceutical industry. Similar accusations have been made by others, including a series of articles by the Milwaukee Journal Sentinel that accused the University of Wisconsin School of Medicine of promoting opioids in return for millions of dollars.
I respect the efforts of another group I’ve described– PROP, or Physicians for Responsible Opioid Prescribing. Their efforts have been promoted by Ms. Skolek to some extent, and vice versa. I do not know of any formal relationship between PROP and Ms. Skolek. But I hope that PROP’s efforts take a more reasoned approach than the latest article by Skolek, where she compares Purdue Pharma to Adolf Hitler. Why? Because among the many clnical trials by Purdue is one that studies the use of potent opioids like Oxycontin in children and teenagers. Some of the most sobering experiences of my medical training were at Childrens Hospital of Philadelphia, providing care for brave, hairless children, knowing the years of pain that awaited them– if things went well.
I think I’ve provided enough background and links to start interested parties off on their own holiday reading. Yes, there is an epidemic of opioid dependence in this country and elsewhere. There are many reasons for this epidemic, and MOST of the reasons have nothing to do with the marketing tasks used by Purdue decades ago– for which they have paid dearly. While there are clearly areas where opioids are overprescribed, and in some cases grossly overprescribed, it would be a shame if the current swing in regulatory sentiment takes us to the point where doctors are afraid to provide pain relief for people who are suffering. This is already the case in some instances; people labelled as ‘addicts’, no matter the length of their remission, are likely to wait a long time for their first dose of narcotic, should they be unlucky enoough to develop a kidney stone.
I’ve spent a great deal of time and energy defending those poor souls, and discovered, sadly, that most doctors just don’t care about the pain experienced by recovering addicts. But there is a saying, also often referenced to the Holocaust, referring to mistreatment of others being ignored, until eventually similar mistreatment is directed at those who didn’t care about others. There are times when attempts to ‘cure’ go too far. Suggesting that methods of pain relief should not be investigated, clarified, and perfected for children is going a bit too far.

The Downside of Methadone

An Article by Mike Berens and Ken Armstrong, Seattle Times, discusses some of the problems with using methadone as a first-line treatment for pain:
When it comes to battling pain, Washington health officials have encouraged doctors to reach for methadone, a powerful and inexpensive prescription drug. For the past decade, the state has declared methadone to be as safe and effective as any other narcotic painkiller.

Methadone

But in a striking reversal that has gained momentum this week, doctors are receiving stark warnings that methadone is riskier and more dangerous — a drug of last resort — because it’s unpredictable and poses a heightened risk of accidental death.
“It’s a dangerous drug because it accumulates in the body and people die in their sleep,” Dr. Jane Ballantyne, a pain specialist at the University of Washington, said Friday. “It’s very tricky and difficult to use safely.”
Ballantyne and the university are helping spearhead a series of state-sponsored training programs to educate physicians, pharmacists and advanced nurse practitioners about the risks of pain drugs.
Earlier this week, while delivering a continuing medical education course for dozens of physicians and other medical professionals at the university, Ballantyne presented a slideshow in which she cautioned that methadone “should be considered a last option opioid, never a first line opioid.”
The state’s effort is a response to a Seattle Times series, “Methadone and the Politics of Pain.” The investigation, published in December, detailed that at least 2,173 people in Washington have died from accidental overdoses of the drug since 2003.
The Times found that year after year, a committee of state-appointed medical experts sanctioned methadone, empowering the state to designate it a “preferred drug” and steer people with state-subsidized health care — most notably, Medicaid patients — to the drug in order to save money.
The state has included only two drugs, methadone and morphine, on its preferred list of long-acting pain drugs.
During the committee’s meetings, officials from state agencies that have a financial stake in methadone’s selection consistently deflected concerns about the drug.
Methadone’s death toll has hit the hardest among low-income patients. Medicaid recipients account for about 8 percent of Washington’s adult population but 48 percent of methadone fatalities.
After the series, the state sent out an emergency public-health advisory that singled out the unique risks of methadone.
Medicaid officials faxed a health advisory to more than 1,000 pharmacists and drugstores about methadone, as well as about oxycodone, fentanyl and morphine. The state Department of Health mailed advisories to about 17,000 licensed health-care professionals.
The health advisory confirmed that Washington ranks among states with the highest rates of opioid-related deaths, exceeding the number of deaths each year involving motor vehicles.
Most painkillers, such as oxycodone, dissipate from the body within hours. Methadone can linger for days, pool into a toxic reservoir and depress breathing. With little warning, patients fall asleep and don’t wake up. Doctors call it the silent death.
Ballantyne noted that methadone is an indispensable drug and plays an important role in the treatment of many patients. However, due to the heightened risks, methadone should be prescribed only by those with extensive training and experience — and only after every other option has been exhausted.
Dr. Jeff Thompson, chief medical officer of the state’s Medicaid program, now readily agrees that methadone use carries unique risks and that it should not be the first choice if other drugs are equally suitable.
He said physicians are stepping up efforts to unravel the long-term impact on the body from prolonged use of prescription drugs now that Washington’s new pain-management law has gone into full force beginning this month.
The groundbreaking law requires practitioners to follow new standards for treatment and record-keeping. It also requires prescribers to consult with state-certified pain experts when narcotic dosages reach higher thresholds.
While the law’s goal is to lower doses and, if possible, wean patients from narcotic pain drugs, doctors are finding the task more difficult than hoped, Thompson said.
For instance, methadone patients can suffer prolonged withdrawal symptoms, like nausea and depression. With most pain drugs, withdrawal subsides within a week. Methadone’s grip can last for months, even years, he said.
State officials will review methadone’s role on the state’s preferred drug list during a meeting next month.
“I think we’re going back and relearning how to treat pain,” Thompson said.

Suboxone, depression, anxiety, and pain

A question about Suboxone and mood:
I came across your website while looking for answers to Suboxone. I was wondering what you thought of a patient being prescribed Suboxone for depression and anxiety disorder? I have tried almost every antidepressant you can think of. I have also tried lithium and depakote because my doctor (at the time), thought I may have bipolar II. I recently started taking Suboxone and I feel like a brand new person who now is excited to wake up in the morning and do the things I need to do with enjoyment. I no longer have chronic headaches, IBS and constant anxiety. I was never addicted to pain killers (hydrocodone), which was given to me a few times for an injury and also severe migraines. I did however, like the feeling of the hydrocodone but was unable to get a doctor to prescribe it to me for my problems. I am very leary about taking an opiate, especially after reading many of the questions and comments on your website. I am doing well on the minimum dosage (2mlgs) once everyday. I would really appreciate your thoughts and opinion on this. Sincerely, “leary about taking Suboxone for help with my depression and chronic anxiety disorder”. Thank You.
My Response:
Thanks for writing.  There has been a number of case reports over the years describing the use of various opiate agonists for treating depression.  There are also studies using buprenorphine, the active substance in Suboxone.  A couple years ago, a writer named Lauren Slater discussed her use of Suboxone for her own depression in an article in Elle magazine–  the response was mixed, as would be expected.  Some people welcome the idea of using opiate narcotics to treat depression, but the general medical opinion is against that use.
All opiates that have agonist or partial agonist activity do have some euphoric effect.  The problem with all of these medications is tolerance;  the effects wear off over time.  I have observed the effects of Suboxone in a number of depressed opiate addicts;  most patients will have a bump up in their mood, but the ‘bump’ tends to go away over time and the depression tends to return.  Because of the unique actions of buprenorphine however, I know that there are patients out there who are taking it mainly for their depression, hoping that the tolerance doesn’t take away the mood effects completely.  Since buprenorphine seems to be helpful for pain for a longer period of time than one would expect, perhaps the mood effects will last longer than we expect as well.
In general a patient who does not get better with medication should at least consider the idea that they have personality factors standing in the way of happiness.  Borderline personality is often confused with bipolar;  nobody asks for personality disorders and there is nothing to be ashamed about…  I suggest you read online about ‘borderline’ and see if anything fits.  People with that condition have horrible episodes of depression and suicidality, and they don’t respond well to medication, but a bit of insight into their condition can go a long way toward easing their pain.
SD

Pain Relief Network

I am moving the post below from the comments section to here because many readers will benefit from the information.  As a doctor treating chronic pain I can attest to the problems and challenges from all angles.  I worry about leaving patients in pain– but at the same time I know that for long-term pain, opiates are rarely the answer because of tolerance and the eventual erosion of personality that occurs with opiates.  I also worry about regulators and licensing boards.  I also worry about contributing to the problem of opiate diversion– nothing makes me more angry than the thought of a patient that I trust and believe going out and selling meds that I have prescribed for pain.  In my home town, the local health system tries to scare the docs into not prescribing pain meds, putting the burden on the few docs in town who work independently.  With all of these concerns it is good to see efforts to bring the issues involved in treating pain out into public awareness.  I also am optimistic that buprenorphine, the active ingredient in Suboxone, will make a big difference for a number of patients struggling with chronic pain.
The Comment:
The readership here might be interested in the following item from War on Doctors/Pain Crisis blog, which has links to other medical-blog discussions of buprenorphine for pain from the Pallimed blog. Hopefully some of you will find this interesting.
“High Dose Transdermal Buprenorphine for Pain”– Barutell et. al, Pain Practice, 2008.
which discusses the presented Abstract from a large multi-center study in Spain published just recently. Find also links to the discussion on PRN’s Chronic Pain Forums, which are informative, and to the discussion on Pallimed mentioned above.
Enjoy! Thank you for your efforts with this blog.
Sincerely,
..alex…
doctordeluca@painreliefnetwork.org
Alex DeLuca, M.D., MPH
Senior Consultant, Pain Relief Network
http://painreliefnetwork.org/
http://doctordeluca.com/wordpress/

Chronic Pain and Addiction

The interface between chronic pain and addiction is very complex.  Pain becomes worse the harder one looks at it, and taking narcotics tends to draw attention to the pain… so as a broad generalization patients don’t do as well on pain meds as off.  At the same time, patients will claim that is not true, even as they suffer depression, become overweight, lose friendships…    Again, things are already complex, but if you throw in a bit of denial things really get complicated.
An interchange on the pain topic:
Question:
Dear Sir,
What happens when a chronic back pain ( 2 surgeries ) woman attempts to detox off oxycontin to methadone, gets addicted, detoxes to suboxone, and then can not get anyone to listen to her as she struggles to detox off suboxone?  My sister would like to get off all opiates and they want her to detox over months and she is not receiving any psychological support from her psychiatrist. In addition, at 10 mgs there is little pain relief.
Suggestions?

Answer:
Thanks for writing. Such a tough situation—and unfortunately a very common situation as well.
My first thought is to make sure that everyone understands what she is dealing with.  You mention ‘detoxing’ off oxy to methadone–  methadone is an opiate ‘agonist’ just like oxycodone, meaning that then both do the same thing in the brain—they both mimic endorphins and activate the ‘mu’ receptor for opiates.  Some people use methadone, some use oxycodone, but they are interchangeable for the most part.  Yes, oxy may have a bit more rapid onset and so it is a bit  more addictive, although they both are so additive that the difference doesn’t matter much.
You may find other opinions—maybe not—but I would say that if she has been addicted to those medications, she will always have problems with opiates.  Like everyone else I hate to assign a lifetime diagnosis to people, but I just NEVER see a person who has been addicted to opiates walk away from them without a major change in life that includes going to 12 step meetings regularly.  Even then, staying clean is very difficult for most people, and their opiate addiction tends to relapse repeatedly.  In science lingo (I notice your PhD), attending meetings and taking other steps in recovery are necessary, but not sufficient, to stay clean.
Pain makes addiction much more difficult to treat.  The pain will change along with opiate cravings.  Patients get offended when I say this, but they shouldn’t—to them the pain is the same whether it is coming ‘purely’ from damaged tissue vs coming from deeper brain centers involved in addiction.  I have watched many times as pain patients ‘talk themselves’ into needing opiates for a pain that  they never used to need opiates for.  Because of that interaction, people with chronic pain generally do WORSE on opiates than those who take nothing!  The people on nothing will automatically suppress the pain—try to ignore it—whereas people on opiates will focus in on the pain and exaggerate it.  Functionally the same thing happens.  Patients will ask for opiates, saying that they need them to work, but if you did a blind observation you would see a clear difference in the other direction—that the people on opiates are less functional.  They are also less happy, have less energy, and have worse sleep patterns.

Suboxone has a ceiling effect, so that the dose/response curve isn’t a straight line but rather levels off at about 2 mg of Suboxone per day.  Increasing Suboxone beyond that amount reduces cravings but does not reduce pain.  I recommend 8-16 mg for most people as the ideal dose to get the maximum suppression of cravings.  Patients always claim that more Suboxone will help, and they can abuse Suboxone as well—but double blind studies show that it is all in their heads as a placebo effect, and taking Suboxone , 8 mg once per day in the morning, will work as well as any greater or more frequent amount.
I recommend that she try to understand the nature of her situation—the dead end offered by opiates, and the life long nature of addiction—and consider staying on a stable dose of Suboxone long term.
A very tough situation–  I wish you the best.
SD

Suboxone and Anesthesia; Suboxone vs. 'Recovery'

Yes, I have changed blog platforms again… hopefully for the last time! I spent the past few days learning to use the self-hosted WordPress platform. After reading the instructions about uploading the program using FTP (no small task for non-techies like me) I went to my GoDaddy hosting account and found that by clicking a couple buttons it automatically installed for me. Since then I have discovered the different WordPress templates available, the widgets, the plug-ins… cool stuff!

But back to Suboxone. One of the questions on today’s keywords was ‘Suboxone vs. Recovery’– I won’t go into that at length now but will direct interested readers to my article at Subox.info, where I give some thought to the different things that happen to personality when an addict takes Suboxone vs when an addict goes through traditional step-based treatment. The article is on one of the last pages of that web site.
Another keyword question was ‘Suboxone and Anesthesia’.
As you may know I worked as an anesthesiologist for about ten years before my career was skewered by my opiate addiction.  I still miss the job, but it probably wasn’t good for me… I joke that my arms were getting sore from pushing around that wheelbarrow full of money!  It certainly paid very well, but more than that I loved the feeling of power and control that comes with supporting a patient during surgery, or from totally relieving the pain of a woman in labor.  Anesthesiologists are always heroes in the hospital.  Some patients don’t know just how important the anesthesiologist is, but the nurses and surgeons certainly do.  I felt like a cowboy, as I raced in from home to secure the airway of a 13-y-o boy who had hung himself and whose neck anatomy was swollen and distorted… or as I ran down the hall to the operating room just ahead of the stretcher carrying a woman whose uterus had ruptured as she labored with her tenth kid.  I still vividly remember standing in the middle of the road at about two AM, after we saved the mom and baveby in that case.  It was snowing, and the city was asleep and very quiet, and as I looked at the dark windows of the house down the street I thought that I was the luckiest man in the world to have such a job.  A few years later the job was gone, and my feelings of power were challenged every day as I came to terms with all of the changes in my life– I was doing physical exams for a fraction of my old salary, the weekly dinner parties came to a halt (in seven years I haven’t been invited to a single one of the houses that I used to go to on a monthly basis), two close friends were dead (one a surgeon who committed suicide and the other Commander Shanower killed at the Pentagon on 9/11), our vacation cottage that the family loved was sold to pay the bills…
I didn’t intend to go down this path.  These thoughts used to be very painful for me, but now I can reflect and almost smile.  I see people in my practice who are facing changes in their lives, and it is nice to know what the situation feels like so that I can understand them.  I can also say with complete certainty that one cannot predict what the future holds, particularly when one’s view is colored by depression or other psychiatric symptoms.  I can also say that if an addict stays clean and works a recovery program, good things will ALWAYS happen.
Anyone interested in my personal story by the way can watch for a book that I am writing called ‘Terminal Uniqueness’.  I am trying to decide if I should post it on Twitter as I go or just wait until I am done.
Suboxone does not interfere with MOST anesthetics.  An anesthesiologist has a number of choices of general anesthetics (regional anesthetics using local anesthetics injected into areas to make things numb are not affected by Suboxone either).  A couple examples– one can do a ‘gas-based’ anesthetic where inhaled agents cause amnesia and anesthesia, or one can do a ‘balanced anesthetic’ using combinations of opiates and other IV medications, perhaps with smaller amounts of a gaseous agent as well.  Suboxone WILL block the opiate portion of this anesthetic, but there are plenty of other agents to use to replace the opiates.
The main problem comes after the surgery in the recovery room, when Suboxone prevents morphine, demerol, and other medication from controlling the surgical pain.  One of my patients had an emergency C-Section shortly after dosing with Suboxone and it was difficult to get her pain under control.  Eventually she was transferred to the ICU for close monitoring as they gave her huge doses of morphine– which eventually controlled her pain.  Some surgeries will be of a nature where injections of local anesthetic can provide considerable pain relief for up to twelve hours.  This is a particularly good option for procedures on the extremities.  Sometimes an epidural can help a great deal with pain control after abdominal procedures, or even chest procedures.  In cases where opiates need to be used, the dose will usually need to be surprisingly high, at levels where nobody will be comfortable unless the patient is continually monitored for respiratory function in a step-up unit like the ICU.

I have helped six or seven Suboxone patients through the surgical process and for the most part they have done well.  Stopping Suboxone for three days prior to surgery will make pain control much easier after the surgery.  Even if sufficient time has elapsed to get rid of the Subxone, though, the person will still have a much higher tolerance than patients not on Suboxone, so I strongly recommend discussion the fact that you are on Suboxone with your surgeon and your anesthesiologist.  If you don’t, they won’t know what is going on, and won’t be able to take the proper steps to help you.
SD
Like my style?  Consider TelePsychiatry!
http://fdlpsychiatry.com
http://subox.info
http://suboxforum.com

Striking a nerve with Methadone

Wow. I have heard others talk about methadone zealots ‘out there’ who get very emotional about the drug– I figured the people that described them as a bit crazy were exaggerating… I went ahead and approved a couple of the replies to my last post so that people can judge for themselves. They are 100% free of editing– nothing added, nothing removed.
I don’t want to whip out resumes and see who’s is larger, but I do want to establish my credentials and experiences. The posts make many references to ‘experts in the field of addiction’, and as that is exactly what I am, I am not sure who they are referring to. I assume they refer to people like Dr. Michael Miller, President of ASAP, the American Society of Addiction Medicine– down the highway from the city where I live, in Madison Wisconsin. Or the medical researchers who did the work that led to the approval of Suboxone. I would think those people are ‘expert’ enough. I know the work and the stated opinions of those experts– I have personally met and spoken with some of them, and have read editorial opinions and research papers written by others. I can honestly say that I have read pretty much every major study about opiate addiction over the past 8 years– certainly all of the ones that were in the peer-reviewed literature.
As for my own credentials, I am a Board Certified Psychiatrist; I am on the faculty of a major medical school where I teach mainly about addiction and addiction treatment; I am a trained Suboxone Treatment Advocate—I have been to meetings with the people who did the original (and later) research in Suboxone; I have met many, many opiate addicts over the years in my own recovery activities, as Medical Director of a 50-bed residential treatment center, through my own work treating over 150 patients with Suboxone, and through my work in the state prison system where I treat women and men who are incarcerated. I have worked in a methadone clinic, and have spoken with the VP of Med Services of the large company that has purchased many of the methadone clinics across the country– one of their ‘people’ few out to take me to dinner, to recruit me for a regional position as medical director of several individual methadone clinics.
The comments refer to the molecular actions of methadone; I completed my PhD in neurochemistry in 1986 before I went to med school, and my thesis involved work with brain receptors– characterizing how they bind to their ligands, localizing specific receptors, etc. While my thesis was not on opiate receptors (rather it was on receptors for vasopressin), several of the other scientists in the Center for Brain Research down the hall from my lab were doing the early work with opiate receptors, substance P, and ‘second messenger systems’. It was an exciting time, as that was when our knowledge base really expanded in those areas. Anyway, I have a pretty good understanding of the molecular issues.
Whew. I won’t repeat all of the things that got them so angry, as you can go back to my original post. I will comment on a couple specific things though. First, whenever you come across someone who is so worked up, you have to ask yourself, Why? What fuels the anger? Sometimes a person has their own issue with the topic that they are trying to avoid thinking about– you may have heard the phrase ‘thou doth protest too much’ from some Shakespearien source, in reference to a person who is denying something in an exaggerated manner. Maybe a person has a financial interest at stake; or maybe the person is afraid of losing access to something he/she needs… I don’t know. Maybe since I have a blog they see me as an ‘authority figure’ and that riles them up. Although it is pretty easy to have a blog these days.
Similarly, I am always a bit suspicious about a person who talks about ‘the experts’ without naming specifics. Zenith mentions a study about IV heroin users doing better with methadone– If I get the reference I will look it up and check it out. I have helped many IV heroin addicts with suboxone without any problem at all, so I am curious. If I don’t write about it, it will be because I was never given the reference and couldn’t find it in my own lit search (which I will do after this post).
There is no debate over the molecular actions of buprenorphine and methadone– anyone can find a Merck manual and read for themselves. Methadone is an opiate agonist, just like oxycodone, hydrocodone, hydromorphone, fentanyl, sufentanil, alfentanil, meperidine, morphine sulfate… In all cases the primary effect is at the mu class of opiate receptors (some drugs activate other classes of opiate receptors, like ketamine for example). Buprenorphine is a partial agonist, which gives it unique properties compared to agonists. Tolerance is universal and unavoidable with agonists. There were trials of ‘morphidex’ a couple years ago that gave hope for a way to limit tolerance… but it didn’t work in humans.
Methadone potency increases linearly with dose; buprenorphine levels off and becomes flat (I have read reports of antagonist actions in high doses, actually causing a ‘bell-shaped’ curve). Methadone is just another agonist– as any opiate addict knows. Buprenorphine is different. That is why a person who is using can take methadone to avoid withdrawal or to get a ‘buzz’, but taking buprenorphine will cause withdrawal if the person hasn’t abstained long enough to reduce the activity of agonists at the receptor– the bupe will displace the heroin, methadone, or oxycodone and block the opiate receptor.
Some of the other stuff gets a bit off-topic… yes, I realize that nothing is for ‘everybody’. If a person fails buprenorphine, they may have to go to methadone– including making the drive each morning to the nearest clinic and standing in line for their dose, knowing that if they miss it, it will be a long, long day. Fear of having to do THAT helps keep people taking their Suboxone! I also mentioned the problems with Suboxone and the need for surgery or intermittent narcotic pain treatment.
As far as my comments about the evils of opiates… thanks for reminding me that molecules aren’t people! (is it unprofessional to say ‘duh!’?). I was an anesthesiologist for 10 years– I loved the power of being able to instantly remove pain, in surgery, on the OB floor…. and in myself! Every opiate addict will likely have the need for narcotics at some point in life– but those who have learned to stay clean know that those times are very dangerous, and that pain medication must be feared. Anybody who wants to go the route of total sobriety from all substances– including methadone and buprenorphine– must learn to fear opiates if they are to stay clean. That is ‘recovery 101’– also the ‘first step’ of a 12 step approach. Powerlessness. And since we addicts are powerless over opiates, and since opiates will always destroy every good thing about us during active addiction, we had better fear them. I will talk about the twelve step approach sometime– it is the only approach that has ever worked to maintain total sobriety, and has certainly stood the test of time. Other things have come and gone over the years (google ‘moderation management’ and Audrey Kishline) as people try to find an ‘easier softer way’, but there is none…
As for my hatred of opiates, I lost a career and much more to opiates, and I have known a number of people who are now dead from opiates. So pardon me, but we are talking about ADDICTION here. And in that context, I HATE opiates– I hate them for the friends that they have killed, and for what they have done to my life and to the lives of those who I care about. That is what works for me– I am not into ‘euphoric recall’– talking about the good old days– or even thinking that ‘y’know, opiates THEMSELVES aren’t all that bad’. I will use them if I ever absolutely need to, but I will do my best to hate them the entire time.
Too much writing for a Sunday. I haven’t even taken a shower yet! Methadone users: chill out!
http:///suboxonetalkzone.com
http://subox.info
http://suboxforum.com
http://wisconsinopiates.com

A Reply to Chronic Pain:

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 a woman describing her 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

Why Not Just Take Narcotics for my Chronic Pain?

I received a letter today– a person discussing the use of opiates by a family member with chronic pain.  I was not sure if the letter was asking questions about my opinions, or was instead arguing that my ideas were off-base.  In either case it is worth publishing, as several topics are discussed.  As per usual, the names were blocked to keep things confidential.
Here it is, with my answers:
Why is it wrong to take pain medications for pain?  Especially if you have INTRACTABLE CHRONIC PAIN.
Medications for pain are not ‘evil’—the only way I approach the issue is from a quality of life position.  There are many problems with pain meds as they are now.  At some point I expect we will find a way to avoid tolerance to opiates—that will truly revolutionize pain treatment.  But as things are now, tolerance is the basis for the problems with chronic use of narcotics for pain.  Any person taking narcotics, either for pain or for ‘fun’ (although there is nothing fun about opiate dependence after the first few weeks), will become tolerant to the effects.  The medication will become less and less effective, requiring increases in dose to get the same pain relief.  The dose cannot be increased forever—eventually the patient would be chewing on pills every minute of the day—and so the doc must limit the pills.
If I give enough medication to satisfy a person who is 40 yrs old, what will I do when the person is 42 years old?  Tolerance develops very quickly—this leads to tension between doctor and patient, and eventually the patient takes too many and asks for early refills.  This annoys, angers, or frightens the doc, who therefore eventually stops the narcotics or quits seeing the patient.  The patient, meanwhile, thinks he is being deprived, and gets mad at the doc, mad at all docs, and mad at the world.  Finally, pain meds get inside the head of everyone who takes them, whether they are being taken legitimately or not.  The patient becomes more and more focused on the meds, getting the meds, the pain, and the withdrawal.  Relationships suffer.  Depression develops.  The patient eventually becomes a one-dimensional shadow of who they once were, where the biggest relationship in the patient’s life is the relationship with the pain pills.
I have seen this all happen many, many times, with every patient who takes narcotics.  I do treat with opiates, but I do tell the patient all of this, so they understand what they are taking on.  This is why opiates are always the last resort.  Any good pain doc will tell you that they have seen patients who complain of terrible back pain, who ask for narcotics repeatedly and think they need them…  who get detoxed for some reason and after getting past the withdrawal are surprised to find that the pain is gone, or very small.   I have seen it many times, and I cannot explain it, other than the body trying to trick the person into thinking he needs pain pills as part of an addictive process.
For cancer pain, by the way, none of this is relevant—with a limited life span the doc should just give what is needed to control pain.  But for non-malignant chronic pain, I have never seen opiates improve a person’s quality of life in the long term.  And I have seen many lives destroyed.  The patient may not see it—he may insist things are great on the pain pills, even as his marriage falls apart and his kids disappear.
Why would you want to withdraw, if the pain was being controlled and it lowered your blood pressure?
We have plenty of ways to lower blood pressure—narcotics should never be used for that purpose, except in the case of acute myocardial infarction, when morphine has a number of helpful effects including lowering blood pressure.
What if the patient was limited, and could not do alot of physical therapy to get the benefits of endorphins to work for them.
Patients can do much more than they think with physical therapy.  They need to be taught patience, and they need to work at it every day at home—not only at the therapy center.  Physical therapy is so valuable—but patients generally look for short term solutions.  That is unfortunate.  As far as endorphins go, I caution people against getting wrapped up in thinking about what their brain chemicals are doing.  It is much more complicated than magazines suggest–  endorphins, for example, do many things besides pain control—including things that have nothing to do with pain.  Yes, they have been shown to be released by exercise, but… so what?  We don’t know if that release actually does anything helpful for people.
Like you said, there is a difference between dependency and addiction.  My family members suffer from chronic pain due to chronic pain conditions, that we were either born with or developed.
There is a difference early on, but over time the differences go away.  A person who I see for a congenital pain condition who takes loads of narcotics has very few differences with a person who started pain pills ‘for fun’ and who takes tons of narcotics.  If anything, the addiction is worse in the pain patient, because they are convinced they need the pills, and cannot see the destruction they are causing.  A person who starts ‘recreationally’ is more likely to truly hate the pills, and is often willing to go to greater lengths to get off of them.  That person hates the pills, where the pain patient thinks he loves them.
So, intervention should come, if I am just lying around getting HIGH in a chair, like the rubbish I have been reading
I don’t know what you mean by this sentence.  If you are referring to addicts as ‘rubbish’, you are off base.  Yes, some addicts have bad characters, just as some non-addicts have bad characters.  It sounds like you see a difference between ‘good people’ on pain pills and ‘bad people’ on pain pills.  That difference does not exist.  Over time, any person on pain pills becomes a slave to them, and desperately wants to be free from them.  For some people, it takes longer to seek freedom; some people never seek it.   I can assure you, though, that opiate addicts are not sitting around enjoying themselves—not after they have been doing it for a few months.  They are scrambling for money to get something to avoid being sick—stealing, prostituting, whatever.
OR should it be, I take the pain meds, and I can walk around in the house, function a little better than suffering in pain.
That is your decision.  But it is more complicated than you would like to believe.

I wish you the best, and hope things work out.

J