Opioids Buprenorphine for chronic pain

[MattPsy]

Hi everyone.

I am probably going to start buprenoprphine tomorrow for the treatment of chronic pain. However, because buprenorphine is not prescribed for pain where I live (New Zealand), I will be getting it through the opioid substitution program here.
I have attempted to convince the medical profession here that my symptoms are not imaginary or simply me trying to get high. For around 3 years I have tried my best to do this, getting x-rays, seeing many specialists (arthritis twice, musculoskeletal 6 six times, physiotherapists around 15 times), trying multiple medications etc... I have tried:

• Antiinflammatories/NSAIDs, such as ibuprofen, diclofenac, naproxen, aspirin, and a COX2 selective one, celecoxib; all these do nothing except give me stomach bleeds. Paracetamol actually seems to worsen my pain, but it's not really an NSAID anyway.
• Opioids, such as codeine, tramadol, opium, morphine, oxycodone, pethidine, and 4'-nitromethopholine (I'll come back to this last one); these are really the only thing that has worked, in part, although I didn't find oxy very effective for pain (10-30mg insufflated or IV, or 50mg PO), but I did get pretty high. Morphine and opium have been the best for pain, 30mg IV morphine was effective, but I also got really fucking high and it was difficult to achieve things.
• Cannabinoids, such as THC, HU-210, CP 55,940, CP 47,497, around 20-30 other synthetic cannabinoids, mostly indoles like those from the JWH and AM series; all of them are either pain-neutral or actually exacerbate my pain, sometimes very significantly- none improve my pain in an analgesic sense. Despite this, they help me to cope with the pain mentally, occasionally, so I take some of the more pain-neutral ones for this every so often.
• Other agents, gabapentin (almost worthless for pain, made me retarded and forgetful when taken in daytime. Awesome as a sleep aide however), amitryptiline and nortryptiline (worthless for pain, makes me sleep for >10 hours and retarded for another 6 after that, even when dose is <15mg, ridiculous)

Last year in frustration with the lack of empathy and action from the medical community I ended up getting addicted to IV 4-nitromethopholine (IV because its actually inactive through other ROAs; not my choice). This was a truly awful period of my life so I won't go into it too much, it hurts to remember, but suffice it to say that I had to shoot up ~8 times a day, waking up very reliably in the middle of the night 2 times drenched in sweat, needing to dose to sleep. However, dosing also gave me dysphoria, hallucinations, and compulsions for self-harm; none of these symptoms happened when I first started using it, they resulted from dose escalation where analgesia (presumably from MOP and DOP agonism) reached a ceiling but hallucinations (from KOP agonism) didn't.
I tried to get on buprenorphine or methadone then to make the continuous nightmare end last September, but because they weren't familiar with the opioid I was using, they insisted on me doing an inpatient detox program, which would have resulted in me losing my job and causing enormous disruption to my partner's life (who was/is studying) by my not being able to pay rent. As a result I simply threw my remaining stash, around 6 more months worth, down the toilet to force myself to quit,as I don't have any reliable sources for opioids. It was horrific, but I kept my job,and stayed off opioids till January.

So, i've been more or less (just taking codeine occasionally, 60 to 200mg a time, to keep from wanting to kill myself,and IV morphine 30mg twice - it's really expensive and almost impossible for me to get, so I pretty much have to use it this way to make it worthwhile) clean since then, and was totally clean from Sept-Jan. Around early January to Feburary I became seriously suicidal, despite my resuming occasional codeine use, and sought professional help with this. I'm doing better now. Just extremely frustrated.
A week or so ago I went to a new GP explaining my position, and was told more or less that because i've been a junkie, i'm no longer a human being worth treating properly (in accordance with symptoms, and reflective of empathy, etc), so despite not being an addict/dependent on opioids,and having escaped from this trap in the past, I now must become an addict in order to get treatment POSSIBLY sufficient for me to continue to want to live.

So that's my story.
I've done a awful lot of research on buprenorphine over the last week,reading >20 journal articles, so i'm very confident i'm about as knowledgeable on the compound as its really possible to be, certainly far in excess of what the doctor will be. I think I maybe have a chance of this working,even if it's not ideal.
I thought I should start on 2mg SL.
Your thoughts?

 

[Tommyboy]

Buprenorphine is used in even lower doses for the treatment of pain. Temgesic is a preparation of buprenorphine that comes in .2mg (200 micrograms) and .4mg (400 micrograms) and is specifically marketed for the treatment of pain.

The dosage really depends on what you want to get out of the medication. If you want to use it just for pain, then I suggest using 1mg or less, but if you want to use it more for maintenance and helping with cravings, then 2mg is a good start.

Good luck.

 

[tricomb]

Does your country have BuTrans? Transdermal buprenorphine only needs to be changed once a week. Never tried it though.

 

[MattPsy]

They do not. I was, however,going to say that I wanted patches (but can't get them), to make it really obvious that I don't want to get high or divert them.
Many of the studies I was researching was using TD-BUP, 35 to 70 uh/hr, in cancer, neuropathic, and noiciceptive non-malignant pain. It's a shame I won't be able to get takeaway doses till a few months in, really, as for analgesia I want to keep bupe and nor-bupe (and B-3-G and N-3-G, for that matter, which are biologically active) plasma levels more or less constant. Since I won't be able to split my doses, this won't be possible, and I can't get any doses smaller than 2mg SL. I guess i'll just start at 2, then once I can split them, 1 x twice daily, then try cut that down to 0.75 or 0.5 x twice daily or something.
I also can't get buprenorphine monodrug (as in, "subutex", non-naloxone-combination), so i'll be using Suboxone... not that it's really relevant, other than cost.

Oh yeah. I forgot to state the origin of all these problems. They started 10 years ago in a go-karting accident, where I got severe whiplash. Unbeknownst to me at the time, i'd actually broken the back of a vertebrae off. Only recently in the last 6 months did I learn this has happened. Back when I had the accident, no-one considered it worthwhile, for some reason, to get even the most basic diagnostics done.
I told my doctor/GP about the piece of broken off bone in my neck, y'know, the one where ALL MY PAIN ORIGINATES FROM (radiates from), but she didn't consider it relevant for some reason,even though I had the scans with me and could readily be verified that I was not, in fact, talking shit.
My pain is noiceptive, deep somatic. Main pain is in neck, but other pain is generated through extreme muscle tension which never goes away (and which returns as little as 1 minute after using electrical interference muscle relaxant machine at osteopath), and combination of stabbing-ripping pains in knuckles, ankles, wrists, knees, and shoulders. How this could not be considered relevant I will never understand.

 

[tricomb]

Man this just sounds like an awful length to go to for chronic pain.

If you're in this much pain, you should see a pain management specialist they'll fix you up with what you need.

 

[obscure]

I'm about to start a Suboxone treatment, on Thursday, to get off my other pain meds, which include heroin. My story is similar to yours, trying different "black market" drugs for pain relief and frustration with the medical community for not taking me seriously.

Among my legitimate acquisitions of pain meds I did try the Butrans 100mcg patch. I found it to be not at all worth while. It didn't seem to do anything. I'm hoping that whatever dose I get prescribed of suboxone will give me pain relief and keep me off all the other junk I've got myself addicted to.

I'll let you know later this week if the subs are working for pain, as it seems we're in the same boat of being forced into becoming a junkie to get the help we need...

 

[tricomb]

Yeah I've heard a lot of mixed results about buprenorphine for chronic pain, I don't really like it because it's a partial agonist, and my pain is better managed with full-agonists, I can't have a dose ceiling.

 

[Tommyboy]

^ Yea, I've heard that it works better for pain in lower doses as opposed to maintenance doses. That's the same with methadone, although the suboxone is only a partial agonist. The lower split doses allow for levels of the drug to drop enough for more of the drug to come back in and have an actual effect.

They do not. I was, however,going to say that I wanted patches (but can't get them), to make it really obvious that I don't want to get high or divert them.
Many of the studies I was researching was using TD-BUP, 35 to 70 uh/hr, in cancer, neuropathic, and noiciceptive non-malignant pain. It's a shame I won't be able to get takeaway doses till a few months in, really, as for analgesia I want to keep bupe and nor-bupe (and B-3-G and N-3-G, for that matter, which are biologically active) plasma levels more or less constant. Since I won't be able to split my doses, this won't be possible, and I can't get any doses smaller than 2mg SL. I guess i'll just start at 2, then once I can split them, 1 x twice daily, then try cut that down to 0.75 or 0.5 x twice daily or something.
I also can't get buprenorphine monodrug (as in, "subutex", non-naloxone-combination), so i'll be using Suboxone... not that it's really relevant, other than cost.

Yea I was going to say that I doubt you can get a dose that low at the clinic. I'm actually even surprised that they would give a dose as low as 2mg, aside from during a taper. I was under the impression that you were going to a private doctor, which is why I thought you would have more control over your dose. At clinics though, they will probably want you to be on more of a blockade dose, like they require for most people on methadone. Maybe it is different in New Zealand though.

Have you spoken to the clinic about the dose yet? I would try another doctor before being set on going to the clinic.

 

[GABAking]

I was on BuTrans (transdermal patch of bupe) for chronic pain. It was amazing. It got rid of the pain with little euphoria and fogginess, so I was able to continue my day. I ended up being allergic to the patch though, so I had to switch :/

 

[MattPsy]

If you're in this much pain, you should see a pain management specialist they'll fix you up with what you need.

Agreed, but i've been on the waiting list since December. The "latest" i'll be seen (as in, just an initial assessment) is apparently late May. It would seem they are really aiming for that latest figure. My cynical attitude toward all this has only been reinforced by what other pain-sufferers in this country have said, as well as what the psychologist I saw for suicide said. I don't really feel like I have any real options at this point; life, simply, is not worth living for too much longer. I've quit opioids before, I think I can probably do it again if it's really required.

Perhaps I will just try bupe. at 2mg SL, and if it doesn't work out, then stop using it before significant dependence develops. If it does work, great. Maybe I will be transferred to another medication. Perhaps I will discover what the root cause is of the pain and then I can quit knowing the pain won't be there to make withdrawal even more hellish than it would seem to be for others. Whatever happens, it's got to be better than sitting around like this waiting for something to happen, I figure.

GABAking: It's good to see success stories outside those of journals, despite your non-analgesic-efficacy reason for discontinuation (although, of course, I have seen others on BL, although again i've seen many horror stories to counterbalance these too; thanks for the post in this thread however).

If they try to push me into 8mg or something (hell, 4 for that matter), then I shall simply flat out refuse, and leave. I am not taking this for maintenance. I am taking this because it is the only real option available to me, as a member of a designated near-worthless category of human being, other than methadone. Fuck methadone.

They DO have 2mg SL pills avaliable, so the only reason to force me onto more are ideological reasons. I shall present a concise, well-presented,medically sound argument for my point of view, while also making it clear that I am not doing this out of choice, nor do I think it is the best course of action. If they say no, well, fuck them.

It should go without saying that the medical community here are VERY OPIOPHOBIC and also VERY CONSERVATIVE (I've said it anyway, though, just to be sure) This is not just my option or that of junkies, but rather of the wider community, and has been acknowledged as a problem. We also have a extremely severe shortage of pain specialists. As in, for non-public-health services, there are 3 in the country that I know of. None live within 300 kilometers(that's 186 miles for your US folks) of me. Again, this is widely acknowledged. Here is not the US.

obscure: If you could keep me updated, that'd be much appreciated . Thanks!

 

[MattPsy]

OK so I was just looking through the Chronic Pain thread in tricomb's signature. Useful. Somehow didn't see it before. I'll read through the whole thing now then comment further.

Thanks all for your responses so far. They help

I'm going to ask if I can try Etanercept with my GP at a later date (it was she that insisted that I go on the OST program), no-one can accuse me of trying to get high on TNF-a inhibitors! It'll cross a mechanism of action off the list as it were, too.

 

[MattPsy]

Tommyboy: Here, you cannot get these meds prescribed by a doctor, until you're transferred into what's known as "Shared Care", where your regular General Practitioner takes over the role the clinic did. They will still report back to your previous caseworker though. I have an interview in the morning, with the resident doctor, where I will be asking about the dose (and declining treatment where appropriate, etc), giving some commentary, etc. I've already had my pre-treatment interview. They were actually really nice and understanding, in that one. Hoping for more compassion tomorrow, but from the doctor this time; i'm probably a lot less problematic than some of the clients I saw there, which should surely help! Going to bed now. Wish me luck

 

[GABAking]

MattPsy, i can give you a more thorough answer now that it's not super late and I'm tired.

My PM doctor doesn't know I'm opiate tolerance (usually about 100-120 oxy to get me where I wanna go, or like 30 mg of Opana or so nasally). So I was less than happy when he prescribed these patches, but I figure I'd give it a chance. Even though if you do the math, the patch only releases less than ~3 mg of buprenorphine over the 7 DAYS (on the 10 mcg/hr patch) [go to the bupe patch megathread for the exact mathematics], it will do wonders for your pain. Bupe is an interesting drug, b/c at lower doses, it acts more like an agonist (at higher doses, agonist-antagonist activity). I did chew on the patch after the 7 days though as to get all the drug out, but that's for recreational reasons.

As a huge plus, bupe is an amazing mood lifter. I'm not even depressed (at least not diagnosed or on any meds for it), but while on the patch, I was always so happy and giddy. It was an instant anti-depressant that works within a couple days of using it, unlike all these other SSRIs, SNRIs, etc. I had to switch to percocets cause of the dermatitis like I said, but honestly, I liked how the patch delievered a steady-state amount of opiates into my system at all times. I would wake up pain free, go to sleep pain free, and never thought twice about it. Oxycodone is like a goddamn roller coaster. I feel super good, then like shit, waiting for 6 hours to pass so I can take my second dose as to not run out early.

Any other questions, please PM me.

 

[muvolution]

Hey man, I used bupe for pain for a couple months, I am at work now, but will expound on this later.

 

[MattPsy]

Please do, mu. In the PM thread I couldn't find personal testimony on the efficacy of bupe for you, despite you saying you were going to start it. Then again, it was late... Heh. Maybe I missed it. Oh, just so you know, I haven't just tried meds, I know how you feel about that. Also been to a naturopath (despite my misgivings) and an acupuncturist (15 times or so). No benefit from either.
I'm heading off now. Let's see how this goes.

 

[MattPsy]

So it appears they are cool with me starting on 2mg. They were pretty understanding of my position, and will understand if I want to cease treatment early if efficacy is lacking, so I do not develop unnecessary dependence to something that doesn't help me - "you've thought this through in quite some detail, haven't you?" - sure have. All in all how I expected it would go, but good to get that confirmation.
I am not starting immediately, they want me to start on Monday, so they can monitor my progress through the week. Understandable if a little frustrating. They said there was the slightest possibility I could get some takeaway doses so that I can split my dosing up - I'll talk at length with them to convince them that I'm not a liability. I'm being transferred to a different clinic, which is much, much closer to where I live. I didn't know they did OST (while I DID know they existed, I thought it was just a counselling + support center), so this is a win .

Amusingly, they said my case "generated a lot of discussion" last year, due to the novelty of the agent I was using. I bet it did, hahahaha.

GABAking: Thanks again for your reply. Yes, I did notice that buprenorphine seems to be a pretty good antidepressant, as would be expected from kappa/KOR/KOP antagonism (and mu/MOR/MOP agonism too, but to a lesser degree). This aspect I was particularly interested in, as I suffer from bipolar disorder. I do not take any medication for it, as they all impaired my mental functioning and as such reduced my quality of life, even though the stability was nice - it came at a high price.
I may PM you in future.

 

[Titus]

I've used it successfully to add to perc's that I was prescribed for chronic back pain following an accident. Just needed ot time out the dosing b/c I was using suboxone and had no tolerance at the time and was quite helpful. I acquired it not through a dr though, but it helped a lot with legit pain that lasted 6 months.

 

[Crankinit]

I had a very similar problem (chronic pain, doctors wouldn't touch it, tried all other alternatives, extensive testing/searching for help, eventually said fuck it and ended up self-medicating with non-prescribed IV opiates) and my doctor finally convinced me to try Suboxone last October. It's worked rather well, not as well as shooting up oxycontin and morphine did, but enough that I can get up in the morning and function during the day and mostly ignore the pain, and it kills the cravings rather effectively. I'm back at Uni etc. instead of alternating between 'spend every cent on opiates' and 'too sick from not having any opiates to get out of bed.'

It's definitely worth a shot, and if it doesn't work you could swap to methadone, which as a full agonist is usually effective for pain.

 

[muvolution]

I had decent luck with it. It really works better than I thought it would. I got bupe prescribed through an ort program also. Sounds very similar to your situation.
I think it is important to dose very low and twice a day instead of once a day. This keeps you a little more level and ensures you get pain relief, even at night. Also, I tried combining tramadol with it (don't know if you have read up on the synergy between these two) and that made the combo way better than either drug alone. I found it to give long-lasting and significant pain relief which easily matched a lot of the full-agonists I have been on.

 

[paper planes]

i have severe chronic pain, a serious bleeding ulcer so bad they say im lucky im alive and me being tough and young and the life ive lived i just thought everyday for 4 yrs now maybe it will be better tomorrow but it never was so i took a short cut cuz i figured drs. wouldnt take me serious, so i took the only thing i could come up with and that was methadone and it was too far of a drive everyday so i went with suboxone.. and it helped me i could actually get out of bed and get a job, but it didnt take the pain away just took maybe a point off but compared to what it was before it was manageable.. stay at low doses and it might work for you but honestly i hate suboxone for many reasons.. so now im finally going to the dr and they continue to disrespect me to the fullest, shit sucks i cant do anything and it just keeps getting worse.. best of luck to you tho