Opioids Tapentadol (Palexia/Nucynta) Maximum Dose Whist On Tricyclics

[Rybee]

Hi All,

I've been taking Tapentadol (Palexia/Nucynta) for sciatic pain management which is often referred to "Tramadol's Big Brother" and I was very keen to try it because I've always responded very well to Tramadol for pain, and I used to love the high, many years ago when I had a reasonably low tolerance to Tramadol anyway.

Unfortunately it's not helped in the slightest with regards to pain management, which is a big shame really - it looked so promising, so I've been taken off of it and put back on 20mg Oxycodone TDS. As such, I still have a lot of 100mg ER tablets left over. Most literature says that the max dose is ~600mg per day. I used to take 100mg BD spaced out over the day and never felt any kind of high in the slightest. So tomorrow I'm going to try ~600mg in one dose just to see if I can get any recreational high out of it - otherwise I'll bin it.

However, I also take a 100mg nocte of Dosuelpin/Dothiepin, a Tricyclic similar to Amitriptyline & Nortriptyline, essentially a SNRI - for my pain management. Tapentadol is a centrally acting analgesic with a dual mode of action as an agonist of the μ-opioid receptor as well as a norepinephrine re-uptake inhibitor.

As such, I'm a little bit worried about the increased risk of serotonin syndrome kicking in, if I take 600mg of Tapentadol along with my Dosulepin. I'll probably take some diazepam/lorazepam to try and minimise this risk of a seizure.

I used to take 450mg nocte of Venlafaxine (Effexor) an SNRI - and the very maximum licensed dose for that was 375mg, with only around 5% of patients reaching 375mg. Although my GP said I should only take a maximum of 200mg of Tramadol whilst on Venlafaxine, I used to take ~400mg of Tramadol along with that, (400mg being it's maximum dose before the real risk of seizures kick in with patients not taking any other SSRI/SNRI medications.)

So my question is, how safe is this going to be? I know it will carry a risk, but I want to know what the real probability of such risk is? 100mg of Dosulepin is not the maximum dose, I think ~200mg is, so I'm currently at 50%.

With Tapentadol being a fairly new drug, and Dosulepin being a rarely prescribed drug, I've not really been able to find out much information because of this.

Any guidance would be appreciated.

Rybee

 

[Numb19]

Do not mix the two. Period. You could really do a lot of harm to yourself and by all accounts serotonin syndrome is god awful and can be life threatening. Do NOT mix them!!!

And you can't really quantify these things regarding dosages. Mixing them in any way, shape or form is dangerous. Period.

I also really hope that your doctor did not prescribe both to you because that would be incompetence. (I've had both trams and nucynta prescribed to me and I don't touch either of them any more).

 

[HdoubleODeezy]

Well, i was on 40mg olanzapine at one point of my life (for about a year of the 7 i was on it, dose changed a lot depending on how i was feeling).
With that said, the max dose for that is 20mg/day. Antipsychotics lower seizure threshold.
In addition I was also on 400mg tramadol, 100mg amitriptyline, 20mg ambien, .3mg clonidine, 200mg hydroxyzine, .25-1mg IV buprenorphine, 4mg clonazepam, and was experimenting with phenazepam (which both benzos probably helped me steer clear from seizures) a day. There's probably more but cant remember all of it ATM it was years ago.

Anyways, i never seized up. Even tapering from 20mg a day phenazepam my dr put me on 10mg clonazepam/day and tapered me and screwed up and accidentally stopped at 1mg.. i was sick as fuck but still never seized up.

NOW im NOT saying I am immune to seizures just because of those facts and that i have skated by safely SO FAR.
Basically what I'm getting at is, you could go your whole life without having one, OR you could be fine for years and years and then with the same combo and dose you could have a seizure.
I don't think anyone can tell you definitely if you will or will not have one.
Odds are you won't, chance is still there that you could tho.
It's up to you if you wanna gamble it.

50/50 IMO.

Be safe. I don't wanna be the person to say you will be fine and then find out i was wrong.
%)

-HOOD

(EDIT: Besides me meaning all this towards seizures, it also goes for Serotonin Syndrome as well with the meds I was on)

 

[Rybee]

Do not mix the two. Period. You could really do a lot of harm to yourself and by all accounts serotonin syndrome is god awful and can be life threatening. Do NOT mix them!!!

And you can't really quantify these things regarding dosages. Mixing them in any way, shape or form is dangerous. Period.

I also really hope that your doctor did not prescribe both to you because that would be incompetence. (I've had both trams and nucynta prescribed to me and I don't touch either of them any more).

Yes it was my anaesthetist/pain management consultant that prescribed both of them to me. He's been in pain management for 30+ years so I trust he knows what he's doing.

50/50 IMO.

Be safe. I don't wanna be the person to say you will be fine and then find out i was wrong.
%)

-HOOD

Yeah I get that, appreciate the advice though.

 

[Numb19]

Yes it was my anaesthetist/pain management consultant that prescribed both of them to me. He's been in pain management for 30+ years so I trust he knows what he's doing.

I appreciate that you respect your doctor. I personally would object that type of risk but it is not my place to suggest any type of treatment.

I'm not sure anyone here would be willing to suggest you mix those medications or tell you how much to take and everything will be fine. There are individuals on this forum who have suffered from serotonin syndrome. Not to mention on top of mixing the tricyclic with the nucynta, adding mixing benzos with opioids can also be a dangerous combination. It's like a double whammy.

By the way, the manufacturers of tapentadol are not even 100% certain on its mechanism of action. u-opioid receptor agonism and NRI inhibition is most likely is what they say.

"Tapentadol is a centrally-acting synthetic analgesic; the exact mechanism of action is unknown."

http://www.nucynta.com/mechanism-of-action

The best I can say is that the risk is there for sure so I still advise against it.

 

[Lorne???]

^^^ You can't really go by that though, I mean Purdue still claims that the mechanism of OxyContin is "unknown", but "most likely" Mu agonism, which we know is silly

Serontonin toxicity is hard to get, but considering how little is know about it, I would be cautious prescribing them. But 100mg was clearly fine. However, if you've never taken more than that, then DO NOT just take 600mg at once. Try 300-400 first, and make sure the side effects are tolerable.

 

[Numb19]

^ That's a good point, however; whne you add the NRI or SNRI into the mix it compounds matters.

I remember taking 7.5mg flexeril and totally forgot about it. I then took 150mg tapentadol and experienced a very scary episode, where I felt weak, light-headed, shaky and very strange. I'm not sure if it was sero-syn but it was still extremely scary and it just went away on its own after a while of lying down. Tapentadol is also a syntehtic opioid while oxy is semi-synth derived from paramorphine/thebaine, which is an opiate alkaloid.

 

[Rybee]

Well I've tried 700mg now which seems to be the maximum recommended dose and literally felt nothing.

Maybe it just doesn't have as much recreational value as I had hoped...

 

[muie]

^^^

You took 700mg tapentadol for a recreational experience?

As far as recreation goes, think a better version of tramadol with less side effects, less stimulation/jittery feeling. Is tramadol recreational for you? Tapentadol is along the same line, more suitable to alleviate w/d symptoms, minor pain, or if you are expecting a recreational experience expect a minor high akin to that of codeine or tramadol. Codeine is better in my opinion (more recreational..to me). Its something to be taken with other things for ex I took it with benzos or amobarbital (25mg-50mg) or soma and never needed more than 200mg-300mg to get a much better effect had I done the same with tramadol!

 

[Rybee]

You took 700mg tapentadol for a recreational experience?

Yes.

Is tramadol recreational for you?

Yes, probably my favourite opiate/opioid in terms of effects.

Though I cant/don't take it any more because I've been on fairly high doses of MS Contin/Oramorph/Fentanyl/Oxycodone for ~6 months for a couple of herniated spinal discs and a PARS defect of the lower spine - so am now fairly tolerant to opiates. I used to be comfortable taking 400mg of Tramadol in one dose with no real worries of a seizure but due to tolerance it just does very little for me now. If I took 500mg I'd also take 20mg of Diazepam an hour before, 600mg and I'd take 40mg of Diazepam before, to try and decrease the risk of any seizure. I don't feel comfortable taking 700mg+ of Tramadol period, and any more than 40mg of Diazepam starts to sedate me and null the euphoric buzz/stimulation/high so ultimately, it starts to defeat the initial purpose.

if you are expecting a recreational experience expect a minor high akin to that of codeine or tramadol.

I think my expectations were just wrong from the start then tbh.

When I used to take MS Contin, a 200mg morning dose would give me a quite intense high for 12-14 hours or so throughout the day. Although the high was quite nice, it was definitely more sedating than a Tramadol high, which is more 'buzzy'. When I looked at equipotency charts, 200mg of MS Contin appeared to be equivalent to ~500mg of Tapentadol (both formulas being extended release). So I expected to at least feel ~300mg of Tapentadol to have some effect but nothing. Crept up 100mg day-by-day to 700mg which is the max recommended dose and just didn't feel anything. Though I'd still get a buzz from 200mg MS Contin... so beats me.