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Levorphanol?

sneakdiss

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My sister just entered a state program type rehab for her oxycontin use because she doesn't have insurance. They use a drug called Levorphanol instead of suboxone to detox their patients.

I wiki'd this drug and it seems like it's an opiate that I was totally unaware existed. Does anyone have any experience with this drug?
 

Captain.Heroin

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I don't have any experience, sorry.

I thought it was a plain old mu-agonist...maybe I was wrong. The reason they are giving her that instead of suboxone is because without health insurance, suboxone is worth it's weight in gold.

Let us know how it goes.
 

Tchort

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Levorphanol is an old opioid, but it doesn't get a lot of use. It's a relative of DXM. It has NMDA activity like Methadone, which makes it a useful analgesic in certain situations (nerve/neuropathic pain patients and several other illnesses react much better to opioids with NMDA activity vs those without), plus the lack of complete cross tolerance with other opioids (like Morphine) make it potentially useful in specific situations.

It has a long half-life compared to other opioids of similar strength (Wiki lists it as 11-16 hours, compared to like 6 with Morphine).

I'm sure it could be a good candidate for opioid maintenance and detox via taper.

Like all drugs, certain doctors have sort of med fetishes: they find a medication, and only prescribe that drug for a condition believing it to be the best. Some docs only prescribe Lexapro for depression, or Sonata for insomnia, or Ativan for anxiety, and so on. In this case the doctors involved obviously believe in the efficacy of Levorphanol to treat opioid addiction.

While this is a good thing, I am surprised they do it given the extremely draconian laws relating to treating opioid addiction with opioids (technically using Levorphanol like this is not approved or really even legal).

I've never used it but would expect it to feel subjectively a lot like Methadone, only more euphoria and shorter lasting.
 

morphonorconic

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I am surprised to hear of the use of a full agonist such as Levorphanol for Opioid dependence treatment. Levorphanol is a full agonist that is a member of the Morphinian class, and is similar to Morphine in effect, but is much more potent. Honestly, if not used correctly, and possibly even if used correctly, it seems like Levorphanol could be just as desirable, and therefore potentially just as abusable as whatever original Opioid the user is trying to abstain from.

In my opinion, not a good choice on the Doctor's part.
 

morphonorconic

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So is methadone what? A full agonist? Yes, but Methadone has reached the status it has by being the best option among full agonist Opioids for ODT for many reasons, including it's very long half life. Also, Methadone has been shown to provide a minimal amount of euphoria in MMT patients, especially when compared to another full agonist such as Morphine. A shorter half life and subjectively higher levels of euphoria is a recipe for abuse in my book.

But Methadone is quite abusable as well, this I am not disputing. Hell, even Suboxone can be abused.
 

morphonorconic

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Another point I want to make here is that Maintenence Opioids like Methadone and Buprenorphine have a certain stigma associated with them, that being that these drugs simply "hold" the user from craving, and help "take the place of" the more commonly abused Opioids. This stigma creates a psychological predisposition in the user, consciously and/or subconsciously encouraging them to think they will not get high from these drugs.

Now the inverse: All other Opioids like Morphine and Oxycodone have their own stigma, which tell the user they can and will get high if they use/abuse these drugs. Therefore, in my mind, if I was given an exotic Opioid such as Levorphanol for Detox, I would have an extremely hard time not getting excited about having a rare Opioid in the first place, but more so, I would find it extremely difficult to not "test the waters" with the Morphine-esque full agonist, and from there, well, we all know where it goes from there.

My point is that I think ODT Opioids like Methadone and Bupe/Suboxone are as effective as they are not only due to their chemical/structural make up, but also due to the number of successful cases they have promoted over time, and the psychological impact that that concept presents/invokes.
 

memphishottie27

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Methadone withdrawls are horrible but I have never heard of Levorphanol. What exactly is it? I will never go back on methadone because I was having financial problems after I was on it for about a month so I had to go through the horrible withdrawls because if you don't pay, you don't get the medication.
 

memphishottie27

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My doctor told me that Levorphanol is not for getting people off opiates. In my opinion suboxone is the best. Suboxone and methadone can be abused also but you have to be commited to your recovery. Why would this doctor give her Levorphanol to get off pain killers? Thats odd to me.
Suboxone is expensive but it worked wonders for me.
 

Tchort

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I disagree morphonorconic. While you're right that the pre conceived conscious or subconscious ideas of what different opioids are or what they do is real among modern addicts, I disagree that certain opioids are better for maintenance than others.

Any opioid can successfully be used in an Opioid Replacement Therapy maintenance program. Back in the teens and '20s, Morphine and Heroin injection maintenance clinics were very successful, as they are today in Switzerland, the Netherlands, etc, as well as Morphine oral maintenance in Germany, Dihydroetorphine in China, Hydromorphone in parts of Europe (Jurnista/Hydromorphcontin), etc.

Levorphanol's metabolites, like Propoxyphene and Norpropoxyphene, have long half lives which make them just as useful in maintenance as Methadone and Buprenorphine if you follow the very American notion that long half life synthetic opioids are 'better' or 'superior' for maintenance than shorter acting semi-synthetic or natural opioids.

We need to get out of this box the medical community has constructed. Diamorphine, Morphine, Dihydrocodeine, Hydromorphone, and in several studies Propoxyphene, Dextromoramide, and several other opioids have been used to successfully treat ex-MMT and ex-BMT patients, or those still in MMT/BMT who continue to abuse opioids.

A combination of a short acting oral or IV opioid (Dextromoramide, Hydromorphone, Diamorphine) and a low dose of oral or IV Methadone has been shown to be far superior to Methadone alone or the short acting opioid alone in many patients in Britain, parts of Scandinavia, etc.

This box of 'Only long half-life synthetic opioids are useful in ORT' needs to die. And die now, fast.
 

morphonorconic

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I may have mis-worded what I meant to say. Let me clarify: Whether or not using Opioids with long(er) half live's for detoxifying/tapering a patient wishing to get clean is an American Ideal or not, it is a good idea IMO. Using Opioids like many of the ones you just named with short half lives, that also are among the most abused in the first place due to the euphoria they provide, for detoxing is playing with fire.

Now, however, in the case of strictly maintenence purposes, meaning for those who wish to maintain a long term regimen of one(or even two, I suppose) Opioid(s) in a controlled, supervised manner, I feel that there is absolutely no reason why patients should only be limited to Bupe and Methadone, seemingly, at least in the U.S. It seems silly when you think about it. When considering long term Opioid maintenence, there should be no reason that one Opioid would be better than the next.
 

Cane2theLeft

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Tchort- I'm going to be a drug counselor soon and will be working with a lot of opiate users/addicts... I see you write frequently about maintenance but what are your thoughts about detox/tapering? Do you think they are better options for detox/tapering purposes or like maintenance, do you think that basically any short or long acting opioid would be useful for this purpose?

Much to my surprise, one of professors didn't even know that buprenorphine is used commonly for maintenance, she thought it was almost only used for detox. Most of my professors and classmates are very anti-maintenance programs and its quite disheartening, I constantly hear "its trading one addiction for another" and all this 12-step, "you're not clean on methadone" bullshit.
 

Hammilton

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Wait, what country are you in? Using levorphanol in the US to treat addiction is more than a little illegal.
 

Tchort

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Tchort- I'm going to be a drug counselor soon and will be working with a lot of opiate users/addicts... I see you write frequently about maintenance but what are your thoughts about detox/tapering? Do you think they are better options for detox/tapering purposes or like maintenance, do you think that basically any short or long acting opioid would be useful for this purpose?

Much to my surprise, one of professors didn't even know that buprenorphine is used commonly for maintenance, she thought it was almost only used for detox. Most of my professors and classmates are very anti-maintenance programs and its quite disheartening, I constantly hear "its trading one addiction for another" and all this 12-step, "you're not clean on methadone" bullshit.

I am very happy to hear you are going to be a counselor for addicts- and that you have a very good idea of the actual situation regarding medical efficacy for different treatments and harm reduction.

It sounds like your peers and most likely professors are using rhetoric and ideology rather than science to back up their treatment goals and protocol/methodology.

My personal opinion with maintenance is that any opioid or combination of opioids can be used successfully if the appropriate dosing and RoA protocol is used (i.e. I fully support IV Heroin maintenance, the Dutch vaporizing Heroin maintenance where they provide freebase Heroin and a harm-reduction related smoking/vaporizing apparatus, etc, not just oral or extended release dosing, and so on).

I do think the same can be said of tapering. The reason I often recommend long half life opioids to people on BlueLight, especially those in the US, is that those are the only options they have.

I think that tapering, like maintenance, is successful only when the protocol is consistent. Meaning, you can't give someone oral Heroin once a day like you would Methadone in MMT, then say Heroin maintenance doesn't work when the patient gets withdrawals, or quits the program, etc.

Likewise, you cannot use short acting opioids in a way similar to long acting opioids in a taper aimed at detox. I am convinced that as far as personal comfort goes, a short acting opioid like Hydromorphone or Fentanyl, if given in minutely decreasing dosages with frequent dosing can result in just as if not a more comfortable detox taper than with the infrequent dosing of long half-life opioids with larger gaps in doses as you go down (i.e. in a 21 day period, a Methadone taper may go down 5 or 10 mg every day or two or three, whereas with a Hydromorphone taper, giving an injection every 4 to 6 hours with maybe 1/8 of a mg going down every second injection, or 1/4mg every two or three days, may be an equal protocol in terms of patient comfort).

So, I think any opioid can be used to taper comfortably, if appropriate doses, route of administration, and most importantly protocol is used. However, outside of very brave doctors doing so with individual patients, this doesn't happen in the US, it is illegal to do so.

Wait, what country are you in? Using levorphanol in the US to treat addiction is more than a little illegal.

Definitly. However, another poster here in OD awhile back claimed to be a doctor who used Oxycodone via OxyContin combined with Methadone to taper opioid addicts- however he did not use Oxycodone for the express purpose of treating narcotic addiction (which is illegal), he used it to treat 'pain', which is legal. Certainly a grey area, as there is nothing illegal about maintaining or detoxing a pain patient on opioids, and withdrawal is pain that can be treated with narcotic analgesics. Though the Feds have arrested doctors for much less, so it all comes down to if you get caught or not.
 

morphonorconic

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Hey Cane- Great news! The medical community can definitely benefit from some genuine smarts and common sense, via some(your) real visceral experience.


I want to add one more thing in regards to Opioid Maintenence and the drugs used for this purpose. Though I see no reason why one full agonist is no better than another full agonist, ie. Methadone compared to Opioid X, in the case of Maintenence only, I do see one huge reason why this could be potentially be unsuccesful. And as Tchort mentioned, it all comes down to Protocol, and more specifically, RULES.

If a serious addict was admitted into one of these maintenence programs that would provide consistent re-dosing of Morphine or DiacetylMorphine, or whatever, yet the addict is thorougly incapable of complete gratification, no matter what (amount)is offered by the clinic, what is to stop this addict from taking (back) to the streets for extra drugs? In a case like this, without strict testing and monitoring, a patient could take advantage of such a program with ease, which leads me to my next point: I feel there is a huge advantage to Mixed Agonist-Antagonist Opioids like Buprenorphine not only for Detox, but as well as for Maintenence, due to their pharmacology which does not allow any outside Opioids, so to speak, to be used to any substantial degree of effect. But I see no reason why Bupe, specifically the name brand Suboxone, should hold a monopoly over this concept, when there are others like Nalbuphine and Butorphanol that have the same or similar properties, that could be used to the same degree, and provide these patients with a greater array of options when it comes to long term maintenence. If used correctly, these Opioids are capable of providing the same desirable effects to the user as full agonists, while not allowing the recreational use of an illicitly obtained Opioid, unless A) the user ceases use of the Mixed Ag-Antag. long enough for a full agonist to work, or B) the user illicitly obtains another Mixed Ag-Antag. to use in addition to the prescribed Opioid, or C) the user stockpiles. But other than that, it simply seems like a good idea and a natural course of action to me.

Also, the addition of a full antagonist, such as Naloxone or Naltrexone, could further decrease the chances of abuse.
 

paranoid android

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But I see no reason why Bupe, specifically the name brand Suboxone, should hold a monopoly over this concept, when there are others like Nalbuphine and Butorphanol that have the same or similar properties, that could be used to the same degree, and provide these patients with a greater array of options when it comes to long term maintenence.

Both nalbuphine and butorphanol are kappa agonists/mu antagonists arent they? Therfor hardly anyone would take these over bupe or methadone i don't think because most people just don't seem to like the effects of these drugs even if they arent addicts.
 

Cane2theLeft

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Morph and Tchort, I truly appreciate the thoughtful and thorough responses. Bluelight has been a cornerstone of my education regarding harm reduction and keeps my pulse on the community so to speak. If it weren't for bluelight, and especially posters like the two of you, I definitely wouldn't have gone down this career path. I really hope to make some waves in the treatment community and challenge some conventions that from this angle, are doing more harm than good. Thanks again guys, and sorry to hijack the thread, OP.
 

Tchort

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Hey Cane- Great news! The medical community can definitely benefit from some genuine smarts and common sense, via some(your) real visceral experience.


I want to add one more thing in regards to Opioid Maintenence and the drugs used for this purpose. Though I see no reason why one full agonist is no better than another full agonist, ie. Methadone compared to Opioid X, in the case of Maintenence only, I do see one huge reason why this could be potentially be unsuccesful. And as Tchort mentioned, it all comes down to Protocol, and more specifically, RULES.

If a serious addict was admitted into one of these maintenence programs that would provide consistent re-dosing of Morphine or DiacetylMorphine, or whatever, yet the addict is thorougly incapable of complete gratification, no matter what (amount)is offered by the clinic, what is to stop this addict from taking (back) to the streets for extra drugs? In a case like this, without strict testing and monitoring, a patient could take advantage of such a program with ease, which leads me to my next point: I feel there is a huge advantage to Mixed Agonist-Antagonist Opioids like Buprenorphine not only for Detox, but as well as for Maintenence, due to their pharmacology which does not allow any outside Opioids, so to speak, to be used to any substantial degree of effect. But I see no reason why Bupe, specifically the name brand Suboxone, should hold a monopoly over this concept, when there are others like Nalbuphine and Butorphanol that have the same or similar properties, that could be used to the same degree, and provide these patients with a greater array of options when it comes to long term maintenence. If used correctly, these Opioids are capable of providing the same desirable effects to the user as full agonists, while not allowing the recreational use of an illicitly obtained Opioid, unless A) the user ceases use of the Mixed Ag-Antag. long enough for a full agonist to work, or B) the user illicitly obtains another Mixed Ag-Antag. to use in addition to the prescribed Opioid, or C) the user stockpiles. But other than that, it simply seems like a good idea and a natural course of action to me.

Also, the addition of a full antagonist, such as Naloxone or Naltrexone, could further decrease the chances of abuse.

In practice the Heroin maintenance clinics have proven a few things:

-When given access to an unlimited amount of Heroin to inject per shot up to 3 times a day, every addict eventually settles on a dose per shot and does not continue to increase their dose.

-Most Heroin maintenance patients do not wish to stay on Heroin maintenance indefinitly, or even for very long. A large percentage of Swiss Heroin Rx patients simply went back onto MMT after a year or two, a minority detoxed from IV Heroin with IV Heroin, and only a small minority wished for extended IV Heroin maintenance.

-Almost if not all addicts who participate in these studies stop using black market Heroin (as determined by blood/urine tests for AcetylCodeine, which is present in all black market Heroin available on earth at present)

-However, a large percentage of patients in Diamorphine IV Maintenance are poly-drug abusers, especially Amphetamines, Cocaine & Benzodiazepines.

I doubt such a population of Heroin addicts exist that could not find satisfaction with unlimited amounts of Heroin 3x a day, and be allowed to continue using other drugs at will- same could be said of Oxycodone, Methadone, Meperidine, Oxymorphone, Hydromorphone, etc primary abuse populations when given access to unlimited amounts of their DoC to ingest.

While I agree that it is certainly possible to use a partial agonist to maintain or detox an opioid addicted person, and in some cases may be particularly benficial (such as patients whose compulsion to use black market Heroin combined with extremely poor injecting technique and low hygeine standards puts them in an unusually high amount of danger), the use of partial agonists over full agonists has pretty much been tested: After MMT started up in the '60s, studies were done with Cyclazocine and Pentazocine throughout the '70s. The side effects of partial agonists (confusion, irritability, inability to feel 'held', insomnia, etc) seem to outweigh the benefits- until Buprenorphine was studied and found to have a modest side effect profile compared to earlier partial agonists, plus several very valuable benefits (long half-life, low overdose threshold, etc).

I don't think of maintenance programs as confinement, I think a patient should be able to choose their dose with input from nurses and counselors, but with the final say with the patient- along with what drug they wish to use for maintenance. I don't believe antagonists have a place in ORT maintenance- as deterrants or otherwise.
 
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