Tramadol has unique properties in buprenorphine to

Buprenorphine Post
rickbennettmd
Posts: 90

Postby rickbennettmd » Mon Apr 11, 2016 10:02 am

I agree with the above comments.

My standard advice to patients with acute pain of moderate intensity is also to increase their Suboxone dosage by 4mg. Also, of course, NSAIDS are always recommended in these circumstances. A good friend of mine is a hospie director. I was surprised to learn from him that Tylenol can be used with these medications, such as ibuprophen, as well. He often has patients dose acetamenophen in between their Motrin doses.

I will note that Dr. Passer's suggestion of q6h for pain dosing is very welcome and helpful.

These complementary strategies suffice quite well for dental pain and procedures in my experience, as well.

Our next step "up" for treatment of pain as the pain becomes more severe, such as after more extensive surgeries than dental work, is to bite the bullet and covert patients to pure agonist analgesics. But this is certainly much less than ideal. There is the troublesome period when the mu blocking effect of buprenorphine remains very strong. And just as troublng is the administration of pure mu agonists to those we are treating for opiate dependence.

I know very lttle about Tramadol, and I have no personal experience in its use. However I am aware that it is in ways distinct from our traditional mu agonists. It differs not only chemically, but also in sensorium effect. It ultimately does not possess the full analgesic capacity that the tradtional mu opiates do.

As I posted, I have had patients report to me that they took Tramadol for analgesia without interrupting their Suboxone regimens and that, counterintuitively, it was indeed effective for their acute pain. That is, buprenorphine did not seem to interfere with the analgesic activity of this drug as much as one would ortherwise expect.

Of course,this is purely anecdotal with a very small sample size. Surely it is too good to be true. We very much need another tool to augment acute analgesia need in our patients with severe pain circumstances without having to resort to interrupting our MAT regimen. A tool other than a fentanyl drip, that is.

These spontaneous comments by patients thus have indeed gotten my attention.

Has anyone else had patients relate a similar experienc with this analgesic?

Richard Bennett

drpasser
Posts: 1404

Postby drpasser » Mon Apr 11, 2016 10:02 am

Exactly Dr. B.

What I often suggest for pts, let say for a planned dental procedure or other minor deal; is to take slightly less bupe for one or two days before hand. Then, take the amount skipped as extra for the day or two following the procedure, only with q 4 hr dosing for those one to two days.

Let say, a pt takes 12 mgs bupe/day-8 mgs AM and 4 mgs PM. For the day before the dentist, the pt takes 4 mgs BID. The day of or after, the pt takes 4 mgs QID. (16 mgs total).

That way, the pt can get by with the same number of tabs as Rxed, thus, not having the hassle of calling in more bupe to the pharmacy, avoiding having the pt run out. It also seems like, taking a slighly reduced dose before hand, sort of "primes the pump," if you will, so the next day-the bupe works better. Plus, the pt gets a little extra and thinks it makes sense and is a good idea.

Best,
Kevin

DrBallester
Posts: 84

Postby DrBallester » Mon Apr 11, 2016 10:02 am

The original concern was additional therapy for analgesia if I am interpreting the post accurately.

The history of buprenorphine is that it was first used IV in the hospital, usually by Anesthesia, later the sublingual dosing was used for MAT and analgesia.

We should avoid combining opiate agonists with agonist/antagonists, if a patient needs MAT and pain management, it makes more sense to adjust the dose of buprenorphine and dose it every 4-6 hours to benefit from the analgesic response.

drpasser
Posts: 1404

Postby drpasser » Mon Apr 11, 2016 10:02 am

Most say, the euphigenic properties dissipate after a few weeks.

Generally, I encourage my pts to take the fewest daily doses as possible; so as to help break the habit of taking something all the time.

I explain to my pts, you feel bad-you take a drug-you feel better; that's how you get addicted. Usually, I have pts split doses greater than 8 mgs/day.

I do not want my pts to "feel" their dose. Ideally, it should be like water, except for preventing cravings and wdrl sxs. Pts and their families say, the pt seems like they were, before ever starting drugs. The person's " good ole self," as they say here in Mizzippi :-)

Most pts eventually say that bupe makes them feel "normal" or "regular."

Best,
Kevin

Bruni
Posts: 49

Postby Bruni » Mon Apr 11, 2016 10:02 am

quote:
Originally posted by drpasser

For pain, bupe generally lasts 4-6 hrs. Splitting one's usual one time per day dose, can provide enhanced analgesia.



Most of my patients prefer to take the bupe TID, rather than QD or even BID. None of them so far has been able to be any more specific about the physical or mental effects they feel than to say that bupe 'seems to wear off after a few hours'. I have wondered if there was a short term euphoriant or anxiolytic effect with each dose. Anyone observations?

Bruni

mattkeene
Posts: 32

Postby mattkeene » Mon Apr 11, 2016 10:02 am

I have yet to encounter a dental procedure that cannon be managed by doing as described above:
- increase bup dose and take in 4 divided doses
- add 800 mg motrin TID.

From root canals, to wisdom teeth, to more complex extractions...this works as well as anything.

drpasser
Posts: 1404

Postby drpasser » Mon Apr 11, 2016 10:02 am

For pain, bupe generally lasts 4-6 hrs. Splitting one's usual one time per day dose, can provide enhanced analgesia.

:-)

entjwb
Posts: 180

Postby entjwb » Mon Apr 11, 2016 10:02 am

I have a patient that was on 11/2 strips Suboxone daily. She had a full mouth extraction. I increased to 1/2 q 6h. She also used 800mg Motrin q 6h X 2 days then stopped the Motrin. On day 10 she went back to 1 1/2 strips a day and did fine.

fishdoc
Posts: 111

Postby fishdoc » Mon Apr 11, 2016 10:02 am

I have treated 3-4 patients for tramadol addiction with buprenorphine. It is highly addictive, yet not much better than nsaids for pain. why use it?

I find that patients with acute post traumatic or surgical pain can divide their normal daily dose of buprenorphine into 4 equal doses and have excellent pain relief.

kcairns
Posts: 571

Postby kcairns » Mon Apr 11, 2016 10:02 am

Who would believe there is still no safe effective med for most people for chronic pain..I guarantee tramadol will accomplish Nada...nor does being sent for behavioral... Individual choice. We live w the pain or mess selves up more


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