duration of treatment with buprenorphine

Buprenorphine Post
drpasser
Posts: 1404

Postby drpasser » Mon Mar 17, 2014 11:24 am

It does seem, as though the most recruitment relative to Dopamine system enhancement works best, at buproprion doses of 450 mgs/day, which is the maximum recommended dose.

I've read where 50% more Dopamine activity occurs at doses of 450/day, compared with 300/day. Doses of 600/day, can have 50% more seizure activity, which is why I push for 450/day, but not higher than that.

Best
Kevin

Dave
Posts: 187

Postby Dave » Mon Mar 17, 2014 11:24 am

Dr. Passer, thank you very much for your detailed reply. I was thinking only of using bupropion in those people who succeeded in getting past the withdrawal phase with clonidine, yet still have a feeling of being unwell or not normal.

drpasser
Posts: 1404

Postby drpasser » Mon Mar 17, 2014 11:24 am

Yes, buproprion does help, or appears to help some.
For example, I had a pt, who could never get below 8 mgs per day. I tried 6/8 QOD. I tried 6 mgs for two days in row, and then 8mg q 3rd day. Every time I tried 6 q day, he would become fatigued with constant yawning.

I went back up to 8/day, started buproprion SR, 150 q day for two weeks, then 300/day. After about another month, I was able to go down to 6/day with him, and his fatigue and yawning did not reoccur.

Still stuck at 6 mgs q day with him. So, I guess it was partially successful. He wants to taper off completely, but now, cannot seem to get down to 4 mgs/day.

Otherwise, I think clonidine works better for WDRL. I try and use the Catapress TTS # 1, to skin with a new patch q 5 days, as it usually doesn't last an entire week.

Buproprion, in theory should work better than it does.

Dave
Posts: 187

Postby Dave » Mon Mar 17, 2014 11:24 am

Dr. Passer, A long time ago you mentioned Welbutrin as the only antidepressant that increases dopamine in the brain, which may help the patient who has gone through withdrawal and now still does not feel "normal". Have you actually tried Welbutrin for this purpose and does it really work to improve the mental state? I have some patients who are getting to that stage and I was wondering if I could try this if need be.

drpasser
Posts: 1404

Postby drpasser » Mon Mar 17, 2014 11:24 am

I do not decide it's time. I ask pts every visit, whether they would like to reduce their dose. Often, when I do think it is time, I offer a very slight taper. Like, for pts on 8 mgs or bupe/day; I might suggest 8 mgs alternating daily with 6 mgs. (which averages out to 7 mgs/day)

And yes, some pts, especially after a while, do come in requesting to taper. It's like, now they are finally ready to get off of it.

I am very reluctant to push it, as if the pt relapsed and died, well-............

BTW-I have had pts die. Not because of tapering, but just due to relapse. Both were young. I attended the funeral.

I explain, or try to anyway, that just like one had to increase their dose of opiates over time due to tolerance, the same thing has to happen to get off of bupe. One does need to lower the dose, then wait, then repeat.

It is more difficult to taper off very small doses completely. It's generally easier for pts, over time, to decrease from say, 16 mgs/day to 2 to 4 mgs per; than it is to go from 2 mgs/day to zero.

Those last little bits can be a BEAR.

Best
KP

deegee
Posts: 137

Postby deegee » Mon Mar 17, 2014 11:24 am

In my experience, it's a rare patient that brings up the topic of tapering (other than as a stated goal at the initial appointment). So, I find that if I raise the topic, it creates enormous anxiety (even though I explain that it could take a year just to taper slowly).
I'd be interested in how people go about tapering. Do you decide it's time? Do you decide that your patient is ready? Or do you ask the pt to let you know and wait for the go ahead (assuming the patient is actively participating in recovery and not just clocking time).
Thanks.

drpasser
Posts: 1404

Postby drpasser » Mon Mar 17, 2014 11:24 am

So,of course, the duration of tx is based on many factors, which IMO include:

The length of time the pt abused opiates
The daily dose/peak doses
The potency of the opiate
The route of administration, IV vs IN vs PO
Family Hx

plus:
if the pt has underlying problems with depression, anxiety and pain.

In general, it often seems to be about half the amount of time the pt was opiate dependent. That is very ball park. A longer duration is often the case, for older pts with chronic pain and with decades of opiate use. For such pts, and I have a few over 60, the duration of tx will probably be lifelong at that point.

If underlying problems with anxiety d/o and depressive d/o, it can be quite difficult to completely taper the pt, if the depression/anxiety are not controlled.

Best
Kevin

kcairns
Posts: 571

Postby kcairns » Mon Mar 17, 2014 11:24 am

McChaplin,always nice talkin w you...not easy stuff.. humans are destroying the world over own/opposite beliefs of what is right thing, ...as dave says wisely on another thread right for one is to put the mussels back in the bay and for another right thing is to eatum... i much respect the 100% great people on this forum including those whose right thing on this issue is different from mine...to me tho what is clear are the data...which imo give us a clear choice of paths either toward pureness or toward livingness...and i know i do get impassioned by the controlling forces in this field, high above our little forum which powerfully fight OMT and powerfully force clients into "TREATMENT"/"JAIL-COLD TURKEY OFF MED" when data clearly show high rate of OD right upon exiting those -- ie wrongful deaths imo ...above all tho thank you especially for closing words of your last post, above , which i find to be in the service of life and of our individual survival in the service of doing this painful/rewarding work...kinda like in the advice of joseph campbell...."participate joyfully (and i would add, strongly) in this world of sorrows" ...to do our best ...and also ...to win ...not meaning to win our own "right thing" over someone else' "right thing" ...but to win...for our own patients...life ....and if we believe in them ...their life lived in their own conception of what a right life is for them...and if they wish us to help guide and we can ...all the more fun for all

MChaplin
Posts: 183

Postby MChaplin » Mon Mar 17, 2014 11:24 am

Thanks Ken- you nailed it- it really is too much sometimes and i love your words of wisdom- "it is not about an occassional positive uds...bup is working for the person who is alive and ....capable of doing the work that they have to do in life". You did not flinch from the cold hard reality of doing this kind of work- we must be advocates for saving lives without judgement. ON the other thread i asked how to know what is the right thing to do- perhaps we know we are choosing to do the right thing when we do the best we can with the tools and talents we have available...M.

kcairns
Posts: 571

Postby kcairns » Mon Mar 17, 2014 11:24 am

McChaplin...it really is just too much isnt it?...your are deeply compassionate and highly on top of your game...and you will hurt and you will incorrectly blame yourself, long and much as i and we all do... but - read your first two posts on this thread, you have stated it all exactly correctly...except - that - it is not necessay for us to wait to review all our own results to know what to do --it is long proved...as for example what Mary Jane Kreek simply states...nonmedication treatment works for 10-20% and fails for 80-90% and medication treatment works for 80-90%...it is long proved that in opiooid addcition medication added to nonmedication therapy decreases deaths by 75%... this is THE ONE issue of opioid addiction treatment --it is about keeping people alive and and allowing them to make their lives work for themselves ...it is not about an occasional pos uds...who bup is working for is the person who is alive and getting up in the am capable of doing the work they have to do in life...the same conclusion you reach in different words in your first 2 posts....but we get beat and beat w this thing of putting this and that ahead of the importance of having a person be alive and dealing w their life in ok way for them...it is not your fault, you knew but we who know these things end up appeasing others in order not to appear unreasonalble all the time...and -- as a nation -- i no longer say "we" to inlcude me and the nation, ....sadly i have to divorce myself from we-ness w such punitive preponderant life view...but so gladly i live as much as i can in solidarity w earths wonderful voiceless majority that they may remain strong before their enemies including opioid addiction - the "painkiller" component of this worldwide plague having in fact been greedly unleashed for profit by the powers that be in this nation Chris Hedges writes, of "...the hope that allows human beings to cope with inevitable despair and suffering, in the healing solidarity of kindness, compassion and selfsacrifice, especially when this compassion allows us to reach out to others, and not only others like us, but those defined by our communities as strangers, as outcasts"... ... the "we' of we who do the work of real addcition care are blessed to be able to choose, instead of sadness, a glorious healing powerfulness based on our unique and earned ability to define and to effect...to me this is meta-addiction care , a component of meta-life care


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