Archives for Pharmacology

Addiction

Buprenorphine’s Relationship with Traditional Recovery

Regular readers of my blog know that I believe buprenorphine is the most important development for treating addiction during my lifetime.  At the same time, my own recovery from opioid dependence began over 20 years ago, long before the use of buprenorphine.  I am grateful for the change in my perspective that occurred one desperate afternoon, when I first recognized the uselessness of ‘will power’ for stopping opioids.  I was one of the lucky...
Continue Reading

Pharmacology

Psych Treatment Gray Areas

I recently heard parts of a lecture by a healthcare provider (not a psychiatrist), who was speaking to a group of general practitioners about psychiatry.  She answered questions about the best approach for treating depression, anxiety, and other psychiatric disorders by relating anecdotes from her own experience and suggested by her favorite mentor.  “Add a little of this, and if that doesn’t work, try adding some of that” she said.  “Psych is all a gray area. ...
Continue Reading

Addiction

Drug Testing: Not Always the Whole Answer

A recent exchange with a reader:

I have been on buprenorphine for 5 yrs.  Recently my doctor stated that my u/a t looked like I have been ‘loading my meds.’  He said my levels where ‘backwards’ and that would happen if I took just a few doses just before my appt.   My doc had me come back in two weeks to go over my next u/a, and again it came back funky.  So my doc starts having...
Continue Reading

Buprenorphine

A Lesson in Side Effects Using Buprenorphine

We can now leave naloxone out of the discussion, and focus on the side effects of Suboxone that are caused by buprenorphine.

Side effects are symptoms caused by a given medication that are not part of the therapeutic benefit of that medication.  Whether a symptom is a side effect depends on the reason for taking the medication.  For example, decreased intestinal motility is the desired effect of opioids...
Continue Reading

Buprenorphine

Side Effects II

In my last post, I wrote about the work-up of a patient who experiences symptoms similar to opioid withdrawal that start about an hour after each dose of Suboxone.  We decided that the symptoms were signs of withdrawal— reduced activity of mu-opioid pathways—and that the symptoms were triggered by taking a daily dose of Suboxone (buprenorphine/naloxone).

Note that I wrote that the symptoms seemed to be caused by reduced mu activity, ...
Continue Reading

Buprenorphine

Side Effect Work-Up

I struggle with the length of my posts. I shoot for 1000 words—an amount of reading that most people can knock off in a typical trip to the bathroom--- but I find it difficult to limit posts to that size. So as I have done in the past, I will break this post into a couple of sections. In the first, I’ll lay the groundwork for investigating symptoms of withdrawal in...
Continue Reading

History

I Told You So

The FDA recently released a Drug Safety Announcement regarding the use of codeine in young children after tonsillectomy/adenoidectomy surgery for obstructive sleep apnea.  I was somewhat surprised to see a safety announcement on a medication that has been in use for decades, but the release underscores our improved knowledge of drug metabolism, and the broadening demographics of the United States.

Codeine has little activity at opioid receptors.  The analgesic effects of codeine...
Continue Reading

Addiction

Tolerate THIS

I recently accepted a young man as a patient who was addicted to hydrocodone (the opioid in Vicodin), prompting a discussion about treatment options for someone who hasn’t been using very long, and who hasn’t pushed his tolerance all that high.  Perhaps it will be informative to share my thought process when recommending or planning treatment in such cases.

In part one I’ll provide some background, and in a couple days I’ll follow up with a few more thoughts on the topic.

Most people who have struggled with opioids learn to pay attention to their tolerance level—i.e. the amount of opioid that must be taken each day to avoid withdrawal or to cause euphoria (the latter about 30% more than the former).  For someone addicted to opioids, the goal is to have a tolerance of ‘zero’—meaning that there is no withdrawal, even if the person takes nothing.

That zero tolerance level serves as a goal, making having a high tolerance a bad thing, and pushing tolerance lower a good thing.
Continue Reading

Buprenorphine

Treating Depression with Opioids?

I received this message today:
Hi, you probably answer this quite a bit. I've been depressed for as long as i can remember.

Ive been on the ssris, snris, amphetamines and methylphenadate but none of these have worked as well as opiates. (Certainly short term,I don't take for long periods of time). But have you ever used suboxone or oxymorphone for depression?
Depression is probably a broad term, for what may be multiple conditions. For example, some people become depressed almost as if it is part of their nature--- they will get episodes of depression even when everything in life is going well, in spite of good marriages, healthy children and an absence of significant baggage from the past-- at least baggage that is visible.

Other people will present with depression that has developed after a series of blows to their sense of self or self-worth--- after a health scare, job loss, divorce, death of a child, or perhaps from carrying around guilt or shame from abuse that occurred during their childhood.

Does it matter whether the depression is more like the first or the second category? I think so, but I have no proof that my perception is accurate. I will see different responses to medications by people with different types of depression, but I'm always challenging that perception, realizing how easy it is to be 'fooled by randomness', to copy a phrase from a book title.

In my experience, the second person is more likely to bounce back, providing the negative onslaught eventually stops. But the people in the first group are more difficult to treat, especially if the depression becomes part of how a person defines him or herself--- as it is very difficult to change self-perception.
Continue Reading

Addiction

Ceilings Revisited

A question was asked about the last post that warrants top billing:

"Buprenorphine acts similar to opioid agonists in lower doses, with the same addictive potential as oxycodone or heroin. In higher doses—doses above 8 mg or 8000 micrograms per day—the ‘ceiling effect' eliminates interest and cravings for the drug.”

I’m not sure I followed this. Can you explain more? What would you think about someone who is taking 1-2mg of Suboxone twice a day without a prescription, and says they want to stay on that dose once they find a prescriber? Are they better off on 8mg or more per day, or would it be ok for a prescriber to keep them at the lower dose? Is the answer the same if they hope to taper off the medication completely within a year (they don’t feel able to do this on their own right now, but hope to be able to when some life circumstances change). Thanks!

This gets a bit complicated, but I'll do my best.  A couple background issues;  buprenorphine has a 'ceiling' to its effect, meaning that beyond a certain dose, increases in dose do not cause greater opioid effect.  That is the mechanism for how buprenorphine blocks cravings. 
Continue Reading