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  • BDD Moderators: Keif’ Richards | negrogesic

Buprenorphine/subs with full agonist for breakthrough pain. Does this work ?

C

copium7777

Bluelighter
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Apr 26, 2020
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If I'm not dependent on suboxone or other opioids could I take low doses of suboxone and then take other opioids for breakthrough pain on top of it without wasting or causing precipitated withdrawls-I have heard that some doctors do this combination.
 
And if it does work what would the max doses of subs be that would make it work ?
 
debored13 said:
If I'm not dependent on suboxone or other opioids could I take low doses of suboxone and then take other opioids for breakthrough pain on top of it without wasting or causing precipitated withdrawls-I have heard that some doctors do this combination.
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The only way I could see this working would be daily doses of buprenorphine in the 0.2 mg to 0.8 mg range.
 
A couple hours, but you'll have a roughly 50% mu-opioid receptor blockade at that point with a 4 mg dose. Depending upon what you're trying to accomplish, it would likely be worth waiting longer.
 
Deru said:
A couple hours, but you'll have a roughly 50% mu-opioid receptor blockade at that point with a 4 mg dose. Depending upon what you're trying to accomplish, it would likely be worth waiting longer.
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Okay. What about 4 hours
 
It really all depends.

This is all highly variable, so I'll just use my experience as an example:

For a 5-10 mg oxycodone for breakthrough pain, I can't see that being very effective for up to 48 hours from last 4 mg buprenorphine. And even this would depend if you've taken 4 mg buprenorphine daily for a period of time or have taken 4 mg on a single occasion.

If the goal is to feel euphoria, at least 12-16 hours with a compensated oxycodone dose to factor in, but 24-48 hours would be even better.

If the goal is to stop withdrawals, I've found the sweet spot to be at a minimum of 4 hours, but I've taken it as early as an hour after last buprenorphine dose with no issues with precipitated withdrawals before the buprenorphine plasma levels peak.
 
Or 6
Deru said:
For a 5-10 mg oxycodone for breakthrough pain, I can't see that being very effective for up to 48 hours from last 4 mg buprenorphine. And even this would depend if you've taken 4 mg buprenorphine daily for a period of time or have taken 4 mg on a single occasion.
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damn. Well , okay. It's too bad bupe plays this poorly w other meds.

But thanks for the heads up and helping me not have this go to waste.
 
have heard of doctors using this combination with the bupe at low doses so it can keep some pain relief going long lasting, but at not a high enough dose to block full agonist opioids. Is this a myth or does it really work

how low would the doses of bupe have to be to not block a full agonist? how about .5 mg?

this study says "
Combination and rotation with opioids

Recent studies indicate that buprenorphine could be effectively and safely combined with full μ-agonists, and switching between buprenorphine and another opioid provides comparable pain relief using equianalgesic doses.2,10,12 The results indicate that adding opioids to patients currently receiving buprenorphine therapy is safe and effective, while the addition of buprenorphine to patients receiving other opioid therapy should be used more cautiously. Buprenorphine has been combined with other opioids (morphine, tramadol) and has demonstrated additivity. In one study, supra-additive analgesia has been reported in combination study of buprenorphine with oxycodone or hydromorphone. Although buprenorphine has demonstrated very high affinity for μ-receptors, it occupies fewer receptors for analgesia, which leads to a significant receptor reserve for other μ-agonists. Buprenorphine increases μ-receptor expression, which allows other μ-agonists to interact with receptors.
Supplemental dosing with an opioid is the main treatment suggested to manage breakthrough pain in cancer patients. Combination of immediate release or iv morphine and a basal analgesic regime of transdermal buprenorphine has been used as an effective and safe treatment. Clinically, the treatment shows an additive analgesic effect, without any safety relevant issues.10,88 No cross tolerance was observed during rotation between buprenorphine and fentanyl.10,89 Future studies will need to confirm combination therapy and the role of buprenorphine in opioid rotation."
 
this basically says bupe can be more easily rotated and even combined with full agonists and no ceiling dose. is this true?
 
"Contrary to previous concerns, no analgesic ceiling effect and no antagonism on a combination of buprenorphine with pure μ-OR agonists is seen within the therapeutic dose range in humans.12,28 "
 
Recommendations for Patients Receiving Maintenance Buprenorphine Therapy
Clinical experience treating acute pain in patients receiving maintenance therapy with buprenorphine is limited. Pain treatment with opioids is complicated by the high affinity of buprenorphine for the μ receptor. This high affinity risks displacement of, or competition with, full opioid agonist analgesics when buprenorphine is administered concurrently or sequentially. There are several possible approaches for treating acute pain that requires opioid analgesia in the patient receiving buprenorphine therapy (Table 2). With such limited clinical experience, the following treatment approaches are based on available literature, pharmacologic principles, and published recommendations. The most effective approach will be elucidated with increased clinical experience. In all cases, because of highly variable rates of buprenorphine dissociation from the μ receptor, naloxone should be available and level of consciousness and respiration should be frequently monitored. Treatment options are as follows.

  1. Continue buprenorphine maintenance therapy and titrate a short-acting opioid analgesic to effect (90, 98). Because higher doses of full opioid agonist analgesics may be required to compete with buprenorphine at the μ receptor, caution should be taken if the patient’s buprenorphine therapy is abruptly discontinued. Increased sensitivity to the full agonist with respect to sedation and respiratory depression could occur.
  2. Divide the daily dose of buprenorphine and administer it every 6 to 8 hours to take advantage of its analgesic properties. For example, for buprenorphine at 32 mg daily, the split dose would be 8 mg every 6 hours. The available literature suggests that acute pain can be effectively managed with as little as 0.4 mg of buprenorphine given sublingually every 8 hours in patients who are opioid naive (47, 99, 100). However, these low doses may not provide effective analgesia in patients with opioid tolerance who are receiving OAT. Therefore, in addition to divided dosing of buprenorphine, effective analgesia may require the use of additional opioid agonist analgesics (for example, morphine).
  3. Discontinue buprenorphine therapy and treat the patient with full scheduled opioid agonist analgesics by titrating to effect to avoid withdrawal and then to achieve analgesia (for example, sustained-release and immediate-release morphine) (90, 98, 101). With resolution of the acute pain, discontinue the full opioid agonist analgesic and resume maintenance therapy with buprenorphine, using an induction protocol (98, 102).
  4. If the patient is hospitalized with acute pain, his or her baseline opioid requirement can be managed and opioid withdrawal can be prevented by converting buprenorphine to methadone at 30 to 40 mg/d. At this dose, methadone will prevent acute withdrawal in most patients (97) and, unlike buprenorphine, binds less tightly to the μ receptor. Thus, responses to additional opioid agonist analgesics will be as expected (that is, increasing dose will provide increasing analgesia). If opioid withdrawal persists, subsequent daily methadone doses can be increased in 5- to 10-mg increments (103). This method allows titration of the opioid analgesic for pain control in the absence of opioid withdrawal. When the acute pain resolves, discontinue the therapy with the full opioid agonist analgesic and methadone and resume maintenance therapy with buprenorphine, using an induction protocol (98, 102). If the patient is discharged while full opioid agonist analgesics are still required, then discontinue methadone therapy and treat the patient as stated in the third buprenorphine approach.
If buprenorphine therapy needs to be restarted (buprenorphine induction) after acute pain management (that is, the third and fourth approaches), it is important to keep in mind that buprenorphine can precipitate opioid withdrawal. Thus, a patient receiving a full opioid agonist regularly should be in mild opioid withdrawal before restarting buprenorphine therapy (98, 102).
 
To be clear, taking a full agonist like oxycodone after taking buprenorphine will not cause precipitated withdrawals. I see a lot of speculative posts, which are unfortunately about all you can expect. Most of the medical world doesn't know the first thing about buprenorphine, let alone unorthodox pain management regimens consisting of a partial agonist and a full agonist for BT.

Not enough science exists yet to substantiate or discredit such an approach. You can expect it to mute the effects of oxycodone for up to 4-5 days, and in my experience the degree to which the bupe outcompetes a full agonist for receptor sites will decrease sharply after 36-48 hrs after administration
 
My thought is that at doses lower than 1 mg at a time it shouldn't outcompete full agonists, but since I took 6 mg a couple days ago maybe its muting the oxy I took now?

I'm wondering about taking a .5 mg dose of bupe rn with the oxy. Some might say "if you have full agonists why take bupe" but the reason is I want to possibly have. a longer lasting subtle baseline pain relief that will still be there when the oxy wears off. However if its gonna cause precipitated w drawals I guess I'd prefer not to. although if in not physically dependent on oxy that seems unlikely ?
 
I'm trying out this difficult and risky paradigm. Took about .5 mg bupe at 5:20 est. Seeing if it will knock the oxy off my receptors totally. And if it will block the rest of the oxy I took tonight
 
morphonorconic said:
You can expect it to mute the effects of oxycodone for up to 4-5 days, and in my experience the degree to which the bupe outcompetes a full agonist for receptor sites will decrease sharply after 36-48 hrs after administration
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The pharmacological profile of buprenorphine is pretty well studied and well known.

Only long term usage of dosages over 8mg/day would you really start seeing the effects of another opioid muted for that long.
 
Yes bupe has an established pharmacodynamic profile. However making a credible and accurate determination with regard to its therapeutic benefit for said individual using it in conjunction with a full agonist for pain management is not plausible. Gets into mostly uncharted territory.
 
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