Bupe Super High Bupe > Oxy (Calling all BL pharmacists!)

[Dispatchick17]

Hey there to everyone, and esp to all of our BL pharmacists and big brained pharmaceutical experts... I need a little hope (and maybe someone who's been through this).

I'll explain the whole backstory someday if anyone wants it, but here's the short version.

I'm currently waiting on cervical spine adjustment/revision surgery and am on the cancelation list because it honestly can't come soon enough.

I have two herniated discs compressing my spinal cord, severe nerve impingement on both sides, the disc above my previous fusion has essentially degenerated to bone-on-bone, and to add insult to injury, I've also developed multiple bone spurs. Because who doesn't love added content, right?

Pain level? 10/10. Would not recommend.

Years ago I had an ACDF (Anterior Cervical Discectomy and Fusion) at C3 - C5. Since then I've been through just about everything on the menu for pain: opioids, non-opioids, injections, procedures, products, physical therapy, etc.

The medication that actually seemed to help me the most was buprenorphine. It controlled my pain better than anything else I'd tried, and coming from the a medical profession that saw addiction at its absolute worst, I also appreciated that it felt like a safer option for me than traditional opioids.

Most recently I was taking:

• Suboxone 24 mg/day (for pain)
• Lyrica 600 mg/day
• Celebrex 400 mg/day
• Topamax 75 mg/day

Because I'm preparing for surgery, my longtime pain management provider switched me from Suboxone to Subutex so the naloxone wouldn't complicate perioperative pain management.

For two weeks I took:

• Subutex 32 mg/day (4 × 8 mg)
• Same doses of the other medications.

Did it completely control my pain? No. But it definitely helped.

Then four days ago everything changed.

We have a new physician who took over the practice. He wasn't comfortable continuing the Subutex, despite my regular provider managing my case from the beginning still recommending it. Instead, he stopped it and switched me to:

• Percocet 5/325 mg three times a day.

Three days later he increased it to:

• Percocet 7.5/325 mg three times a day.

Here's my problem...

I'm not in precipitated withdrawal. I'm not sick. But my pain has become even more unbearable, and now it hurts in my lower back and further down my spine.

This isn't my "normal" chronic pain. This is a whole different beast. The only way I know how to describe it is, "slap my own deceased mother" level pain. (Obviously kidding *Rest in Peace, Mama*... but you get the point.)

The Percocet honestly feels like it's doing absolutely nothing.

I've read a lot about buprenorphine's incredibly high receptor affinity, how long it occupies the opioid receptors, and why full agonists sometimes don't work well until enough of the buprenorphine had been evicted.

So here's my question...

Am I wrong in thinking the Percocet may simply not be able to do much yet because the bupe is still occupying those receptors?

If that's the case, how long does that usually last after stopping high-dose buprenorphine? When should I realistically expect the Percocet to start providing meaningful pain relief?

Is there anything that can safely speed up that process, or is it simply a matter of waiting?

I'm frustrated because I feel like I voiced these concerns before the switch, and they were largely dismissed.

I'm looking for experiences, education, and maybe just a little hope that this won't be forever.

Thank you all so much.

Edit to add: My last dose of Subutex (32 mg) was the evening of July 22. Since then I've only been taking the Percocet (along with my Lyrica, Celebrex, and Topamax). I'm currently about three days out from my last buprenorphine dose.

 

[Keif' Richards]

Dude, is your ultimate goal here to remain on Subutex? If that is the case, there are ways of accomplishing that. You might not like it. Pretty much any adult with identification can get a Buprenorphine prescription, over the internet on a Zoom call if that´s what they want. The kicker is that this is only done for addiction maintenance, not for pain. You would have to bite the bullet and go through the process. You don´t necessarily need to say you´re an addict, but you will need to tell them your story of essentially being ¨cut off¨ and not knowing what to do.

I hate to be a pessimist, but the majority of these places online are for-profit enterprises and they are more concerned with getting your a script and billing your insurance than they are about asking probing questions. You can do a consultation with them with no risk unless you decide to proceed with treatment. They can tell you what to expect, what they will prescribe, etc.

32mg Buprenorphine is actually a very, very high dose. It is a partial-agonist, as I´m sure you are aware, however, these extremely high doses still lead to very high Opioid exposure regardless of the drug´ś partial agonist qualities. 22.5mg Oxycodone per day is not even close to 32mg Buprenorphine, though an apples to apples comparison is not easy.

There are ways of finding general equivalencies.

First, we know that sublingual Buprenorphine is 1/8th the potency of oral Morphine.

We also know that 1mg Oxycodone = 1.5mg Morphine, both by the oral route.

Now, we are starting with 32mg Buprenorphine. 32 x 8 = 256

We now have what are called our Morphine Milligram Equivalents (MME). It´s not a bad number to know, as a lot of prescribers communicate using these MME´s as a benchmark.

256mg x .66 = 168mg

So, even with our rough estimate, we come to an equivalent of 168mg oral oxycodone per 24 hours to equal your 32mg Buprenorphine. You can see how the figure you have been prescribed is essentially erroneous. It is possible your physician might not be familiar with the full, complex nature of Buprenorphine. As you can see, there is a lot to know and they typically don´t know shit and I mean no disrespect, it´s just how it is.

Is your doc hoping to just put you on this to prep you for surgery and then return you to your previous Buprenorphine? If this is permanent, you need to immediately start seeking out different options. Buprenorphine is a very long lasting drug especially when you are habituated to it. It is likely your pain will continue to increase to a peak at around 2 weeks. It could continue to get worse.

Let me know how you want to proceed. I´ll do my best to help you through this.

 

[Dispatchick17]

Wow, thank you so, so much. THIS is the information I needed to go into my appointment prepared to say, "Listen, I am in tremendous pain, and you've actually made it worse." (By not fully understanding the very medications you're prescribing... but honestly, why would I expect them to?)

So, I truly don't think I have a preference on which route to go. I guess that's why I allowed my doctor to "persuade" me to go the Percocet route instead of staying on the Subutex. I just don't think they're comfortable using Subutex for pain management, even though that's exactly what I was taking it for.

I really don't want to go through one of the online bupe clinics because of the stigma and the label it seems to put on you every time you walk into a hospital or doctor's office. But I suppose it's six of one, 24g of the other. If it'll stop this pain, it'll be worth it.

Do you have a recommendation on how I should address this with my doctor? I have a medication management appointment on Friday. She knew I was VERY wary of this decision so she's scheduled these little "med check-ups" to make me feel better. Ultimately, I'd just like to make it to my surgery date (in two weeks) without winding up in the ER because I can't move my head due to the pain. (I'm not just being a dramatic, whiny female here. It really is that bad.)

Then we'll figure out pain management after surgery.

Again, my fear is everything you explained above... that the unnecessarily high dose of buprenorphine they had me on has now put me in a position where whatever pain management we choose going forward may not actually work the way it's supposed to.

The really frustrating part is that I trusted the people who were supposed to understand these medications better than I do. Instead, I'm sitting here in worse pain than when we started, trying to educate myself on the very drugs they're prescribing. That's a pretty discouraging place to be. I literally want to eat this whole bottle (I won't, I won't) but the pain is just that bad.

I have 4 8mg suboxone tabs
2 5mg Percocet tabs
And have been taking the 3 prescribed 7.5mg percocets pd.
I also take the Lyrica, 600mg of course.
Celebrex 200mg 2x pd
Topamax 25mg 3x pd
Adderall 15mg 1.5x pd
Bupropion 150mg 1x pd
I do take 1mg clonazepam prn.

And I have some other sad meds I take daily.

What can I do, if anything, to lessen the pain increasing?

Thank you for the support. It means more than you know right now.

 

[Keif' Richards]

Hey @Dispatchick17

I´m happy you got the information you were after. You´re able to follow what I´ve been throwing donn thus far, so I will write you a part 2. We will talk about how to handle your appointment and contingency management options. I am literally just waking up and this is a complex issue. Sit tight and I will be back here in the next two hours with a good explanation for you.

Something you need to internalize right now: doctors do not like being proven wrong by patients. I know people pretty well. It´s how I have survived this long in a world full of douche bags and idiots. Any doctor who would make such a flagrant, nonsensical decision like this is clearly not willing to invest the same amount of time into his patients as a random ass teacher on the internet. Think about that one. He knows damn well he didn´t have a full understanding of this issiue.

Your doc has a narrow view of Buprenorphine as a static tool, if you will. It is not comparable to other Opioids and more or less just exists with little vaiation from dose to dose. Buprenorphine is an extremely complex drug relative to other Opioids like Oxycodone. Lower doses trigger more Mu receptor response without the peripheral receptors really getting involved. As the dose is raised, these essentially unwanted peripheal receptors come into play, contributing more to tolerance than to linear improvement in pain.

Buprenorphine is at its most effective at doses of, at most 4mg SL and ideally less than 2mg. Think about that for a moment and read up while you wait for me. Don´t worry, I on´t leave you hanging. You seem like a genuine, nice dude. Talk to you soon.

 

[Dispatchick17]

I've been a studious BL dudette (lol) and now can understand why the pain in my neck feels like it's down my spine as well. Spinal analgesic. Wish I'd have known that one. This pain... ohhh. And guess who won't answer their phone or return calls.

 

[Keif' Richards]

@Dispatchick17 0qp

Here is the problem as I see it. Buprenorphine, if it is continuing to treat your pain effectively, that is good. I will try not to overload you with too much information. I´ll write what I think is important and you can ask me whatever questions you have.

First off, Regarding prejudice from seeking out a Buprenorphine script "for addiction, you are giving physician's far too much credit, like way more than anyone ever should.

Look what your doctor just did. There are plenty of them ready and willing to judge you as a drug addict/seeker. Many of then are going to see Suboxone in your chart and it will cause an immediate, irreparable trust issue with that doctor. They will do whatever mental acrobatics are required to attach you to addiction, as nothing else fits with their narrow world-view.

When you find a good doctor, you have to keep them. When you have a bad one, change that doctor before shit hits the fan. If nothing else went wrong, it is extremely harsh to make an immediate change like that.

- Buprenorphine acts as a blocker of other Opioids in high dosages. This means it will be difficult to get any alternative pain relief from your docs. In theory, they could just give you high doses of Opioids like Remifentanil. In practice, established ethics and fear make most physicians unwilling to give those high doses. This is especially stupid considering an anesthesiologist´s entire profession is about measuring and administering the correct amount.

This means you won't be able to get any more pain relief than your average day. There are ways of preparing yourself for surgery to get the best outcome for pain control. If it were me, I would skip taking Buprenorphine for 72 hours prior to surgery. Yes, it is uncomfortable. This will allow you to get relief from whatever short acting Opioids they give you post-surgery.

- Buprenorphine is considered a blocker at these doses. As the Buprenorphine leaves your system, it will make the Oxycodone more effective. If you are going to be having surgery anyway, it might not be a bad idea to use Oxycodone for the few days leading up to your surgery. You will be more comfortable post-surgery.

- Are you a user of Cannabis? If you are in a place where you can get it, it can be used for sleep/pain or whatever else, it is a great, versatile drug.

How long do you have until your surgery exactly?

Like I said, if you are able to forego the Buprenorphine a little before surgery, it can make a huge difference. It would help to know when your surgery is. Let me know and we can re-convene.

 

[Dispatchick17]

I think I may have not explained myself well in my first post.

I have not had any buprenorphine in my system since July 22. So, been on just oxycodone, first 5mg for 3 days and now 7.5mg. 6 days total I suppose. Maybe I'm being a big baby here and not just giving the oxycodone a chance. But the pain has just been insane. It hurts to move now, whereas at least when yes, it hurt in my neck, I could at least move.

My surgery is in 12 days. It just seems like a lifetime in this type of pain.

I will check into the possibility of a medical Marijuana card, and if this interferes with my pain contract. My parents and their friends smoked since I could remember, never to extremes, but when they needed/wanted to... and that was waaay back before we had "strains" and such. I never got into it, but can see the absolute benefit when used wisely.

I did receive a call back from the office today. The office manager said they spoke with my provider and she said that because "oxycodone is stronger than buprenorphine" she will not change anything (I only asked for an appointment, mind you.)

I'm just not even sure now what TO say now when I do have my appointment. Do I try to kindly explain that bupe is different? Show her articles from official medical research/resources on how?

If I were to ask to go back on to buprenorphine (after 6 days without it) then I would ABSOLUTELY have to either micro-dose my way back in, or wait a few days without any opiods so I could avoid PAWS. By that time, I'm pretty close to surgery anyway. I'm just so frustrated with living this way, and even more PISSED (if I may say so) at these "medical professionals."

I'm not a huge fan of Google as a source of information, but even a simple search of which med is "stronger" (not a great choice of words to use IMO but I'm not a DoCtOr) and it will certainly tell you differently. Full vs partial doesn't mean more vs less!

I know YOU know this. I'm rambenting at this point. Sorry...

Again, thank you so much for the knowledge (I am one who does like to know the how behind the why.) I've enjoyed learning more about all of this, and it has been an ABSOLUTE welcome distraction from the pain. Thank you.

 

[Dispatchick17]

@Keif' Richards Sorry to tag you out... I know you're super busy. My doc appt is tomorrow and I was just looking for insight. I don't want to go in with an attitude but damn, I'm hurting.
Thank you.

 

[Keif' Richards]

@Dispatchick17 I send you a message homie. I will talk to you soon.