I know in the past there has been a lot of confusion about doctors prescribing Sub for pain. I have heard directly opposite information from members on this board and have been told different things by doctors. Some have said that only doctors with the extra hours of training for dependency and special DEA number can prescribe Sub. Some have said that any doctor can write a prescription for Sub if it is written for off-label reasons, like to treat pain. Well, I had an appointment with my neurologist yesterday. I asked him what the truth about Sub prescribing was. He was actually man enough to admit he didn't know. He then went online with me to the Suboxone website. He could not find the answer on the website, so he called the hotline number for physicians. The "official" answer, as far as DEA regulations, is that ANY physician can prescribe Suboxone/Subutex for any off-label use, such as chronic pain. It is only if the doctor is treating drug abuse that they need the additional training and special DEA number. I hope this finally answers this question for everyone. Long story short, if you ask your doctor to try Suboxone/Subutex for chronic pain and they say the con not prescribe it, they are either misinformed or lying. I hope this helps someone. I am glad my doctor is open minded enough to admit he is not all-knowing.

Thanks for the info. I had a conversation with my pain doctor regarding Suboxone and the big argument he gave was that it would increase my tolerance for other medications I may take and end up doing more harm than good.

He might be right, if it was a high dose. I think were the problem comes in is if the dotor uses the dosage recomendations on the website. Those are for people with abuse issues. If he started you off at a much smaller dose, it should be like any other narcotic. The recomended 2mg-32mg doses are huge for a reason. They block out other narcotics to prevent abuse. That is just overkill for pain treatment. Your doctor needs to find a conversion table for what you are currently on. I'm pretty sure it is like most narcotics. For example, if you were going to switch from a low daily dose of hydro to methadone, and your doctor put you on a huge amount of methadone, your tolerance would increase. But, if he put you on a equivalent dose, it should not increase much. This is about the time Nephro should get invovled in this conversation and explain what I am trying to say much better than I am saying it

Most sources seem to agree that 0.3mg of buprenorphine is about equivalent to 10mg of morphine, although some lists have it at twice that amount. The usual starting dose for a pain patient who hasn't been on strong opioids before is around 0.2 - 0.4mg, titrating upwards as necessary. Seem people find that is enough, but some need more, anywhere up to a milligram or so at a time. In these small analgesic dosages it behaves pretty much as a pure mu opioid receptor agonist, and it can still be used along with other opioid analgesics providing the doses are kept within a reasonable range.

It's a pity you can't get Temgesic or the various buprenorphine patches for pain relief in the States. It must be difficult trying to break off a bit of a Suboxone tablet in order to get a low dose (e.g. 0.2 - 0.4mg) - unless you need 1mg, in which case you could just break them in half (assuming they are scored).

That is good to know. Do you have any documentation? My doctor was trying to find a equivalency chart for bupre, but wasn't able to find one while I was there. Thanks!

I have some charts in books comparing sublingual buprenorphine with other opioids, but have only been able to find info comparing the transdermal patches so far online. The 'Palliative Care Formulary' (UK) has some interesting information on buprenorphine and suggests multiplying the amount of the drug by 60 to arrive at an equivalent dose of morphine. Other sources I've seen list it as anything from 30-40x. It does mention in the Palliative Care Formulary that the analgesic ceiling dose for buprenorphine is about 8-10mg in 24 hours. It also says that "in low doses, buprenorphine and morphine are additive in their effects; at very high doses of buprenorphine (>10mg/24hr?) antagonism could theoretically occur. However, with typical doses, it is possible to switch either way between buprenorphine and morphine (or other mu-opioid receptor agonist).

Hope that helps!

yes, you can use bupe with other opiates up to a certain dosage. its mainly the naloxone that keeps you from taking other opiates in the suboxone preparations.

It's nothing to do with the naloxone because it does not get absorbed sublingually to any clinically significant degree. Buprenorphine is a mixed agonist/antagonist, and at high doses it becomes more antagonistic. It is the buprenorphine itself that blocks the effects of other opioids taken whilst on Suboxone or Subutex.

The naloxone is included to deter abuse by injection.

I have a couple suboxone. I take perc 5s and norcos daily, but need oxy daily too. I just ran out and will be for two days ( I hope only). What would happen if I took the suboxone to get through it? Can I or will it have adverse affect while still taking the lower doses of norco and perc 5s while waiting for the OC? Any advice is greatly appreciated. I dont't want to make things worse than they will already be. Thank you

If you are still taking the hydrocodone and oxycodone, once you take the Suboxone you will be immediately thrown into withdrawals like nothing you've ever encountered before.
Really bad idea. You should just wait to fill your OxyContin prescription.
You're fortunate that you have the additional opiates to use in the meantime.

there is a certain way you can take both. like suboxone before the opiate pills or the other way around, I can't remember and its not worth the risk.

just save your suboxone for when you have NOTHING. and then, you'll want to wait until your withdrawals start and once you take it, I wouldn't touch any opiates until the next day.

Thanks for the responses. That's what I'll do. Better safe than sorry. Still hurting though. Hope my order makes it soon. Thanks again to both. Martind-definitely don't want what you said would happen. Close call. Thanks for saving me additional hell-can I say that? Additional heck just doesn't have the same affect

It would really depend on how much of either drug is being taken. It is perfectly safe to take buprenorphine with other mu agonist opioids within therapeutic analgesic dosages. With higher doses it becomes less certain.

yes, bupe is fine. but the naloxone thats in suboxone is what will make you go into withdrawls. now, if you can get your hands on subutex. thats a little better. but at higher doses it does act like methadone and will keep other opiates from reaching their destination.

DeeRocks,

The naloxone is to stop people from IV injection. Bupe comes with or without naloxone and both cause the withdrawl issue.

http://www.drugbuyers.com/freeboard/ubbthreads.php/topics/955499/nephro#Post955499

Again, it has nothing to do with naloxone. It is not absorbed to any significant clinical degree when taken sublingually.

It is important to understand that buprenorphine IN ITSELF is an agonist/antagonist in high doses, and the higher the dose, the more antagonist effect it will have.

Milvus is correct in saying that Temgesic doses can be usually regarded as mu-agonists, and may be tried if necessary without inducing significant withdrawal. Not many people have done this before and reported back, so you'd have to break the Suboxone into 0.2mg - 0.4mg doses pretty accurately.

I only take Tramadol and the occasional muscle relaxant with my Temgesic these days. I have taken codeine and dihydrocodeine with Temgesic (both within analgesic dose ranges) before and have never had any problems. I don't know at what precise dosage buprenorphine causes antagonism, but the Palliative Care Formulary suggests over 8-10mg in a day could, theoretically, cause problems. Personally, I wouldn't risk taking even half of that - I am only taking a relatively small amount (1-2mg a day). The information sheet that accompanies my regular Temgesic prescription states that it is safe to take it with other mu receptor agonists, but warns that problems could occur for those already dependent on higher doses of another opioid.

The naloxone has no significant effect sublingually - as Nephro said, it's to discourage abuse by other routes.

While the questions about buprenorphine interaction with other opioids sometimes get complicated, it is really not confusing if you think about it this way.
If you are actively taking opioids such as hydrocodone, oxycodone, methadone, etc. and ingest even a relatively small dose of bupe, the chances are very good that a discontinuation syndrome would result. Exactly what bupe dose would cause that is difficult to estimate but I have heard of Temgesic doses causing withdrawals in this scenario.
Once bupe is initiated, if the doses are kept low, other opioids can also be used concurrently for pain control. At higher doses, the bupe will effectively block the other analgesics and you are wasting money. The majority of overdose deaths involving bupreorphine occur when the user tries to overide the bupe with higher opiate doses until breathing ceases.