Bupe desperate need of suboxone/pain management help

[outoftown]

As a brief background - I have very advanced Degenerative Disc Disease, along with bad arthritis/spurs/nerve damage - all in my neck. 5 of the 7 discs are in terrible shape - I've been told by several doctors that it is very advanced for my age (34). I've been through a great deal of pain management including massage therapy, physical therapy, chiropractors, injections and procedures on my neck. Not a whole lot has helped and I'm trying to avoid surgery.

For approximately 12 months the pain was managed by my pain management doctor on short acting oxycodone (30mg 3 times per day). Wasn't the best schedule, especially long term, to manage the pain.

So I made the decision to get off that dose schedule by switching to suboxone. Exactly 1 month ago I switched to suboxone, taking 10-12 mg a day the first week. I was ok (pain wise) the first week and ever since it quickly has advanced to being entirely unmanaged. I'm back in extreme pain all the time again, not sleeping well, etc.

To deal with this, my new pain mgt doctor suggested I increase the suboxone dose (from 8mg to 12/16 mg per day). I went up to 12mg for a few days and it didn't seem to relieve the pain at all. Not wanting to be on this drug long term, I tapered my dose down (again since the higher dose wasn't helping anyway). I'm down to 2-4mg per day (alternating days). In addition, I've tried ibuprofen, advil, tylenon...and have been prescribed diclofenac, tizanidine and clonidine. Nothing is helping me! I stopped everything except the suboxone and clondine (which I take to get some sleep/relief...only lasts for a few hours at night).

My question is - has anyone had success on suboxone for pain management long term? I've read for pain management - it's not a general practice to be on a high dose - which is why i've continued to taper my dose after it still gave no relief at 8, 10 or 12mg. Plus, being on suboxone I don't believe it's an option to take anything short acting for extreme pain (since non of the anti-inflammatories or muscle relaxors have helped). And I really am not too thrilled about taking suboxone long term for pain management due to the cost (my co-pay is significantly higher monthly compared to other things I've taken).

In my situation, I know of oxycontin and methadone as far as long acting pain medications (and I believe you can take things for the extreme pain on top of those). Are there other choices? (I did try nucynta in the beginning but I had terrible side effects to that medication). I'm not thrilled about the cost, but could I manage my pain on suboxone taking 16mg+ per day as my doctor has suggested? Should I entertain the idea of switching to another long acting medication like oxycontin (or other choices)? Any advice would be appreciated as its been about 3 weeks and anyone in extreme would understand that every day seems like a week...I havent slept more than 3 or 4 hours at a time in weeks...I can't concentrate. I have a full time responsible job and two little kids that I adore and everything is a mess right now because my pain is entirely unmanaged. I don't even know if I have to be off suboxone completely prior to switching something else. Please help!

 

[SydneyGal]

Fentanyl patches, maybe?

I'm a chronic pain patient too, and I've personally found transdermal delivery to be best since the continual low dose keeps on top of the pain all the time, and you don't have to remember to take pills. But I get adequate pain relief on a 20mcg/hr bupe patch, plus extra bupe for breakthrough pain; rarely more than 2mg of bupe per day, even on really bad days, i.e. much less than you need!

So I haven't tried the fentanyl patches myself, but I'm sure someone else on here has, and might be able to give you more info about them. In the meantime, this is what Wikipedia has to say about them, which seems to be reasonably accurate to me:

Fentanyl transdermal patch (Durogesic/Duragesic/Matrifen) is used in chronic pain management. The patches work by releasing fentanyl into body fats, which then slowly release the drug into the bloodstream over 48 to 72 hours, allowing for long-lasting relief from pain. The patches are available in generic form and are available for lower costs. Fentanyl patches are manufactured in five patch sizes: 12 micrograms/hour, 25 µg/h, 50 µg/h, 75 µg/h, and 100 µg/h. Dosage is based on the size of the patch, since the transdermal absorption rate is generally constant at a constant skin temperature.

Rate of absorption is dependent on a number of factors. Body temperature, skin type, amount of body fat, and placement of the patch can have major effects. The different delivery systems used by different makers will also affect individual rates of absorption. The typical patch will take effect under normal circumstances usually within 8–12 hours, thus fentanyl patches are often prescribed with another opiate (such as morphine or oxycodone) to handle breakthrough pain.

 

[outoftown]

Hi Sydney - I have heard of Fentanyl patches - the wikipedia definition sounds like they would work well. I don't know - never tried that and my doctor hasnt spoken to me about that. He is willing to switch me to something else...something long acting and that I can use a short acting med for breakthrough pain.

You are taking 2mg suboxone and getting good pain relief from that? Since you are on that medication - do you think it is strange that my doctor would want me to go up to 16-24mg for pain management? I'm just curious - because I've read online that "less is more" for suboxone pain management. I've been on 8mg, 6mg, 4mg and now i'm tapering down to 2mg...and my pain is completely out of control and has been for a few weeks now.

 

[lew629]

I'm on the Fentanyl patch (100s), have been for 6 years. I still get horrible pain flares at times. It is a good overall method, but technically is not supposed to be used alone. Many people get pain pills in addition to the patch for when their pain spikes (breakthrough pain). My doctor won't give me any though because he's opiophobic, so I just have to suffer.

 

[Tommyboy]

I have heard that lower doses of suboxone are more effective at treating pain compared to higher doses. If you are on a high dose then you constantly have about the same high dose (probably the ceiling dose) in you at all times, which your body adjusts too making it work less. With low doses however, the dose will go below the ceiling dose, and taking a small dose will produce more of a change in you since you are going from having a small dose in you, to adding more to you while staying below the ceiling dose. It's probably hard to understand and I don't know how well I am explaining it, but I hope you got something from that.

You can also take tramadol on top of the suboxone if you are on a low dose of the suboxone. There are a bunch of threads on it so try typing in "suboxone and tramadol" (or any other combo of those words, or bupe instead of suboxone, etc) into the bluelight google search on the top right and you should find what you need.

 

[outoftown]

Wow - sorry to hear that Lew! Suffering is no good! Hopefully the Fentanyl helps most days for you?

Tommyboy - You know I did search for tramadol and suboxone and found what you are talking about. I have tramadol (50 mg)...but I found some information that there was significant drug interaction between the two? I did read a lot on this site though from people that did and said it was safe to take a low dose of suboxone with tramadol. Do you know what's considered "low dose" suboxone...i'm on 2-4mg per day and I have 50mg tramadol as I said, is that a low enough dose of suboxone? and 1 50mg tramadol would then help the extreme pain? at least until my dr appt next week where hopefully I can switch to something else. I read that I dont have to taper off the suboxone entirely to switch to another long acting med...I just need to stop the suboxone and wait a couple days?

Anyway - your explanation does make sense for suboxone...that's pretty much what I've read. I've been on 4mg or less for about 2 weeks now and i'm not getting relief. But by what i've read and your definition...my doctor instructing me to increase the dose from 4mg to 16-24mg...would be incorrect?

 

[Tommyboy]

From everything that I have read and from my own experience your doctors advice is incorrect. One of the forms of buprenorphine that is marketed for pain relief is Temgesic, and that comes in 0.2mg, and that is about equivalent to 10mg of oral morphine.

As for what I consider a low dose, 1-2mg sublingual is about what I would consider low, so maybe 0.5mg 4x daily would work well for pain. I'm not sure about tramadol dosing though.

If you were to stop suboxone to use different meds then you would only have to wait to avoid the blockade effect, but at doses of 2-4mg it would only take 1-2 days before feeling the other opioids, and if you were taking only 1mg then you wouldn't have to worry about that as it may actually have synergy with other opioids at 1mg and under.

 

[outoftown]

You have been very helpeful Tommyboy. Thank you! I'm glad I continued to taper the suboxone dose down (which has been easy). i'm currently on 4mg a day...alternating 2mg every other day...working on getting down to 2mg as a daily dose...just about to that. and I am taking it sublingually. I might call and ask a pharmacist about the tramadol - see what they say.

I'm glad it wouldnt be a long wait in switching from suboxone to something else. At 2mg...do you know if I would start to feel withdrawal after 1-2 days prior to starting the new medication (oxycontin for example)? I've been on suboxone for 1 month and constantly lowering my dose...so I was curious how bad (if any) the withdrawal would be. And if there was withdrawal...if the new medication would take care of any withdrawal.

Thanks again - everything you are saying makes a lot of sense to me.

 

[Tommyboy]

With suboxone you usually don't feel withdrawal until you get below 2mg, unless you were tapering down from a higher dose of like 16mg and even then you would be alright until like 4mg.

If you were to switch over to oxycodone or something then you probably won't feel any withdrawal, but if you are at 2mg when you switch then you should wait until you feel withdrawals before dosing to ensure that the suboxone doesn't block the oxy or whatever. Suboxone withdrawals usually take 36 hours to start and 48 hours or so to get kinda bad, and since you have been on it for a month you are dependent so would feel sick if you stopped.

 

[outoftown]

thats for the withdrawal info tommyboy...I guess we'll see once I make the switch (or taper all the way off)

I tried the tramadol in combo with the suboxone last night and did not get any relief from it. oh well it was worth a shot. I took the suboxone sublinqually 2mg and then a 50mg tramadol...no pain relief at all. I have read that has worked for many. I even searched on here after we talked about it and found that people actually "felt" tramadol when taking with suboxone...I didnt notice any difference. guess it just doesnt work with me for whatever reason.

 

[SydneyGal]

Hi Sydney - I have heard of Fentanyl patches - the wikipedia definition sounds like they would work well. I don't know - never tried that and my doctor hasnt spoken to me about that. He is willing to switch me to something else...something long acting and that I can use a short acting med for breakthrough pain.

You are taking 2mg suboxone and getting good pain relief from that? Since you are on that medication - do you think it is strange that my doctor would want me to go up to 16-24mg for pain management? I'm just curious - because I've read online that "less is more" for suboxone pain management. I've been on 8mg, 6mg, 4mg and now i'm tapering down to 2mg...and my pain is completely out of control and has been for a few weeks now.

Sorry, I meant that I take a total of 2mg on a really bad day, in the form of a bunch of .2mg and .4mg sublingual pills for breakthrough pain, on top of the 20mcg/hr in the patch. I find that dose really helpful, but just because it works well for my pain, doesn't mean exactly the same dose will be right for you, even if we were practically identical twins, with the same medical conditions and prognosis; YMMV seems to really apply for effective dosages. If that's the dose your doctor believes will work for you, and they're a decent doc who generally knows what they're talking about, I'd very definitely take their advice over mine if I were you! They probably have a bunch of good reasons why the dose they suggest for you is far higher than the dose that works for me.