Suboxone- Pain management

Very interesting thread, gtrplayer. You certainly made me curious enough to research Suboxone more thoroughly.

We really need to talk about two medications here:

• Suboxone (buprenorphine and naloxone)
• Subutex (buprenorphine only)
  

The Suboxone website states:

Notice the website doesn't mention Subutex is not indicated for pain management; but Subutex doesn't merit its own website, and it's hard to find much information.

You mentioned some posters on other boards are getting Suboxone for pain management, but it's very possible they are not from the United States - and they might be talking about a foreign version of Subutex which is Temgesic.

Yesterday I answered a pill ID question about a sword logo and the letter 'L'. The pill is Temgesic marketed outside of the US. Temgesic has been around in the foreign market for at least ten years, maybe more.

Temgesic is the exact same medication as Subutex (buprenorphine only), and Temgesic is prescribed for pain management.

Here are a couple of excerpts:

From netdoctor.co.uk:

And from the New Zealand government:

I'm more confused now after I started researching this!

Seems to me like Subutex (buprenorphine only) or even Suboxone would be ideal for serious pain management when one drug only is necessary. Since buprenorphine blocks other opioids, wouldn't that be a good thing to deter any type of abuse?

Please enlighten me. But it makes sense to me.

Thanks - and sorry for the long post.

PS: For experiences using buprenorphine in pain management, we'll probably have to wait for some Europeans, Australians or New Zealanders to contribute their experiences. Apparently buprenorphine is not prescribed in the US for chronic pain.

Not to dog on this med, but to me, it was no good. I used to use this stuff not to get sick to got to work when I had none of the devil's pills,
(Oxycontin). I'd Take a half if one at 5:30a.m. and by the time i got home at 4:30, do some things, and take my O's, I'd get tore up just like any other time. Thats just my 2 cents. I guess you just gotta do the was it is supposed to be used and not mess up at all cause to me, it was totally easy for me to relapse on it. For me now, I,m on the long path of the methadone treatment but to each its own.On the mehadone, I never messed up once after iI got to 60 mgs. causethey started me on 40 mgs. and that didn't do the trick now I'm up to 7 to 8 80 mg. pillls a day. So if youre trying to break the habit, talk to a counsoler before you start the long road to recovery. I've been on the mmt for in 3 weeks it will be a year and it has been good to me. This weekk im going to start to drop. hopefully eveerything goes well. I'll keep you posted. Thanks for listening and I hope someome go some help outta it. Peace and be well!

(edited by TeamPharmer) 

I love Suboxone/Subutex. I have developed a problem with my 15mg oxy IRs. Because of a history with Gastric bypass, OContin is NOT an option ( would be passed in the potty before it completely disolved). I went thru my pain meds FAST about 10 days ago.

I am A BIG WUSS! %?#$$ the Withdrawls, I'd rather go to sleep and not wake up then be in that torture ( SERIOUSLY< I MUSCLED IT OUT ONCE BEFORE, NEVER AGAIN). This time I traveled 200 miles, went to a detox hospital. I was buped..... I didn't hurt, I wasn't high. I was clearer than I jhave been since surgery. Period. I was on a LOW dose. ( in the 5 days prior to tx, I went onto 50 mg per day of vicodin) Poor Liver!)  Today I am CLEAN... Sore, tired, feel pain, but am laying low. /bupe worked for me. If I ever go back on to Oxycodone, I WILL have to give them to my fiancee, to dole them out. I cannot be trusted. I will %?#$$ up. I know that, but I thank god for Bupe, cause I thought about going to sleep to avoid the withdrawls from 16 15 mg pills a day. 

my 2 cents, 4 what its worth. 

Apparently Suboxone or Subutex has been used for many years in Europe for chonic pain management.  It is approved in the US only for narcotic withdrawl for which it seems very effective in preventing physical withdrawl symptoms.  It does not seem to produce the same psychic dependance and euphoria that traditional narcotics produce in suseptable people. 

In the US doctors without special license from the DEA are prohibited from using Suboxone or Subutex for narcotic withdrawl in people with drug addiction.  Those with the special license are limited to how many people they can treat per month.  The limit was recently raised.  It is my understanding from speaking with two pain management doctors that you do not need a special DEA license to treat people with chronic pain, who do not have drug addiction, with suboxone or subutex.

I have in my general medicine practice had at least one or two patients who were addicted to Stadol (fast acting nasal butorphanol) which was originally marketed as a "non-controlled" drug, and was later reclassified when evidence of addiction and dependance surfaced.

I happened across this site while looking for information on using Suboxone in a chronic pain patient with a history of cocaine and heroin abuse who is currently about to complete an outpatient drug rehab program.    

Increasing the dosage without your doctor's instruction, craving the medication, anticipation of your next dosage, and using the drug in ways that can be socially or physically dangerous can all be signs of psychologic dependence.  You say that you still are in pain.  Is the pain tolerable?  Did your doctor discuss using Suboxone as a chronic pain medication now that you are off traditional narcotics?

My sister also had problems with meds after gastric bypass.  She had excellent relief of her chronic back pain with Motrin, but after bypass was told not to use any NSAID's including injectable Toradol (ketorolac) even occasionally.  She hated the sedation and nausea of narcotics.  She has been successfully managed with interventional pain management techniques, primarily epidural and facet joint injections.

methadone is horrible in my opinion. it's just another opiate they have you addicted to. like the fact that they up your dosages like that baffles me. Not to mention most people on methadone just mix it with benzos anyway and get even more messed up. And the withdrawals are alot worse than heroin withdrawals.

(edited by TeamPharmer) 

whatever, but the point was i was addicted to opiates, got on suboxone, about 2 months into it i got my tonsils out, they gave me codeine syrup it didnt do anything so i relapsed for 2 days, then when i realized what i was doing i got back on suboxone the 3rd day and i was in horrible pain. so the day after that i tried taking about 4 or 5 times what i usually take and it did absolutely nothing to relieve my pain. So i duno where you're hearing this, but in my experience, no, suboxone has less affect on pain than tylenol

brupenorphine (the drug in suboxone) has been used to treat pain,  but only intravenously; which the naloxone in suboxone would prevent you from injecting it.

Dr Lois.

My gastric bypass was nearly 3 years ago. More Recently I had a Ventral Hernia Repair and a Granuloma removal ( about the size of a medium sized Kiwi fruit). then that was complicated by an abcess the size of the upper knuckle of my thumb, and a Saroma. I had 2 invasive surgeries on Jan 17th and Feb 1st. I was packing (wet to dry) with 13 feet of Kerlix gauze 3 times a day. I was sent home from the hospital with the instructions that i had to wait for my 7 inch inscision to heal from the inside out, insted of having a nice steri striped wound. It BLEW. And yes I still hurt. I feel like I have a hot hatchet in my gut. I have a 17 mo old that I still have to carry around. I have re ripped my gut twice ( 1 time because I was wearing a seat belt and we stopped fast).

The withdrawls scare the Diaharea out of me! I was not a Ocontin canidate because of the gastric bypass, my peristalsis moves far to fast. and stuff is out of my belly in 15 mor less. On top of that some of my absorbtive tract is gone. There by rendering any "extended or Continuious Release" medication a waste of most of the pill.

I went into medical detox while still in pain and was treated with Bupe/Suboxone for a total of 5 days ( 1st day was alllllll lorazapam, I don't remember much).

I would have rather o'd'd and not woken up than go thru cold turkey with drawls again. I have reactions to Clonidine. 80/44 is not normal, I was hospitalized after trying to CT with Clonidine, passed out cause of the blood pressure, woke up feeling normal. Only to find out that the doc put morphine in my IV, and said get your self into medical detox.

I know that MMT can be a lifesaver for people. I commend them for seeing that in themselves and getting their butts to the clinic everymorning, but for me... I didn't want an 8 month detox. I wanted OFF. But comparitively I was not using very long/not self medicating ( you could consider the fact that I went thru a script real fast, not abiding by terms on bottle, but I wasnt' scoring OC, morphine, or other stuff) I just wanted off. I didn';t want to put my fam thru this anymore. It was ridiculus (the thoughts I was having about od'ing) and I wanted off the rollercoaster FAST.

I still hurt. and I could care less if Dr Lois thinks I'm and addict or not. I know I have at the veryleast a problem. When I have to go in ofr a nother surgery, I will have a step down program before I go into the OR. My fiancee will control my med acsess much like a MMT.

Did I take Oxy 15's to get loaded?!?!? No. I took them to releive pain. help me sleep. be a mom ( housework, laundry still needed to get done, wether or not I hurt. There are expectations placed apon me and I can't explain to my kids, sorry, there are no forks or clean plates, underwear or jeans cause mommy hurts to bad). I basicly had to pop a pill and cowboy up. Honestly the only time my pain was FULLY controleed is when I overtook at night so I could sleep. I muddled thru it during the day. I took less in the day, so I could sleep at night, In hind sight, I forgot I had the halcion, so I could have used that, but frankly I'm not a "taker" of benzo's. The week I ran out early, I had asked to be tapered off.... (cut my script by 30 pills) and I had asked for something non habbitforming or addictive SHORT TERM ( like rozerem, like u see on tv) to help me sleep. I hadn't slept more than 3 hours at night since my initial surgery in Jan. I felt like a zombie cause of lack of sleep, and it scared me to overtake at night, even though, blessedly, my pain was gone. 3 hours later It started back with a vengence. But I knew how much I had taken 3 hours earlier, and made the concoius choice not to pop another pill until it was at least 8 hours later. ( i failed at that twice) but for the most part I just stared at the ceiling, praying for sleep (again, a narcoleptic with sleep issues, who would have ever thought). But my pain clinic Doc wouldnt "muddy the waters" with a sleep med becuase I also had a history of Sleep Apnea, so he refered me back to my Sleep disorders med specialist. He is mostly retired, and bec caus of cost issues surounding Modofinil (Provigil) and a cardiac intolerance to Dexidrine, I haven't seen him in a long time, they archived my file, and I have to restart his clinic with a new referal... that takes a ^*#% load of time, when you volunteered to loose 30 pills in a script. ITs now been a month 3.3 weeks, and I still haven't even gotten the referal to process, let alone an appointment. I no longer have Sleep Apnea, because I lost half my body weight ( was 270, now 135) actually after the surgeries, and the sedentary activity (because of the hernia pain pre-surg) ( I also had a thingfor popsicles ( they seemed to num some of the tearing pain, plus becuase of the nasuea related to how painful I was, Half the time Popscicles was the only way I was maintiaining my blood sugar or what I could keep down) I had went up to 155. SInce my first surg, my pain and gut have been so affected by nasuea, I'm back to 135).

Point is. As a "Doc". unless you have my full history infront of you, you aren't capable of making an informed diagnosis. I don't have idopathic pain. I don't have phantom pain. I currently am probably destroying my liver with APAP. but thats MY ONLY option.

I CANNOT TAKE IBUPROFIN. IT IS CONTRA INDICATED FOR GASTRIC BYPASS PATIENTS, ON TOP OF THAT I HAVE AN ACTUAL ALLERGY (DOCUMENTED 2 YEARS BEFORE MY GB) TO IBU. ITS MILD (NOT ANAPHALAXIS) BUT STILL CAUSES MODERATE SYMPTOMS FOR ME THAT LASTS FOR ABOUT A MONTH, JUST WITH ONE DOSE!!!! BLLISTERS AND SUCH. I ALSO RECENTLY (X-MAS NIGHT) WAS DIAGNOSED WITH AN ALLERGY TO ULTRAM (TRAMADOL) THAT CAUSED SEVERE SWELLING OF THE FACE, LEGS, ARMS, WELL, I LOOKED LIKE A MACYS FLOOT WITH LIPS LIKE I JUST HAD A COLOGEN PROCEDURE GONE TEREBLY WRONG. AND IT WASN'T TREATABLE WITH BENYDRYL. I WAS PUT ON CIMETIDINE TO COMBAT IT. SO WHAT ARE MY OPTIONS? OPIOD THERAPY FOR PAIN, BUT I'M A WUSS WHEN IT COMES TO PAIN, AND WITHDRAWL. I KNOW THAT NOW. BETTER NOW AT 28 (HAD TO REMIND MYSELF) THAN AT 40, TRYING TO  DULL THE PAIN) --- NOT PUTTING ANY OF YOU DOWN WHO HAVE GONE THAT ROAD) WE ALL HAVE OUR OWN DEMONS AND ISSUES. I APPLAUDE YOU FOR SEEKING MMT, N/A, WHAT EVER YOU DO TO KEEP IT IN CHECK.

BETTER THAN LOSING MY KIDS.

SORRY I WAS SO UPSET IN THIS POST, I JUST REALLY FELT PUT DOWN BECUASE FOR ME? WITHDRAWLS FROM OPIATES IS NOT SOMETHING I WILL TOLLERATE, I DID IT COLD TURKEY ONCE, AND I KNOW MY LIMITS.

THIS WILL PROBABLY GET DELETED, BUT I FELT I HAD TO RESPOND.

BUPE/ SUBOXONE, WAS MY LIFESAVER, IT KEPT ME FROM OD'ING WITH THE PROMISE OF NO SEVER COLD TURKEY WITHDRAWLS.

"Gutpdx", you asked if anyone was in  the same boat as you and there is.  I am like you.  Before any of my illnesses I had never done anything. After I started taking my assorted med's, everything was fine, then when the scripts stopped everything went downhill.  I was going places to buy other peoples scripts.  As hard as it has been, I have been clean a whole 26 days, although, its not that long, it seems like an eternity when I was used to taking 5 and 6 Oxy 20's to get through a day.  I wake up with aches and pains, I go to bed with aches and pains, but they are nothing compared to the withdrawls.  Like they say at NA, "Just for Today".

"Be kind to all strangers for many have entertained angels unaware. . . "

 gutpdx: 

I am glad to hear that you were able to use suboxone so successfully for withdrawl.  You seem to indicate that now all you take is tylenol, but that you do not feel you get adequate pain relief, and you are concerned about liver toxicity.  Did your pain management doctor ever consider putting you on suboxone or subutex for chronic pain management?

"you could consider the fact that I went thru a script real fast, not abiding by terms on bottle..."

The behavior you mention is associated with psychologic dependance. 

"I still hurt. and I could care less if Dr Lois thinks I'm and addict or not. I know I have at the veryleast a problem."

I agree, you do have a problem.  

"Point is. As a "Doc". unless you have my full history infront of you, you aren't capable of making an informed diagnosis. I don't have idopathic pain. I don't have phantom pain." 

"So now I am an opiate addict."

 I did not attempt to make any diagnosis, nor did I write anything that could even be imagined a "put-down".   I did not call you an addict, although you referred to yourself as an "opiate addict" in an earlier post.  I did not suggest you had idiopathic pain, neuropathic pain, or phantom pain. 

I found most of your incredibally long and whinney post totally irrelevent to the subject. 

Please read my posts carefully for meaning and in the context in which they were written, before rudely going off on me, and I will do the same for you. 

facedown;

My understanding is that the dosage goal for withdrawl is 8-16 mg per day.  There is a ceiling effect, so I can see why taking 5 - 6 pills at a time would not give you more pain relief.  What was the dosage of the pills you were given?

"Appropriate use of SUBOXONE

Oxycodone is a drug that is used in Percocet, Roxicodone, Oxycontion, OxyIR and many other meds. If you have a chronic illness and the instant release meds are not working as well as they have you may be a good candidate for medication management for your pain with the extended release meds. Check with your MD.

Interesting I have never heard of people being prescribed suboxone for pain management. Just x dope addicts like myself trying to stay away from the junk. Although I do know when people take it that are not prescribed to it they get all of the effects of any other pain killer they take. For me suboxone is a wonder drug, it's not as harsh as methadone and it keeps me from getting high..... but pain management, I've never heard of such a thing.

Gtrplayer: 

 agree with what you are saying.  I do not know how the Europeans manage this problem in chronic pain patients.  I can find very little literature on managing chronic pain with Suboxone, which is why I ended up at this site.  I do  not know if a short acting mixed agonist-antagonist like Stadol, which is available in the US as a nasal spray and for IV injection, would do the trick.  I started one very motivated chronic pain patient on Suboxone last week.  I told the patient that because of the mixed agonist-antagonist properties, breakthrough pain management could be a problem.  He has Ultram (Tramadol) for back-up, but in the past that has not been adequate by itself.  

Have you tried any of the new anti-tumor necrosis factor drugs (Entanercept, Infliximab)?  Have you been treated with methotrexate or prednisone?  Are you taking a nonsteroidal anti-inflammatory like Ibuprofen?  Have you tried tramadol (Ultram)?  You can use these in combination which often gives better pain relief than a narcotic alone.  If you are having so much pain on a daily basis that you cannot take care of yourself, you are undermedicated.  If you are taking 60 mg of oxycodone a day, with inadequate relief your doctor should consider switching you to a long acting medication.  One of my favorite is the fentanyl patch (Duragesic).

Gtrplayer:

 Sorry for the confusion.  It is hard figuring out what is in response to what.  Another poster who had tonsilectomy got no pain relief from Suboxone stated, as does the FDA approved Product Information monograph,that Suboxone should never be used for pain management.  However it is apparently used extensively in Europe for chronic pain management. 

I am really not convinced that this med will ever successfully be used in pain management.

to me, it seems as there are far to many cons verses pros.

under the assumption (and i stress assumption) that it can be found to be beneficial in pain management, then i don't really see how medical professionals could manage acute care. for instance if someone has a major accident or something of that nature and needs a strong i.v. medicine then the choices are very limited at best.

to me the whole thing just sounds kind of pointless. why put all this initiative and work into such a risky off label use of a drug? it isn't like this will single handily defeat drug abuse. additionally, company's like remoxy are already developing anti-abuse measures as are several other companies.

if someone has a history of drug abuse it should not exclude them for proper and reliable pain management (which hasn't been shown by sub). there are several other reliable measures that can insure people are properly using their meds such as random pill counts, and random drug testing.

of course all this said, i do respect everyones opinions.

I disagree.

i work with plenty of patients that have prior historys of drug abuse and because of their condition they require pain management. They are a bit more closely monitored b/c of their past but i have never seen it be an issue. usually when someone gets to the point where they really need pain control their desire to use illegal drugs seems to take the back seat to the primary issue.

The last couple sentences of your post kind of suprised me. An HMO suggested that you switch a pain patient to a medicine that is not indicated for that use? Not only would it be considered "off-label", but i believe that it specifically says in the prescribing information that it should not be used in the management of chronic pain.

As for "sub being the most common pain management drug in Europe", i am not sure where you heard that, but i am confident that that is not true.

i think that you are absolutely correct about the cost driven motivation, that was the first thing that i thought of as well.

as for the risk, i personally feel that it would contradict too many other meds used for acute care. additionally (and i may be wrong on this) but i believe that there is a ceiling with this drug if someone did plan to use higher dosages. As you know, morphine  being the "gold standard" or morphine equivs are a great and traditional choice for patients since there theoretically is no ceiling.

when you were doing your rotations did you ever see someone who was too heavily sedated in the theatre when they are given this type of med? usually they wake up or come out from the anesthetic screaming because of the pain coming back.

i dont think that it would be absolutely impossible for this to be an option for pain management. i just think that there needs to be a lot more work-up done before it starts being used in this fashion, primarily for ethical concerns.

i will try to dig up our policy for pain agreements for people w/ hx of drug/ethol abuse ( i dont have it, but can find it). it is really good and has more information than just the pill counts and the random drug testing. of course as you mentioned, if the patient is unable to overcome their addiction issues then other means to treat their pain must be exhausted.