Opiate managment and half life taper.

[blightcp]

I worked this out for my own benefit, but it may be helpful to others.

I find that I have to balance my opiates if I need to go out especially driving. I have been on opiates for almost 6 years and it took a couple months for me to feel like I could drive on opiates.

Do not drive if you are taking a new dose or are feeling ANY effects of the medication, prescription medication is still a DUI and not worth it. I recommend making a log and figuring out EXACTLY what dosage schedule work for you, and then have someone with you and try driving in short trips.

I also laminate the stubs from the pharmacy and keep them in my wallet, in case they find my bottle of pills with me.

I also found this chart very helpful in dealing with the pain clinic, It showed them that I was aware of the nature of the drugs and that i was trying to be proactive and responsible with what they gave me.

all of the numbers I used were from:

http://en.wikipedia.org/wiki/Equianalgesic

There are three big factors to pain opiates. Strength, Duration (half-life), and absorption (Bio-availability)

Strength is compared to 10mg of morphine orally administered and that has a value of 1, this is the reference for comparison to other drugs.

Duration (half-life) This is how long it takes for your metabolism to process 50% of the drug and take it out of your system. So at one half-life you would have 50% and at two half-life(s) 25% and at three you only have 12.5% this does very some from person to person.

Bio-availability is how much of the medicine you body can absorb through the small intestine.

From my experience, I color coded the times that:

GREEN: I function best while keeping them between 50% and up

YELLOW: I need to keep my doseage above 25% otherwise I will have to assume the PN fetal position and wait for the meds to kick back in.




As you can see Hydrocodone is by far the most flexible, even tough I use Oxy as my primary med, I switch to hydrocodone on the days I need go out on.

[Cora]

Just curious to know with being on opiates that long if you have not had issues with needing escalating doses or any problems with
"between dose withdrawal symptoms".
Cora

[stephanies]

Hi Cora,

I have been on low dose morphine sulfate er off and on (mostly on) since September 2007. I am going to try soon to get off for a final time. I need to wait to see my doctor to switch to short acting and then taper down. I never increased my dose and the side effect of some constipation was helpful for my pain.

My best to you,
Stephanies

[ezer]

Hi Stephanie,
It is extremely difficult to taper off using short term opiates. The relapse rate is something like 58% in the first week. It gives you constant ups and downs that are more and more bothersome as you get down to low doses. The current trend is to use Buprenorphine (Suboxone, Subutex), a very long acting opiate that does not give you any "high". You can then manage your taper fairly comfortably.
It is the route I chose. I tapered off in 8 weeks. I was surprised to have lingering post withdrawal symptoms for close to 2 months however (restless, insomnia, strange sensations). No matter what route you choose, your body has to produce endorphins again and that can take a while.

[stephanies]

Thank you Ezer.

My doctor seems to think it is no big deal to just stop since the dose is so low. I take one pill at 8 AM and one at 8 PM each day. Her strategy in the past has been to just skip one pill entirely every 48 hours for a couple weeks, then start skipping evey other pill, etc. The withdrawal effect kicks in quickly and badly right after the first skipped pill. In the past, I increased the time between the doses until I could stop entirely, but this took a long time and was still agonizing. My doc was surprised at the difficulty I had and suggested switching to the the short acting and then weaning, saying there would be no effects. I will try to get her on board with what you have suggested. I would have liked to have done this months ago but I keep putting it off because I am dreading the withdrawal process.

Sincerely,
Stephanies

[ezer]

Hi Stephanie,
I am afraid, I strongly disagree with your doctor. It is a big deal discontinuing short acting opiates. I could not stop my low dose of Percocet that I never abused (I had been on opiates for 8 years). I went to see an addiction specialist that also confirmed that it is quasi impossible to discontinue short acting opiates taken long term and especially not relapse within a year.

Once you have stopped, you are far from done. You have to deal with post withdrawal symptoms (PAWS) for up to 6 months. During that period, the temptation to go back is very strong.

Buprenorphine that does not give you any highs allows you to slowly taper without those terrible cravings. Buprenorphine is highly controlled in the US and only trained addiction specialists can prescribe it. It is a bit of a mystery why because it is quite safe (it has a ceiling effect) but it is a newer opiate so the DEA got involved.

Your doctor is probably not licensed to prescribe Buprenorphine. There are several sites that list addiction specialists that are approved by the DEA to prescribe Buprenorphine (Subutex, Absolv, Suboxone). Theoretically a non addiction doctor could prescribe legally Suboxone, Subutex off-label for pain but few are willing to do it from what I have read.

[stephanies]

Thank you again. Like you, I have never abused the medication and I am not interested in any type of high. I just want to manage the withdrawal symptoms that are so awful. I will look into an addiction specialist as that sounds like the way to go.

Stephanies

[ezer]

I think it is a good idea. A bit of warning though. Not all addiction specialists are ethical. You need to do some checking. They do not make much money if all you want is to taper off and quit. So there are many cases of people in our situation that were mislead into staying on Subuxone on a maintenance program. It guarantees the doctor a monthly visit to prescribe refills ad eternum. I have read cases of people that switched from low to moderate doses of short acting opiates to mega doses of Suboxone. They simply traded an addiction for another one.

Maintenance programs on Suboxone are great for people that are suffering from addiction to various substances. It allows them to go on Suboxone and have a normal active life without any urge to take illegal substances.
That is certainly not our case so you have to be very clear about your goal which is to stop opiates now. That is the other use of Suboxone that allows a slow and comfortable taper without highs, lows, and cravings.

[Violet M]

Thanks for the info, Blight. I was not aware you could get a DUI while on opiates but it certainly makes sense. It sounds like you have your schedule down to to a science. I think Cora had made a post in the past explaining why patients do not develop a tolerance that requires increasing your opitate dose when you take buprenorphine.

Now, what I wanted to say about the ingredient buprenorphine, is that it is now out in a patch form and it has different properties in the way it only partially attaches to opiate receptors and I guess that means for us that there is less tolerance and escalating doses.

Ezer, it's good to hear that you have been able to go off opiates. I would be interested in hearing an update on your progress and how you managed to get your pain levels low enough to taper off opiates.

Violet

[Cora]

One thing I want to clarify regarding Buprenorphine ( aka Subutex) is that it actually is legal to prescribe it for pain. IT is the identical drug in the Butrans patch. What one needs to understand that if it is prescribed for opiate dependency, that is when doctors need to go through specific training, and they are only allowed to take on a certain number of patients at a time. However, and this is very important, it is totally legal for a pain doctor or actually an doctor who will work with pain patients, to prescribe it under the diagnosis of chronic pain. Many doctors in the U.S. especially, are unwilling to prescribe it because of it's reputation as being used for detox. Dr.s will often tell their patients that the "cannot legally prescribe" this medication, but it is not true. Ultimately, if one is on long-term opioid treatment it makes way more sense and it's much safe to be on this drug than long-term use of short-acting opiates. If you google Buprenorphine for chronic pain on a scholarly google search you will see quite a bit of literature on it's use for chronic pain, but again, it's more a lack of interest on the part of doctors to take it on. It's not because they legally cannot use it for chronic pain. The Butrans patch is likely not a strong enough dose for most patients who have been on opiates for a long time that is why the sublingual form is more appropriate. In addition, when you look at conversion charts, be mindful that when taking the sublingual form the bioavailability is quite low- one only absorbs about 25-30%. So if you do decide to transition from oral opiates to the Subligual Buprenorphine, it's not uncommon for a short time to be taking upwards of 16mg a day but that would be just until you got your dose adjusted. In talking with some educated pain docs on this topic, a typical dose for pain patients who are stable is about 3 to 4 mg two to three times a day. I explained in a previous post a long time ago that the key to this drug is that it is called a partial agonist and drugs like Vicodin, Morphine, Percocet are called full agonists. It's complicated but what it means in lay terms is that a partial agonist always leaves some opiate receptors open and when they are open and not fully saturated, it means that you won't need escalating doses. You'll still get the same pain management effect, no euphoria, and no need for higher and higher dosing.