Suboxone- Pain management

Different medicines affect different people in different ways.  Yeah, I'm a snowflake!

Hello,

I have a question about marijuana. I have back pain, ect. but I think I can live without pain meds. I take 1 (10 mg. opiates-Norco) & 1 (100mg. morphine- Avinza) per day. No insurance-like most. My question is can marijuana help me get off the pain meds.   Thanks  jim

Hello,

I have a question about marijuana. I have back pain, ect. but I think I can live without pain meds. I take 1 (10 mg. opiates-Norco) & 1 (100mg. morphine- Avinza) per day. No insurance-like most. My question is can marijuana help me get off the pain meds.   Thanks  jim

HI Kirby,

Buprenorphine is a partial opiate antagonist but mainly an agonist, if for example someone was on high doses of pure opiate agoonists such as morphine , fentanyl, hydromorphone e.t.c.  and they were given buprenorphine ( for whatever reason ) the antagonist component would reverse the effects of the pure opiates and cause withdrawal. Buprenorphine is popular as an introductory analgesic for pain management for a few  reasons , it does not cause as much respiratory depression as some of the other strong opiod painkillers, and it keeps tolerance down lower than the pure opiate agonists and is thus easier to come off. As for the buprenorphine with naloxone added, that's a bit baffling, the only reason I could think of the use of this is with the very elderly or the very young , but with it being a partial antagonist it does not make sense to add to the antagonistic component for pain relief. Your right about the Temgesic it's buprenorphine sublingual / transdermal , but with no added naloxone.   Thanks.

All comments are the users opinion,  and are  not to be taken for professional medical advice, all medical advice should be sought from a medical health professional.   I am merely a student.

I've been working with people on subs for a long time. I communicate with some good drs about buprenorphine regularly.  There are a few good sub drs out there in spite of all the bandit sub drs who take advantage of opiate addicts with outlandish costs.

Most drs who use buprenorphine for moderate chronic pain do so with very small doses.  These drs who RX even 16mg, or especially 24-32mg and what not are not doing this properly.  If sub is used for pain control only very small amounts.  God bless.  :)

I was diagnosed with fibromyalgia in August of 2008.  It's a painful disorder that affects the muscles.  There is no cure and there is no definite cause...doctors have many theories on what it is.  The main one being a central nervous disorder in which pain signals are being sent out that are not mean to be.  This causes extreme pain in the muscles and joints as well as fatigue, spasms, difficulty sleeping, stomach problems, temporary cloudy head (fibrofog). headaches, and more.  My body also registers pressure as pain...so touching, bumping into anything hurst bad. I had been to many doctors over the course of the past year including rheumatologists, physical medicine drs., neurologists, primary care drs.,  and finally pain management.  Before I had gone to the pain management, no doctor had helped with my constant agonizing pain.  There were times when I felt like going to the ER and I would call my doctor and plead with him to give me something for the pain. I actually told him that I felt like throwing myself in front of a truck and he still said he couldn't help me and that the ER couldn't do anything for me. I was at a loss..I started taking percocets my grandfather had given me. They helped, but still didn't dull the pain enough for me not to go crazy. Finally, in December, I saw a pain management dr.  He said he had a lot of success using suboxone for pain and told me it was actually used as an injectable pain medicine in the 80s.  Also, because I had been on the percocet, he felt better using suboxone rather than oxycontin (which he had originally suggested) I really didn't want to keep taking the percocets, I didn't want to go on a strong drug like oxycontin, but he said I needed something long lasting, time released...and that's suboxone. I've been on it since and though I still have pain, I am doing so much better on it. It lasts into the morning so I don't wake up to my body being schocked by pain.  My doctor says it's a mild narcotic and fairly easy to come off of....and there's a lot less chance of addiction than with other opiates.

my moms been on suboxanz now for almost a year to keep her from taking any loratabs and all shes been complaining about the whole time shes been on them is waking up with pains hurting her so bad she could cry. they do block all other opiots and when she does try to take anything besides those she cant feel anything from them. so i would suggest that anyone takin the suboxans doesnt try to take anything else because it wont work or help you not one bit

I don't know if I can clear anything up for anyone- I am a Pain Management RN. I have not heard of suboxone being used here in the US for the primary  management of pain, however, when someone has been on opiates for an extended period of time ( ie. someone with chronic pain) they most likely will develop OPIATE INDUCED HYPERALGESIA.  This is a little complicated to understand- the opiates will effect the pain receptors and the person will interpret their pain as being much greater than what it normally would be interpreted as.  In other words the opiates that once helped you are now turning on you and causing you to feel  a greater amount of pain.  It is never a good idea to be on opiates for greater than 3 months. There are too many alternatives out there to help you with the CAUSE of your pain.  Well once you have developed opiate induced hyperalgesia- a good practitioner will try to wean you off the the opiates and find other alternatives.  In order to wean you off they may try putting you on methadone- it works differently on the pain receptor that what the opiates do, and I think it also has a lesser half life, meaning it stays in your system a shorter period of time.  Well suboxone is also used for weaning you off your opiate medication.  It works because it competes with the opiates for the same pain receptors.  Once the receptors are filled up with the suboxone the opiates are the passed through the body and eliminated- at the same time it will give the person some pain relief.  But remember now that the opiates in their system have caused a greater amount of pain- so as the opiates are leaving their system, their pain (interpretation of pain) is decreasing.  Eventually they will be able to get off of the suboxone- weaning slowly under an qualified medical professional, and find a better option for controlling the remaining pain that they have.   From my understanding the difference between suboxone and subutrex is that suboxone has a little  nalaxone in it (this is what competes with the opiates for the receptor sites ( it is actually used to "antedote" opiate overdose in emergency situations) and sobutrex.  They use sobutrex in Europe and maybe because of its lack of nalaxone they can use it for to treat chronic pain.  Once again there are so many other alternatives for pain management-that these medications should be used very cautiously for extended periods of time.  I hope that was able to clear up some confusion.  Please be safe out there- and know that there are a lot of physicians out there that practice pain management without a specialty in it.  Would you go to a dermatologist for a bladder infection?

When I used to do clinical trial studies, which were Phase I so you had to be completely healthy, one of the drugs in the trial was suboxone. They were coming out with suboxone strips that dissolve under your tongue. Of course they would give us naltexone which is an opiod blocker the nite before, an hour before, an hour after, and 12 hours after the dose of suboxone so we wouldnt feel any effects of the study drug. I am guessing its a pretty strong stuff if they had to give us that opiod blocker so many times. I never felt anything from from the suboxone but the naltrexone definitely made me nautious. There were a few people in the study that vomited from the naltrexone alone so they were ommitted from the study because it would have been dangerous for a person thats never taken opiates to feel the full effects of the suboxone. This study was back in early 2008 so it will probaly be years before its ever on the market, I think the company funding this study was Reckitt Benckiser Drug company, which paid $4200

Wingsalltheway,

Not to be a nay-sayer but low dose naloxone has been shown to releave pain (as well as many other problems).

For a list of scholarly articles on the subject please refer to...

http://scholar.google.com/scholar?q=low+dose+naloxone&hl=en&client=firefox-a&rls=org.mozilla:en-US:official&hs=YkJ&um=1&ie=UTF-8&oi=scholart

Good luck and best wishes.

Hello,

My Wife is on S.S.I.

Her Doctor usually prescibed Kadian (3) 100 mg. Morphine(cap) per day. The last time she got her presciption and turned it in to the pharmacist every thing was fine up to the point of picking up the meds.. Her Doctor got a call from SSI stating these meds(Kadian) was to strong and too expensive. So he prescibed Endo Gen(3) 100 mg. Morphine(pill). She claims they (the Endo Gen) does not work as well as the Kadian. Does anybody know what is the differ between them?

1. Gen?

2. cap vs pill?

Thanks.

Thanks,

My wife is waiting for the Doctor to call. I wonder what the cost differ is? I really think it's the money and sometime today I will look it up. Have a great day!

Southside

I've had two failed back surgeries, laminectomy & discectomies done on L4-L5 & L5-S1, & have a new hernia at L4-L5. I'm in constant pain & was approved for SS a little over a year ago. I've tried many medications & combinations of medications, through Pain Management Dr's, & have only ever had good, lasting, relief from a combination of Oxycontin & Oxycodone. I recently moved from Washington State to Texas & was told by a Dr, prior to moving, that I would have a difficult time finding a Dr that would perscribe Oxycontin & Oxycodone for pain here. (I won't even go off on how frustrating it is to have Pain Management Dr's in different states, let alone in different cities in the SAME state treating pain & pain mangement differently.) Due to my disability status & subsequent HUGE decrease in my income I've had to try to find the least expensive & most effective medication combinations. I've tried Methadone, did not have good results with the dosage given & had the TERRIBLE side effect of profuse sweating, which in this far warmer climate, was unbearable. I've tried the Fentanyl patch. I've tried MsContin with Vicodine & with Oxycodone. I most recently was on 100mg MsContin & 15mg Oxycodone. My son was born last month, the month I was switched to it, & was unable to determine if it really was a good combination before they pulled me off of all of my pain meds. (If the details matter I'll be happy to supply them.) The short, of this long story, is that I was told that the only thing they would be giving me for my chronic pain was Suboxone. I've started reading through the mountain of comments but am unable to sit in front of the computer for extended lengths of time, as I'm sure is the case with many of you writing in, & wanted to see if I could get a couple of questions answer, though they may have already been addressed.

I am having NO pain relief from Suboxone, 8mg 3xdaily, this is up from the "titration"<?sp> schedule from the first two weeks of use.

I have been told that this is all they will be using to treat my pain, even though they know I have kidney stones & at least a couple kidney cysts that give me unbelievable amounts of pain when they're acting up.

They swear up & down that this is a "great pain medication", even though, after reading Suboxone's website, I've found that it's a medication used for treating addiction.

Is this a good pain medication? Am I just one of the unlucky ones that it doesn't seem to work for or am I being misled? I realize that not all pain medications work the same for every person & the fact that the Suboxone website still has it listed with the sole use being narcotic dependancy but I'm REALLY not happy with the results thus far.

IF I have a flair up of my kidney stones or cysts am I going to be completely screwed, relief wise?

I have current Mylograms & MRI's as well as my Neurosurgeons current findings. Would it do me any good to go back to my Neurosurgeon to get an updated status report, in your opinion?

Sorry for the much longer than intended first comment & questions & any help will be greatly appreciated.

Goat

Sorry! the the above comment is for goat or anyone reading 100mg Kadian vs 100mg. Gen. pill.

Kadian can be dosed every q12 or q24

As for SSI:  Normally if you are on SSI you receive Medicaid ( state medical program) and not Medicare (federal)

Medicaid is well known for changing patient prescriptions or refusing to pay for name brand medications when there is a generic available.

In these situations in order to obtain a name brand your physician must obtain a prior authorization, which can be quite time consuming and essentially makes one jump through hoops.   Because of this many healthcare providers will no longer submit them.

Every program is different but many use a formulary of what they will pay for and what they won't.

I currently take 4mgs of Suboxone a day and it is a life saver for me.  I've read all the posts and forums on this site and others warning of it's dependency, but to me, it's better than taking the ammount of opiates I used to take.  I was legally prescribed by my drug pusher( oh I mean doctor) 8, 80mg oxy's a day.  That's enough to get a horse on it's knees, but with my tolerence and the ammount I was taking of norco and percoset it only made sense.  I tried the patch(fetynal sp....), but my doctor was convinced it lasted longer than it did and refused to prescribe me anything for the  break through pain that I experienced.  He had no problem prescribing the oxy's though.  I became a zombie and a slave to the pill.  I guess you can say I'm still a slave, as I take my 4mg of Suboxone every day, but I don't crave other opiates.  I tried an experiment and took two 80 mg oxy's while on Sub's and felt NOTHING.  That was enought for me to never waste my money on another opiate in my life.  I'm not totally convinced that it helps with pain, because i still experience a lot of pain sometimes, but now I just take some advil and it gets me through it.  It beats all the time I spent chasing and lying to get more. I think of the Suboxone more as a drug for people with High Blood Pressure.  If they don't take their high blood pressure pill they start experiencing syptoms due to high blood pressure.  If I don't take my sub because I forgot, I'll notice I feel a little wierd.  So, yes I think they are addicting and if you can trust yourself get on them to not experience the worst of the WD's and get off them as quick as possible.  I continue to take them because I have titrated twice off of methadone and both times were taking pills within a day or two.  When I take my suboxone, I can be around a 1000 80mg oxy's and am not even tempted to take one.  The one problem is that it is SO expensive.  I have a cool doc who prescribes me 3 times the pills I take per month so that in three months I'll have a 9 month supply.  I am unemployed and have to pay COBRA, but it's still less than the 556.00 that the pharmacy wants for 90 sub's.  I'll quit my COBRA next month, get some neurontin(sp) prescribed, and use some kick @!^ valium I got from over seas to help me at night.  I read this as the best way to ween off of the subs.  I've been on them for 2 years now, and I've never had a better quality life than I have now.  I don't have to go to a clinic every day to dose, and I don't spend my entire day chasing pills.  I can spend my time as I choose.  So to make a short story long, I think it is a great drug if you use it for what it's for.  I've been able to come a long way with my spirituality since only taking subs and feel confident that I won't go back to the pills.  You never know until you're there, so I'll make sure I have plenty of Sub's left just in case.  It also helps that I have the most understanding doc in the world.  By the way, if you meet certain criteria(and it's easier than you think), and you get your Sub's from a regular Doc, the manufacturer of Subloxone will send you a months worth at a time for a full year to your doctors office.  You just have to make sure your doc fills out the paperwork.  If approved, you just stop at the docs and pick up your pills, just like you used to do with a script.  I went from 40mg of methadone a day, waited 16 hours, then took 16mg's of Suboxone for 3 days straight.  I didn't feel great, but I only felt like I had a little flu and was even able to work.  Once the three days were up, I felt fine and went down to 8 mg's a day.  Now I'm down to 4mg's.  There really isn't a price cut if you get the smaller ones, I think they are 2mg's, they cost almost the same as the exact same quantity of 8 mgs, so I will try to break down my 8's as evenly as possible for now, then hopefullly not take them anymore.  THEY ARE ADDICTING.  THEY JUST LAST LONGER AND YOU CAN GO A DAY WITHOUT SOMETIMES AND NOT NOTICE IT.  THE LONGER YOU TAKE THEM, THE HARDER THEY ARE TO GET OFF.  Last bit of news, I heard they were coming out with a generic this fall in the U.S., anyone hear about this?  If you did I would love some info to research.  Keepin' it light,

Jber72

subutex is perscribed for pregnant/breastfeeding people mainly because the opiate blocker in suboxone transfers to the baby. all i know is that its a miracle drug whichever one you take.

I started Subs in April 2008.  I was on them for a year.  They did not help with my pain at all.    What should I do?  Stay in a moderate amount of pain daily and not work because I don't want to do anything to "hurt" myself  (and plus the pain throughout the day would drive me crazy) or should I go back on meds. to improve my quality of life and then it would be possible for me to work.   My pain level on average is about a 6, and then of course I have my days where my pain level is about a 20...  I don't even know if a Dr. would prescribe me pain meds. after being on Suboxone.

I have bulging discs (L4-L5), Degenerative Disc Disease, bursitis in both hips and a Fractured Coccyx.  I had fractured my coccyx while working for FedEx,(fell down a flight of stairs right on my ^*#%) Ouch!  This was on top of all of the diagnosis'.  Since the fall, my lower back has not been the same.  Cannot stand or sit for long periods of time.  Lifting, stooping, bending all aggrivate the lower area.  I started out of Hydrocodone 5/500 and ended with Norco 10/325.  I am wondering if I was prescribed something longer lasting, maybe I wouldn't have went through the Norco's so fast.  That is what my problem was.  I would take a months supply in three weeks.  They would prescribe me Ibuprofen 800mg along with the opioid. That was it.  I started on Suboxone because I was sick of doing the pain pill thing.  Worrying about my pills all of the time and most of all, being labeled as an addict by the pharmacist.  Suboxone didn't help with my pain.  I know everyone is different and some might get  a relief from Suboxone, but not me.  Next, do you think a dr. will prescribe me pain pills after being on Suboxone?  I appreciate reading posts, it helps me to realize I am not the only one living a complicated life.  Thanks for listening.

Here in Ireland buprenorphine is indicated for moderate to severe pain for acute or chronic pain at the discretion of the physician , there is the temegesic sublingual tablet and the amps,  because it causes less respiratory depression than most other opioid analgesics it is often used by obstetricians , and because it is a partial opioid antagonist it is considered relatively safe.

I have only used 1/4 of a Suboxone once. It helped me stay out of withdrawel. I get 240 Norco's ( 10/325 Hydrocodone/APAP) a month. Some one gave me a quarter Sub so I tried it. Like I said, it kept me from withdrawing (which was good) but it did not help me with my lower back pain very much til about 10 hours later. But the pain relieve was very little. If my lifetime of lower back pain (I'm 37) ever does go away I will try to use them to get off the Norco's. I've been taking them for over 6 years so yes, I'm dependent on them. Withdrawel really sux. !^!!$@* out my @!^ all day. Laying in bed the whole day. ???$* of a time getting to sleep. Hard time staying asleep (unless I smoke some herb,that does help me to sleep in that situation). I just try not to take more of my pills than I need. Even if I have to take 1 1/2 (15mg's) a day (which I had to do for about 2 weeks one time). The key to staying out of the withdrawel stage is just make sure you have something to take,even if it's just a little. I survived 2 weeks doing 15 mg's a day (1 1/2 10's). I hurt for the whole 2 weeks but @ least I wasn't even more miserable going thru withdrawel's. I'll deal with the pain if I have to. But going thru both makes ya want to kill yourself. Hope this helps someone/anyone that gets in that position. Best advice I can give anyone is-"If you don't need to take pain killers,don't start taking them to get high for fun. Cause eventually it isn't no fun anymore when your addicted" I know several people who started taking Tabs for fun/to get high and they're regretting it now. I've even warned people about it and they didn't listen. Peace Love & Recycle

editg

I am a new user on this system.  Please don't flame me if I don't know all the netiquett.

I saw the post on Saboxone and I had done a Google search on "Saboxone" and "Chronic Pain Management" because I have started taking Saboxone for CPM today so I wanted to learn a little more than my doctor told me.  I have a few thoughts to share that might add value to the discussion:

First, it seems from reading many of the posts, that a lot of people are not clear on what the goal of a decent CPM progam is.  The goal of a well designed CPM is *not* the elimination of your pain!  Hence the word "Management".  I have had severe, chronic low back pain for eight years and there is nothing (surgically) that can be done to eliminate my pain.  I accept that, and my goal (and that of my doctor), is to mitigate the pain as much as is possible and give me the highest level functioning life that I am capable of having.  I am on permanent disability because of my back.  In the past, I've been treated with various anti-inflamatory and narotic drugs: Percocet, Vicoden, Morphine, Ibuprofen and Flexeril.

My pain management doctor has made it clear to me that Saboxone is not useful to everyone for treating chronic pain.  In my case, I have been a long term Percocet user (5mg on average 1.5 tablets per day), and the problem (in my case), is that Percocet manages my pain well, but requires increasing doses for the same level of pain relief (and don't like dealing with the sometimes hard-to-manage constipation).  I'm not anywhere near what one would consider a dangerous dose, but I also don't like the slightly dopey feeling that I get if I take more than 2 Percocet in a 24hr period and I certainly don't feel safe doing things like driving, using power tools, etc.  I wanted to change to Fentanyl (the patch) because it has given a lot of people good results and since the dosing is constant I thought it seemed perfect for my situation.  Unfortunately, my primary care physician is *very* conservative and was not willing to try it.  He refered me into a highly regarded pain management program at Kaiser Permanente.

When I asked my new pain management doctor to try the Fentanyl patch, she explained that chronic long-term dosing with the Fentanyl patch in men is a very dangerous thing (long term meaning greater than 3 years).  Fairly new pain management research is demonstrating that in men, heavy long term narcotic use results in dangerously reduced levels of testosterone which leads to a whole host of other potential health problems for men (yes, hormone replacement therapy is an option, but that too has it's side effects, the most appalling (to me) is the loss of testicular mass).  Sadly (for me), if I were a woman, she would have considered my type of pain a good candidate for the Fentanyl patch.

She started me on a very low dose of Suboxone (2mg sublingual 1x daily), and we'll ramp it up until it we hit the dose that manages my daily pain.  She said that Suboxone has been used for CPM for years in Europe, but that not many doctors in the US are familiar with it in that context because a) the FDA has never bothered to study it, and b) Chronic Pain Management research in the US laggs far behind Europe.  I suspect that there's also a stigma attached to using Saboxone because it has been used for nearly fifty years to treat opiate dependancy.

Of course, there *are* downsides:

1) If you are taking Saboxone, you should *NOT* take benzodiazepines or non-benzodiazepines (like Ambien) since Saboxone may either unpredictably counteract them, or for some people even *enhance* them (making accurate dosing nearly impossible).

2) As someone in an earlier post pointed out, Saboxone is not really meant to treat severe breakthrough pain (for most people, considered above an 8 on the 10 point scale).  If you do take Saboxone, taking another opiod for breakthrough pain *WON'T* work.  However, on the plus side, since Saboxone is not considered addictive you can safely increase your dosing and because it is taken subliqually (under the tongue), it works pretty darned fast so you *can* increase your dose very quickly if you experience breakthough pain.

So, I'm not claiming any kind of expertise, but there's what I know.  On a more personal level, I already feel like this is an improvement over the Percocet.  Since it's sublinqual, it doesn't pass through the intestinal tract and is likely to cause less constipation and (so far), the Suboxone is giving me some pain relief (I'd say about 50%), and I'm not feeling at all dopey like I do on Percocet.  If I can maintain this level of pain reduction, I'll be very satisfied.

On another personal note... I read the posts from Dr. Lois, and the post from the poor soul who's had the gastric bypass.  First, Dr. Lois, you're an amazing soul to spend your time and though in posting both what you know and in being frank about what you don't know.  Second, to Gastric Bypass.  I think you deserve a medal for doing everything in your power to meet the needs of your children!  I wish that you had more support from your family and community so that you could function at the level that you're capable of and that the people who love you could make up the difference so you don't have to push yourself past your limits.  Unless I am completely mis-reading you, you're a very good person stuck in an awful situation.  I don't consider myself to be a religous person, but I will say a prayer to the universe for you.

My prayers also go out to anyone else who is in this situation.  Chronic pain is a very misunderstood disability and I know personally how devastating it can be.  In my case, I am fortunate that it's not a major financial problem, but it pervades every aspect of my life from keeping me awake at night, to depriving me of the ability to sit in a theater seat at the movies.  I think that meaningful health care reform is of major importance to all of us who face health challenges like chronic pain.

Michael

I have chronic back pain and started taking 10 mg hydros and then it just increased to oxys, fentynl patches and whatever I could get my hands on  but nothing helped my pain and withdraws are like dying, so I started taking 8 mg suboxone 3 times a day and it has been 40 days.  I feel better and the pain in no where near what it was but I still have a hard time getting through the day and I sleep all of the time and have NO energy.  I asked my primary Dr. today if there is anything stronger than a Motrin but not an opiod that would help my pain.  Does anybody have any suggestions?  I would also like to say that this is a miracle drug it has changed my life, it is no nice not to feel like your dying all of the time and not have to worry about getting enough pills to keep you from going through withdraws and having money is nice to.   When I was doing research on suboxone I couldn't find any info on the cost so I am going to let people who are thinking about know about the cost.  I have to pay $360 a month to go to the Dr. and then I have insurance so my script is $40 but without ins. it's about $500. It's worth it if you're like me and blowing all your money on pills.

menlomike.

First, I am glad that suboxone is working for your pain. Amen!  Next, I just wanted to clarify a couple things. First, the statement saying suboxone is non-addictive is inaccurate. Any and all full opioid agonists, as well as partial opiate agonists (suboxone) are potentially addictive.  Also, the statement where you said that since suboxone is sublingual, so it does not pass through the digestive tract, hence, it is less likely to cause constipation is also inaccurate.  What determines whether an opiate will have side effects on the digestive system, in this case, suboxone, is related to the receptor/subtype it reacts with, and the resulting side effects. Suboxone is a partial agonist.  So it has partial activation of the mu receptor.  (looks like backwards u, but I don't know how to make it on the keyboard. LOL).  Suboxone stimulates receptor subtypes mu 1 and mu 2.  Opiates like this that stimulate receptor subtype mu 2 results in the constipation so often seen with opiate use.  Some have less constipation, some have more, depending on the effects on this subtype receptor.   This is what causes the side effect of constipation, not having the medidine go through an intestinal wall or not.  These receptors are located in the central nervous system, and have resulting effects throughout the majority of the body, where the nervous system has its effects.  Just wanted to clarify that mate.  Best of luck with continuing success with your pain management. 

The biggest problem with the Suboxone regimen is quite a simple one, actually: it is extremely difficult to use properly, for the simple reason that it is extremely difficult to be CLEAN for 24 hours before starting.

The WHOLE cycle is thrown out of kilter if the timing of the first effervescent tablet is off.

The semisynthetic opioid addict has terrible difficulty keeping himself clean for the requisite 24 hours, since all he can think of is his current discomfort and the abject terror of the withdrawal symptoms to follow. But stay clean he must!

Another possible factor--I say 'possible', though 'probable' is more like it--is the extent to which your doctor trusts you, which probably relates to how he regards you (e.g., as a consummate professional who fell into the same trap as millions of people, or as a wife-beater-shirted, leather-jacketed criminal ne'er-do-well). (This is true for other "narcotic substitutes," such as the pentazocine-based pain relievers Talwin Nx versus Talwin [Schedule IV in USA].) How can you tell? Well, did he put you on Suboxone or on Subutex? The difference is that Suboxone (overwhelmingly more frequently used) contains Naloxone (a narcotic antagonist) in addition to the fundamental Buprenorphine, whereas Subutex is pure Buprenorphine. The theory behind a narcotic antagonist is that it reverses (or tries to reverse!) the opioid high. And, if you scratch your li'l egg about it, why, O why, should the doctor want you to take Naloxone in addition to the underlying addiction therapy if he trusts that you won't simultaneously be sneaking an O here and an M there?

(The entire manufacture of Suboxone gives me the creeps. Why field such a product--which assumes that the patient is concurrently taking opioids--when the entire therapy is bound to fail in that case? Better to fall off the wagon with your system [not to mention your head!] clean than with a body full of controlled substances!)

Methadone treatment provides an instructive example. It turns out that methadone is both an agonist (inflicting narcotic effects) and an antagonist (suppressing narcotic effects): while some find methadone to be an outstanding pain reliever that also makes them high as so many kites, others find that it causes them to suffer an unbearably oppressive, strait-laced "straight." Even when the therapy (typically intended as a weanable substitute for heroin) is going well, the patient balks when the doctor tries to lessen the dose. (I mean, eventual wean-off is the whole purpose from the word "go": otherwise, what is to be gained by merely substituting one dangerous, Schedule II [USA] narcotic for another?)

(By the way, for those on the lam, it's a good idea to secrete some smaller OxyContin tablets between your toes. If/when you get locked up, some jails forget to check there, whether by having you remove your socks or just running their fingers across and between the toes of your stockinged feet to discover any hidden goodies.)