Bupe Can Oxy IR work for Breakthrough pain when using Subutex?

[milagro]

Can Oxy IR work for Breakthrough pain when using Subutex/Butrans?

I was going to put this in the Pain management thread and if I would get more responses there then, mods, please move it.

My question is can you effectively use opiods such as Oxy IR if you are on 8mg/day subutex? I saw my PM doc's ARNP the other day and told her one of the reasons I do not want to use buprenorphine is the blocking effect it has on full opioid agonists. She said that she has seen many people on low doses of 4 even 8mg (which isn't that low)/day of bupe that take norco, roxi, etc.. The patients claim they work during an acute flare up.

I have occasional flare ups that leave me nearly incapacitated for weeks and oxy has been my miracle solution. I recently had a scare when my previous doctor skipped out and left me with not nearly enough medication to effectively taper. It made me realize that I am tired of doing the "dance" as I refer to it, of constant dosing due to oxy's short half life. Even Oxycontin wears off on me in about 4-5 hours. I find myself constantly dosing to avoid WD and it is getting old.

I discussed this with her and she suggested a rotation of bupe and oxy followed by a discontinuing oxycontin altogether as a baseline med and using bupe and oxy IR for BT pain. I have never heard of a full opiod agonist being effective while using bupe even though she swears some of her patients do use bupe and when the pain gets too bad . They either take more bupe or a couple of norco.

This is completely up to me. She is not forcing the issue. I just want to know if anyone out there on bupe, not suboxone, has been able get relief from acute pain with a typical fast acting opiod? I would love to stop having to dose every 4-6 hours with oxy. I am also tired of waking up in miserable pain.

 

[ErgicMergic]

If you are on a blocking dosage of bupe, then as far as I know, only Tapentadol, O-Desmethyltramadol (from tramadol, or as an RC), or Fentanyl analogues will work for BT pain, as they have an even higher binding affinity than bupe.

If you are on a pain-relief dosage of bupe (non-blocking), which is 0.2mg-2mg sublingually, less if insufflated and even less if IV'ed (don't IV bupe), then suboxone acts more as a prodrug for norbupe, which is a powerful, full-agonist opioid, and you can effectively use any full-agonist opioid, just be careful as the effects can be potentiated. There's a reason why 0.2 and 0.4mg dosages of bupe are marketed as pain relievers as Temgesic... norbupe is seriously powerful.

1mg suboxone = 40mg oral oxycodone, iirc, as far as opioid activity goes. It's when you get to over 2mg (or 4mg, there was a debate about this in abother thread), that bupe begins acting as a competitive partial agonist at the MOR, blocking out norbupe, oxycodone, hydro, heroin, etc.

 

[tricomb]

The doses you need are exponential.

 

[BiggDirty01]

I don't believe that the combination would be very effective. Perhaps if you were switched to Methadone in chronic pain dosing you could use Oxy IR as I do for breakthrough and Methadone in dosing 3 times daily.

 

[mrflowers00]

it wouldn't work for me i'd do bupe then take oxy (right?) well the oxy would do shit and when i did my next bupe if i didn't wait 24hours after the last oxy dose id be sick as shit with pwds

 

[Fire&Water]

The two meds' work great in combination, but she has the recipe all scrambled up...
A small amount of pure bupe' act's as an extended relief for the oxycodone...
Ripleys: believe it or not (Dont care who or why anybody doesnt believe it anymore)

Edit: 7 years ago my first CPS told me the same thing she told the OP, (she moved in the first year) my steady 6 year CPS found out pretty much the opposite as far as dosages.
Do not use more than 2 mg's of subutex at a time, though it is sometimes effective to use a second 2 mg's in 24 hours, w/ the oxycodone.

 

[milagro]

Thanks for all the information everyone:

As we (I hope) know, you have to be in active WD from taking oxy at the dose I am currently on, 90-100mg/day, before using bupe. So I started the induction process a couple of days ago with the bupe. I felt like absolute shit for a day and a half while taking far more than prescribed of the subtex because 8mg was just not doing Jack.. I kept waiting to feel better and took some oxyER and IR thinking it would help. NOT. It was completely blocked by the bupe I had taken ~16mg bupe because I thought taking more subutex would help stave off the Oxy WD’s faster.

This morning, nearly 2 days since starting the bupe I woke up and I felt great. Not drugged out and no pain which is always the worst in the morning. I had coffee and breakfast, appetite was back, and thought ‘this is what I remember the bupe felt like when I used it before. I just feel normal. No buzz and no depression. It was the induction process that was so flipping awful.

Normally I would wake up in agony and have to immediately pop some oxy. That is what I hated the most. I didn't know if the morning pain was WD from the meds, normal pain, or both. Today was just a smooth wake from a great night's sleep. No worries about dosing. Is the induction or change from the full agonist to the partial agonist supposed to be that hateful?

I never considered Tramadol. I have taken it once for a shoulder separation, cannot remember the dosage but remember it did nothing for the pain. Damn PA in the ER spent 5 minutes with me and ordered no xrays. I am sure he thought I was a drug seeker when I told him of my chronic pain and treatment. I was not using opiates at that time. I went back and got xrays that showed a clear shoulder separation and the attending gave me vicodin and muscle relaxers with a warning that the ER does not refill pain medication but made an exception in my case. The new regulations for opiod/ate prescription are very strict and at times, completely ambiguous.

As far as using BT meds, the incident with the aforementioned experience and use of tramadol soured me on the med. I have used fentanyl patches and found them ineffective and very cumbersome due to my hydrotherapy. They also left large red rectangles when removed

I did a little research on Temgesic based on ErgicM’s reply and found out some very interesting information about using it and how it relates to norbupe. It is also used strictly for pain whereas subtex is used for pain and WD. That is where the FDA or DEA ambiguity of prescribing bupe needs to be, IMO, changed allowing more doctors the ability to prescribe it. My ARNP had to write “for pain management” on the prescription for subutex.. Another story for another thread/post.

The fact is that I have reached a pleasant plateau with the bupe and do not need to take another dose, 4mg, until this evening. The only question I would have left is why was the transfer, induction, whatever from oxy to bupe so uncomfortable. Is that the norm?

 

[Znegative]

For some people transitioning is very hard, and it really depends on the half life of the full agonist, the formula it comes in (IR,ER), and obviously, how long it has been since you last dosed. For most people that take IR opiates (due to abuse or for legitimate pain), it is suggested to wait at least 24 hours before taking any form of buprenorphine (unless you're switching from methadone, which is more complicated). Some people can get away with taking it sooner, some need to wait longer, however, you should never take it before the onset of withdrawals, or you will almost certainly get precipitated withdrawal.

I've transitioned from full agonists to buprenorphine way more times than I'd like to admit, and found that initially the transition was very smooth. In fact, the first two inductions, I even became stoned off of it (though my tolerance was way lower then), and after that, I just felt relief from withdrawal as well as a mild mood lift. I first started having problems transitioning when I dosed way to early after a week long oxymorphone binge, and experienced excruciating precipitated withdrawals which lasted what felt like forever, but probably was really about 3-4 hours tops. However, once the precipitated withdrawal dissipated, I was left feeling edgy and 'out of it' for about two days before I started to feel normal and then good. Ever since that experience, the transition was more difficult, and the fear of precipitated withdrawal would often turn my 'vacations' into full blown runs.

As for using buprenorphine in conjunction with a full agonist for break through pain, I can only see that being possible if your dose of bupe is at a maximum dosage of 2mg. Like Ergicmergic said in his post, when bupe came out originally for the use of pain management, it was used in microgram dosages (so even 2mg is not really a "small" dose). I am not a pain patient, but through my extensive experimentation of buprenorphine, I truly do believe that less is more with this drug. The lowest that I tapered was .5mg 2x/day, at which point I felt a strong lift in energy and mood each time I dosed. I imagine that had I tapered lower, that these effects would be even more amplified. One thing for certain is that after about a week or two, you really will not feel the subutex at dosages of 8mg or above (perhaps 8mg might work, but anything higher wont). IME, from extended periods of taking 8mg or more of buprenorphine, once you stabilize on a dosage above the ceiling effect, taking your daily dosage feels like taking a sugar pill, and raising your dosage wont do squat. Since I'm not a chronic pain patient, I wouldn't know for sure if it would still be effective at such a dosage at relieving pain (without feeling anything from the bupe), but logically it seems that it wouldn't work too well. So your best bet with subutex is to stay at a low dosage so that you can feel full agonist pain meds effectively.

-also, just a final note, buprenorphine is a really potent drug, so even when you're at a non-blocking dose, there will still be an issue of tolerance.

 

[milagro]

I do understand the chemistry behind PW which I why I was already above 12 on the "Cows" scale (something I have not heard much of in BL) before taking the subutex. I just did not remember the induction being so harsh. Again, I was at 40-60mg/day of oxy the first time I switched to bupe. Who knows? At least all is well now but you are right, I have to keep in mind the damn issue of tolerance and cross tolerance. Long half-life opiods make tolerance skyrocket. Bupe's half life is around 37hours?

Fortunately, the ARNP I am seeing is aware that I worked in toxicology for a time and I understand the micro as well as the macro in pain meds, some of the time. However, I never had experience testing buprenorphine so it is new to me. ErgicMergiic definitely got me doing some hardcore research on Temgesic and norbupe. I am just happy to be sitting here at ^-clock and not have to think about taking my medication.

I honestly cannot see taking a full agonist and getting any effect from it while on a bupe dose of >4mg/day. She swears that she has patients on double that figure that undergo incredibly painful procedures each month and use norco for the off scale pain. I said "it must be placebo". "No, it can't be", she replied. Who am I to argue? I am the damn patient trying to argue with a nurse practitioner? Though, she is a doll.

 

[Znegative]

I'm sorry, I just don't see how in earth taking Norco's on top of buprenorphine would do anything. I have to agree with you that if she is telling the truth, than its most likely due to a placebo effect in patients that have no real knowledge of buprenorphine's high affinity/potency.

 

[milagro]

Yes, I am getting the feeling that something isn't right here. I think she really wants me to get on the bupe and will do anything to alleviate my hesitancy of taking it due to the acute flare ups and not being able to use a full agonist like oxy.

I got off the phone with my pharmacy and the pharmacist, who seems to know less about this than you and I, did not understand that I was going to be rotating between Oxy and bupe. The pharmacist alarmed me when I told her about the strategy of bupe rotation. She claims she has never heard of such a thing and kept asking who my doctor was. It kind of pissed me off. "You mean you are going to go back on your narcotics?!". I could only say, "well at this point I kind of have to". It might be because my insurance will not cover Subutex? I have to pay out of pocket for it. Has anyone heard of rotating bupe this way?

It is complicated because I have refills for this subtex that can only be used after 14 days have elapsed. But I went through 1/2 a two week supply in a matter of days. I know about ceiling effect can anyone tell me when taking more than say 16mg of Subutex becomes useless? I was on a heavy dose of oxy but waited for the onset of WD (20 hours) after my last dose of oxy. It took nearly two days and 40+mg of Subutex, over 2 days, before I felt normal. Did I waste the bupe by taking that extra?


The more I think of it the less logical it seems. I might have to go through this hell again. Going from bupe to oxy is cake but vice versa and no dice. I just do not want to get myself or my doctor in trouble here.

 

[Znegative]

Taking fourty milligrams of buprenorphine is a waste, as the cieling effect is definately below that dosage (probably somewhere between 2-8mg in all honesty, and that's with acute use).

I know some people are prescribed the combo, but it does seem way too tricky to be worthwhile, as you'd want to be on a dose low enough that the oxy could be felt, as well as have to fear precipitated withdrawals every morning/evening..

 

[milagro]

I do not know if you read that <40mg>was taken over a two day period and is probably more around the 60 hour mark. I still think I wasted some. I was just having such a difficult transition and the oxy wouldn't help once the bupe was in my system. I was caught in the freaking twilight zone and just kept taking the subutex 1/2 pill at a time until I finally felt better.

I like it because I haven't had to take any yet today probably due to saturating my system, I will take a dose tonight. Waking up and being able to get out of bed without wincing is an experience I haven't had in a long time.

I think ErgicM had the best recipe for using bupe with a full agonist and that would be Temgesic, from what I have read. Unfortunately, unless I used the wrong keywords Temgesic is not available in the US. Please correct me if I am wrong or offer an alternative.

I cannot contact my ARNP for another week and a half but will definitely bring it up. I did get to know what I suspected about one of the lead pharmacists at my pharmacy. She is definitely not a person to discuss opioid use with. She flipped out thinking I was detoxing rather than using it for pain. She did not even know it was used for chronic pain.

 

[tricomb]

^Regardless, taking 20mg a day is still a huge dose, highly unnecessary if you ask me. Don't get me wrong, I am not questioning that you were in enough pain to try anyways, I just don't think that 20mg would have significant analgesic power when compared to 0.25mg, 0.5mg, 0.75mg, 1mg, 2mg.

Temgesic is not marketed in the USA, If memory serves me correctly, the only forms of buprenorphine that are on the market in the USA are transdermal delivery patch indicated for pain, and the 2mg and 8mg tablets which are usually indicated for addiction, (although generic buprenorphine has been available off-label for pain for a very long time) it's not unheard of to hear about people getting Subutex for chronic pain.

 

[milagro]

I was going to let this thread die out but I had to ask a question that might belong in the Buprenorphine/Suboxone megathread. The thing with megathreads is that I do not have the patience to look at every post to find an answer that may or may not be present.

I refer back to ErgicM's suggestion about Temgesic. I spoke with my pharmacist today about what is available in the US that might be similar. He suggested Butrans patches @ 5,10,and 20 ug (sorry no sign for micro on my keyboard and too lazy to cut and paste).

I am trying this rotation with oxy and bupe and it is not going well at all. It takes me 3-4 days of being on Subutex before I start feeling normal. This last time fooled me. I started taking the bupe about 16 hours after my last dose of oxy because I had just woken up and was in hella pain. No PWD. I took about 12mg during the day but the pain continued getting worse. The following day I was sick as a dog. Not PWD's just non stop vomiting for nearly 24 hours. Couldn't get the damn pills to dissolve under my tongue before I started throwing up again. Sorry, this isn't for the faint of heart.

Short story, I used more Subutex pills than I had for the allotted time between refills. Guess what that means? Back on the oxy. The big problem is my insurance will not cover buprenorphine in any form unless the doctor writes a pre-authorization. That means I have to go on bupe and stay on bupe. No more Oxycontin for extended release.

As Znegative correctly surmised, the breakthrough (full agonists) have no effect while I am at more than 4mg of bupe/day. My doc is out of town for the next month and I was just wondering if anyone out there uses butrans patches with something like oxy, roxi. whatever, for BT pain? I have taken the bupe for an extended period and it is fine as long as I do not have a flare up and need something stronger. The oxy doesn't work at the doses prescribed and I am not about to fool around with mega doses of oxy.

So the question is "do butrans patches work well for baseline pain that is usually around an 8 untreated? If so, can BT meds be used more effectively at the lower micro doses provided by butrans"? I know some of you are saying "just stick with the oxy" and I can do that. I just wake up miserable everyday and have to dose immediately upon getting up. I can't even take a shower until I have upped my plasma level of oxy again. I tend to either metabolize oxy very quickly or I develop tolerance to it much to fast.

Help? Anyone? Butrans?

 

[Morgman]

Butrans

I was going to let this thread die out but I had to ask a question that might belong in the Buprenorphine/Suboxone megathread. The thing with megathreads is that I do not have the patience to look at every post to find an answer that may or may not be present.

I refer back to ErgicM's suggestion about Temgesic. I spoke with my pharmacist today about what is available in the US that might be similar. He suggested Butrans patches @ 5,10,and 20 ug (sorry no sign for micro on my keyboard and too lazy to cut and paste).

I am trying this rotation with oxy and bupe and it is not going well at all. It takes me 3-4 days of being on Subutex before I start feeling normal. This last time fooled me. I started taking the bupe about 16 hours after my last dose of oxy because I had just woken up and was in hella pain. No PWD. I took about 12mg during the day but the pain continued getting worse. The following day I was sick as a dog. Not PWD's just non stop vomiting for nearly 24 hours. Couldn't get the damn pills to dissolve under my tongue before I started throwing up again. Sorry, this isn't for the faint of heart.

Short story, I used more Subutex pills than I had for the allotted time between refills. Guess what that means? Back on the oxy. The big problem is my insurance will not cover buprenorphine in any form unless the doctor writes a pre-authorization. That means I have to go on bupe and stay on bupe. No more Oxycontin for extended release.

As Znegative correctly surmised, the breakthrough (full agonists) have no effect while I am at more than 4mg of bupe/day. My doc is out of town for the next month and I was just wondering if anyone out there uses butrans patches with something like oxy, roxi. whatever, for BT pain? I have taken the bupe for an extended period and it is fine as long as I do not have a flare up and need something stronger. The oxy doesn't work at the doses prescribed and I am not about to fool around with mega doses of oxy.

So the question is "do butrans patches work well for baseline pain that is usually around an 8 untreated? If so, can BT meds be used more effectively at the lower micro doses provided by butrans"? I know some of you are saying "just stick with the oxy" and I can do that. I just wake up miserable everyday and have to dose immediately upon getting up. I can't even take a shower until I have upped my plasma level of oxy again. I tend to either metabolize oxy very quickly or I develop tolerance to it much to fast.

Help? Anyone? Butrans?

I've been using butrans for 6 months now and it's been extremely helpful for WDs but not so much for CP, but you can however take other medication for BTP because of the absence of naloxone.

 

[opallove13]

I was going to let this thread die out but I had to ask a question that might belong in the Buprenorphine/Suboxone megathread. The thing with megathreads is that I do not have the patience to look at every post to find an answer that may or may not be present.

I refer back to ErgicM's suggestion about Temgesic. I spoke with my pharmacist today about what is available in the US that might be similar. He suggested Butrans patches @ 5,10,and 20 ug (sorry no sign for micro on my keyboard and too lazy to cut and paste).

I am trying this rotation with oxy and bupe and it is not going well at all. It takes me 3-4 days of being on Subutex before I start feeling normal. This last time fooled me. I started taking the bupe about 16 hours after my last dose of oxy because I had just woken up and was in hella pain. No PWD. I took about 12mg during the day but the pain continued getting worse. The following day I was sick as a dog. Not PWD's just non stop vomiting for nearly 24 hours. Couldn't get the damn pills to dissolve under my tongue before I started throwing up again. Sorry, this isn't for the faint of heart.

Short story, I used more Subutex pills than I had for the allotted time between refills. Guess what that means? Back on the oxy. The big problem is my insurance will not cover buprenorphine in any form unless the doctor writes a pre-authorization. That means I have to go on bupe and stay on bupe. No more Oxycontin for extended release.

As Znegative correctly surmised, the breakthrough (full agonists) have no effect while I am at more than 4mg of bupe/day. My doc is out of town for the next month and I was just wondering if anyone out there uses butrans patches with something like oxy, roxi. whatever, for BT pain? I have taken the bupe for an extended period and it is fine as long as I do not have a flare up and need something stronger. The oxy doesn't work at the doses prescribed and I am not about to fool around with mega doses of oxy.

So the question is "do butrans patches work well for baseline pain that is usually around an 8 untreated? If so, can BT meds be used more effectively at the lower micro doses provided by butrans"? I know some of you are saying "just stick with the oxy" and I can do that. I just wake up miserable everyday and have to dose immediately upon getting up. I can't even take a shower until I have upped my plasma level of oxy again. I tend to either metabolize oxy very quickly or I develop tolerance to it much to fast.

Help? Anyone? Butrans?

Holy hell you have really been thru the wringer my friend. Yikes!! I will just let you know my situation and maybe it will help. I was on percocet for 2.5 yrs for chronic pain. Well of course over time, it just doesn't do the trick anymore. I finally got in with a pain management doc. First he started me on butrans patches together with the percocet for breakthru. I started on 5 mg, 10 mg & finally 20 mg patches. And yes, the percocet works fine while wearing the patch. You can't feel the terrific oxy effects, but it does work for the breakthru pain. However, at 20 mg patches, which cost $275/box of 4, I was still requiring something else for pain. He then put me on suboxone. However, the suboxone builds in my system and nods me out if I take too much, so I'm now on a 10 mg patch, 1/4 pill of suboxone every day or second day, and percocet for breakthru. Once I can get my suboxone to a higher level, I won't need the patches anymore and hopefully no more percocet. My plan covers all these meds, however, most plans have a ceiling cap and the 20 mg patches would max out my plan wayyy before the year is up. The 5 and 10 mg patches are a lot cheaper than the 20 mg patches.
I'm currently on a 2 mg suboxone pill and taking 1/4 of that. Holy Hanna that is a friggin strong medication.