Bupe Breakthrough pain while on buprenorphine

[mrincognito1221]

Hello all,

I am managing a chronic pain condition resulting from musculoskeletal and nervous system pathology. I am currently taking tramadol, with oxycodone for breakthrough pain.

One issue I have is trying to alleviate/tolerate pain while maintaining my cognitive function. I work in technology sales, and it requires me to be very alert. For nerve pain I have tried gabapentin and pregabalin, love their efficacy toward pain control, but find I am not sharp enough to handle my workloads and grasp new information effectively.

I intentionally under medicate my pain to retain cognitive functional ability. My pain doctor has suggested a shift from tramadol to a buprenorphine pain patch, I have yet to make the shift due to an imposed "step therapy" mandated by my insurance company, but the transition will be soon.

From reading other threads here, I have seen that some use tramadol or tapentadol for BT pain, due to the fact that these medications aren't exactly analgesically opiate driven, and as such do retain some pain relieving qualities?

Because I am naive to painkiller medication, can anyone speak with experience to what works, what they have experienced, and/or what they find helps them in a situation such as this?

Brandon

 

[mrincognito1221]

Is this the most appropriate place for this thread?

 

[dirzted]

Is this the most appropriate place for this thread?

Ya it's okay to post that here but you might get someone more knowledgeable on the subject at:

http://www.bluelight.org/vb/threads/539142-The-Pain-Management-Mega-Thread-v2-0 - (also found in the Other Drugs section)

 

[mrincognito1221]

Thank you, I will follow your suggestion.

 

[dirzted]

Thank you, I will follow your suggestion.

Oh whoops did not realize that thread was closed, I'm sorry, still there might be some good info in there if you read through it.

Otherwise just search up other pain management topics on BL I'm sure you'll find helpful info somewhere in there.

Good Luck

 

[chase_in_56ace]

Hello all,

I am managing a chronic pain condition resulting from musculoskeletal and nervous system pathology. I am currently taking tramadol, with oxycodone for breakthrough pain.

One issue I have is trying to alleviate/tolerate pain while maintaining my cognitive function. I work in technology sales, and it requires me to be very alert. For nerve pain I have tried gabapentin and pregabalin, love their efficacy toward pain control, but find I am not sharp enough to handle my workloads and grasp new information effectively.

I intentionally under medicate my pain to retain cognitive functional ability. My pain doctor has suggested a shift from tramadol to a buprenorphine pain patch, I have yet to make the shift due to an imposed "step therapy" mandated by my insurance company, but the transition will be soon.

From reading other threads here, I have seen that some use tramadol or tapentadol for BT pain, due to the fact that these medications aren't exactly analgesically opiate driven, and as such do retain some pain relieving qualities?

Because I am naive to painkiller medication, can anyone speak with experience to what works, what they have experienced, and/or what they find helps them in a situation such as this?

Brandon

Unfortunately, buprenorphine has an extremely high affinity and tends to completely overtake the brain's opiate receptors. Anything short of Fentanyl will most likely be rendered useless. And not giving you medical advice here, but take this from someone Rx'd 175mcg of duragesic Fent... it skyrockets your tolerance.

The bottomline is that there is a certain amount of pain we chronic pain patients must live with. May I ask how effective oxycodone is at alleviating your BT pain and at what dose? You may have success with IR Oxymorphone (Opana) or switching to the Fentanyl patch. I recommend having a talk with your doctor about the Fent before switching to a bupe patch for pain. Like methadone being Rx'd for pain, it isn't unheard of... but certainly not common.

As far as Tapentadol is concerned, I have taken it. If I remember correctly it is a schedule II opiod with SNRI like properties. I was prescribed 100mg namebrand "Nucynta" and was thoroughly disappointed. Each one was equivalent to about 10mg of oxycodone for me. They were so weak I had a good amount of withdrawal symptoms and had to do an emergency switch back to the Oxy. My advice is to talk to your doc about Fentanyl.

 

[mrincognito1221]

Hi Chase,

I have only been using the BuTrans patch for 5 days, and I have been treating BT with tramadol as per Dr suggestion. I am at the lowest prescription dose for Butrans, and I take tramadol at 25-50 mg at a time.

I had been using tramadol 50-100mg IR for about 1 year immediately before this transition to BuTrans, using a 5/325 percocet maybe 6 times a year when I couldn't walk. I am probably at the opposite end of your spectrum. I have high levels of pain which I have purposefully under-treated palliatively, trying to be conservative in my approach. However, because I have been in constant pain for the last 3 years and don't anticipate relief soon, I have decided to escalate my treatment and work harder to immediately improve my quality of life through pain control. This is all brand new territory for me.

I appreciate your response, I have a follow-up with my pain clinic in 2 days and I have a lot in the way of informed recommendation to bring his way.

Brandon

 

[Lorne???]

It is a common misconception that any dose of buprenorphine automatically blocks any other opioid. It is a great deal more complicated than that. Bupe blocks other opioids because if it's obscenely high binding affinity. However, it can block receptors ONLY RECEPTORS THAT IT ATTACHES TO. Due to it's high potency, bupe only needs a small receptor occupancy to achieve analgesia. Thus, at low doses, you have plenty of receptors left for other opioids to attach to. As the dose of buoe increases, obviously the effectiveness of other opioids will increase, quite dramatically in fact, but even at moderate doses, other opioids are not useless for analgesic purposes, but you need an increased dose.

But at that low of a dose, you should have no problem with breakthrough. What I don't understand us why not simply get buprenorphine for breakthrough pain? Or better yet, go up one more step to the next patch strength if your having trouble. Buprenorphine is an extremely effective analgesic for the opioid naive, and well tolerated.

But you (should) have a lot of options. However, tramadol is really horrible for breakthrough, since it takes circa 3 hours for the active metabolite(M1) to reach full effect.However, some people love the combo of tram+bupe, so who whatever works. But good luck, pain is a bitch.

 

[Lorne???]

I'd say stick with Percocet for breakthrough, it is certainly more effective than tramadol, I mean 25mg isn't gonna do shit, they give up to 100mg to the opiate naive! But really, low dose morphine IR would be perfect. If you could get the 10-15mg tabs, on top of butrans, your pain should be relatively well controlled. But again, if the pain becomes to dehabilitating, you will simply have to increase the bios dose, or switch to a PRN full agonist. And what you are saying about "cognitive impairment" makes no sense. Opioids don't really impair you in the first place, unless they ate abused, but when used properly for analgesia, they cause no cognitive dysfunction whatsoever. I mean just do some research; if you are pain pain it sounds ridiculous to worry about "cognitive" impairment from taking a few Percocet, I mean no I e would suggest to go out and start slamming heroin!

Again, let me stress that at that low of a buprenorphine dose, full agonists can be used to enhance analgesia, with no problem. In fact, one source indicates that even at a dose of 24-32mg, only 87% of receptors are filled. So do not limit yourself to tramadol, it's ssri etc, effects are not gonna help pain severe enough to need round-the-clock opioid treatment.

(And, morphing is good because of it's (relatively) high binding affinity, 5-6x higher than oxycodone. Studies have also shown, that buprenorphine combined with morphine (with both in low doses) is a good combo analgesia, so they're ya go!

 

[mrincognito1221]

Hi Lorne Very helpful and insightful information. I appreciate your contributions regarding BuTrans and receptor affinity. I had not been considering morphine until coming to this site. As I mentioned before I am fairly new to this method of pain treatment. Regarding your comment about my worry for cognitive impairment, I am speaking from experience. I come from a health and wellness background (I worked as a fitness trainer and massage therapist) until my health declined to the state at which it exists today, forcing me to move from the career in which I once thrived to sedentary employment, while I seek recovery from some trauma based injurys, and a few of insidious onset as well.

I now work in technology sales, which is not what I spent my adult life pursuing, and not what I went to school for. Lyrica and oxycodone would absolutely be my drugs of choice if I was able to function on them. But I am in a place where I just have to be so alert and able to retain the information that I am provided with, in order to succeed in this field. I tried to do it with those stronger medications, I just wasn't keeping up. So now I am trying to find that happy medium, relief without the mental fog.

But again thank you for your input. I do think your points on the binding affinity of mophine are solid ones to bring up to my dr as we navigate my patch strength and a proper breakthrough med.

Also, because I do have weekends off and would value a more pain free quality of life during those times, I am open to trying a more potent regimen on the weekends. That might be the perfect place for your recommendation.

One reason I am also interested in Nucynta is because it has a cross indication for nerve pain. I have an ilioinguinal pathology, and have a hard time treating this with anything. Finding something that I can take as needed for a flare up, and not something I have to commit to BID would be welcomed.

Brandon

 

[TheFlashBooker]

The buprenorphine patch works for mild pain such as arthritis. I tried it, and it did nothing for my condition. It would only last 4-5 days also. I've used (and abused) every opiate under the sun, and bupe is on the low end of effectiveness. But tramadol did absolutely nothing for me as well, so you might respond well. Bupe withdrawals are extremely long and protracted