My mom (who has been on prescription opiates for many years) was recently in the hospital and they prescribed her suboxone to take along with her hydromorphone. She said the doctors told her to take the suboxone 3x a day (2 mg strips) and use the hydromorphone for breakthrough pain. Has anyone ever heard of such a regimen? Obviously makes no sense to me as 6 mg of suboxone per day is going to block the hydromorphone from working almost completely.
I told her to pick one or the other and that the combo was useless but she trusted the doctors over me and took both. Only after really pressing her about it did she admit the hydromorphone doesn't seem to be working anymore and now she thinks I may be right.
This actually makes PERFECT sense!!!
At 2mg doses, you still have about 60% of your opioid receptors available! So basically, that means a strong narcotic will have its potency effectively halved, but DOSAGE IS EVERYTHING, when it comes to Bupe. There is actually an entire multi-chapter guidance paper written about this.
The reason they likely chose hydromorphone is is three fold. 1. It has a wicked high binding affinity, making it harder to fresh doses of Bupe to *displace* it from Mu receptors, and thus reducing (though not entirely eliminating) the risk of percepitated withdraw. The risk of percepitated withdraw is already going to be diminished with 2mg doses, versus say 6mg or 8mg, because again, the Bupe is only occupying about 40% of receptors and hydromorphone does not occupy as many receptors in quantity as Bupe, so there’s more receptors left over for the Bupe to bind to. Hydromorphone utilizes a lower dose, so it’s less molucules fighting for a limited number of receptors. Hydromorphone binds *extremely* tightly and is highly activating! It’s binding affinity is only slightly lower than Bupe, so it’s not easy to knock off receptors (though again, with Bupe having a slightly higher affinity, PWDs are still possible). dose will correspond to much greater pain relief than morphine or oxycodone. 2. I alright kind of hit on this, but hydromorphone is highly potent and needs only a low dose. Even with 40% diminished effects, it’s still going to give superior pain relief to Oxycodone and Morphine, even when these two aren’t complicated by the Bupe situation. 3. Because Bupe provides moderate-level pain relief on its own, even a diminished potency hydromorphone can provide enough Mu receptor agonism to fill the void.
Full opioid agonists can be used in the 4-6mg range, though this is when opioid receptors occupancy becomes more of an issue. The risk of PWDs and inefficient pain relief increases, though again, I have personally seen others be prescribed both. My best friend is on 6mg Bupe each dose and had to get surgery. Her doctor (honestly a compassionate guy as he also wrote her an MMJ recommendation), told her if she was concerned, she could try tolerating 4mg dosing for the week leading up, and this would help reduce both risks. It wasn’t easy but she dropped to 4mgs, especially as she suffers from chronic pain, depression, and debilitating anxiety, so just some food for thought if someone is on Bupe and has surgery in the future.
Where Bupe REALLY becomes problematic is 8mg doses every 8-12 hours, because it’s at 8mg+ dosing where the steady state means the Mu Receptors are heavily occupied by the Bupe, so not only will full opioid agonists lose the majority of their effectiveness, PWDs become a bigger concern. Obviously less of a concern then the ineffectiveness of the pain killers since PWDs are far more common when one is *already* dependent on a full opioid agonist and the Bupe displaces them. Respiratory Depression can be an issue too, even with the ceiling effect as the ceiling effect isn’t a cutoff, it’s more like a slope. At 8mg doses, 80% of receptors are occupied and at 16mg doses, nearly 90% are occupied!
PS- I personally am a STORY MYSELF of how Bupe for baseline pain and Full Opioid Agonists (Oxycodone) for spikes and breakthrough pain can be effectively utilized! I used to be purely on Oxycodone. Over 3 years, it’s effects started to diminish. I had a choice my doctor gave me…..Use Belbuca (low dose Bupe) for baseline 24/7 relief and Oxycodone for bad days, spikes, and breakthroughs, or up my dose. I opted for choice 2. It works and I have better pain control. It’s not perfect, but wow, it’s way better then Oxy alone was! I currently take 300micrograms of Bupeprenorphine Buccal Film x2 daily. Due to the formulation, it’s total bioavailability is about 10%-15% higher than the formulation in Subs, (300mcgs of Belbuca per dose is roughly 400mcgs in subs). However, it’s NOT CHEAP, lol. Thankfully, insurance covers 80% of the cost! Still it works, though I will be the first to admit, at a low dose like that, Oxy for spikes and breakthroughs are still necessary.
Thanks for listening, and I really hope this helps!
. So these are good questions.
