Suboxone once a day for pain management ?

[allaboutmary]

I read in another post that it's important for addicts to take their Sub only once a day.  I understand the reason for this, but is it prescribed differently if your taking it to manage pain now ?  I take about 1mg in the morning and can get about 5 hours of work done. About 12-1 in the afternoon, I must lay down with a heat pack, and the rest of my day is pretty much wasted. Do you think it would be better to split my dose and take it twice or should my one dose be upped so it gets me through the day ?
(I was put on Sub a year ago for addiction, but remain on it for pain management)

I also wanted thank the doctors on this forum. Your posts are very helpful.
Thanks again,
Mary

[J T Junig, MD PhD]

As I have mentioned before, I do use Suboxone to treat chronic pain--  I have had more and more area pain clinics refer patients to me, asking that I help convert the patients who are struggling with opiates to Suboxone (i.e. the patients who run out early every month;  who are always 'losing' their meds and asking for more, etc).

As you mention, the original instructions for the use of Suboxone for opiate dependence included dosing only once per day;  I am a real 'stickler' on that point and regret that this part of the instructions is so often ignored.  That said, I struggle with this issue with the pain patients.  Most of my pain patients insist that Suboxone gives them more relief if they can take that second dose late in the day;  I don't argue the issue as much as I used to, but rather I simply let them take it that way.  Knowing the long half-life for buprenorphine, I have to think that the relief is 'psychological'-- in essence a placebo response.  With addiction, that is part of the addictive cycle-- the need to take something to feel better... but in pain management, a placebo response is a GOOD thing, not a bad thing.  If a person can take something and feel like it makes their pain go away, what good am I doing, convincing them that their pain isn't REALLY going away?!

BUT... In your specific case, allaboutmary, things are a bit different   My comments apply to cases where a person is taking a dose above the 'ceiling' dose of about 4 mg.  If a person is taking 8-16 mg in the morning, his/her mu receptors are fully blocked-- that is why a second dose late in the day has nothing to offer as far as additional opiate effect.  But YOU are taking only 1 mg-- and at doses below the ceiling dose, the dose-response curve for buprenorphine is a straight line.  This is an important point to understand, because it is at the heart of the issue of why buprenorphine is different from opiate agonists like methadone, which have linear dose/response 'curves' throughout their dose range.  

When you plot out dose on the x axis and response on the y axis, and plot out buprenorphine, you get a diagonal line going up and to the right until a dose of 2-4 mg;  at that point the line flattens out to become parallel to the x axis (hopefully everyone took geometry in high school!).  If a person takes 16 mg in the morning, as the blood level decreases slightly over the next 24 hours the opiate effect remains constant-- no loss of opiate effect means no cravings.  On the other hand, a dose of 1 mg is on the diagonal part of the line.  At this dose, buprenorphine behaves and 'feels' much more like an agonist than a partial agonist.  This is why, by the way, people who abuse Suboxone tend to do poorly;  they tend to 'chip' the tablet 'as needed';  they are staying in the diagonal part of the dose/response curve, and they might as well be using vicodin or oxycodone, as that is how the buprenorphine is working at that dose!

Back to the case at hand...  with a dose of 1 mg, I would expect you to have an effect similar to the effect of taking methadone, where the effect would tend to wear off over time.  I would expect a dose in that range to need to be repeated at least a couple times, to cover an entire day.  I don't want to get too specific with recommendations as I want you to talk to your doctor, but that 4 mg dose is an important thing to be aware of, as buprenorphine and Suboxone become a different drug at doses beyond that level.  Below that level, a person will continue to have cravings, because as the buprenorphine is metabolized the opiate effect decreases.  If a person on that low dose complained of cravings, the correct response would be to increase to a higher dose taken once per day-- say 8 mg or so.  The downside to that is that you would then have constant stimulation of the receptors, resulting in rapid tolerance to the buprenorphine-- although people tend to continue to claim pain relief even after becoming tolerant to the psychic effects of the drug.  The benefit of going to a higher dose would be the reduction in cravings, and the more level opiate effects throughout the day.

I hope this was clear-- it is a bit hard to grasp initially, but once a person understands the 'ceiling effect', the reason that buprenorphine is so 'different' becomes clear.  I have mentioned this before, but it is very interesting to go to clinicaltrials.gov and search under 'buprenorphine'.  If you do that you will get a sense for my excitement for the medication.  Not so much for my own 'business', although I may get an extra pain patient or two... but rather because my first education was in neurochemistry, and I find it fascinating when the unique properties of a chemical are recognized and applied in new ways.

Thank you for your question,

JJ

[flmagi]

Dr. J,
What are the dangers of a person doing Coke while on Suboxone? I know there are dangers doing Coke by itself, but are they increased while doing Sub?  This involves sister #3, not myself. I would like to be able to give her some real info on the danger she's dealing with.

[J T Junig, MD PhD]

Thank you for the feedback.  Yes-- it is a useful medication, but not immune to abuse.  The good news is that it is more difficult to die from abusing Suboxone than from a pure opiate-- although adding a benzodiazepine or alcohol can be dangerous.

Take care, and I wish you a Happy New Year--

JJ

[flmagi]

Great answer Dr. J. This does answer a lot of questions.
AllAboutmary  and I are sisters, we also have another sister, all 3 of us are on Sub, but at different doses.
Mary at 1 mg once a day, myself at approx. 5mgs once a day and the other sister, maybe at 4-5 mgs daily, but takes little bits at her sub, when ever she "feels the need".
And you've pointed out, as we've suspected, sister #3 is using the Sub just like she did the pain pills.
Thanks again for the info.

[allaboutmary]

Thank you so much. This even answered some other questions I had about my sister's Suboxone use.