Belbuca, Suboxone, and a mini-rant about their underusage

11 replies [Last post]
gtrplayer
User offline. Last seen 1 week 3 days ago. Offline
Moderator
Posts: 2934

I am posting this in the "new medicines" forum because it seems not many people have heard of Belbuca. For those who are not aware, Belbuca is a buprenorphine only drug that is administered the same way Suboxone films are. However; the doseages are astronomically low. From the Belbuca website, the drug comes in 75micrograms (hereafter, mcgs), 150mcg, 300mcg, 450mcg, 600mcg, 700mcg, and 900mcg. Belbuca, unlike Suboxone, is FDA approved for the treatment of chronic pain requiring around the clock dosing. The only other buprenorphine drug that has FDA approval for pain is the Butrans Transdermal Patch, with dosages of 5mcg, 7.5mcg, 10mcg, and 20mcg/hour to be worn for seven days. To me, this is a setup for failure when patients are asked whether or not these drugs helped their pain. 

I was on Suboxone, 8mg/2mg films 3 times daily for pain management, and it was the best I ever felt in my life. After that doctor's office kicked me out for continuing to take my psychiatrist prescribed Klonopin, I have had to be placed back on 7.5mg hydrocodone, and the pain relief simply is not there. Prior to being put back on the hydrocodone, the dr did try Butrans, and it was a horrible experience. Maybe it was my Dr, maybe it was my high expectations of the drug due to my success with Suboxone. Regardless, it was a complete failure of a drug. 

The thing that really upsets me is that, in other countries outside of the US, buprenorphine has been an analgesic used in pain for years. As a matter of fact, Suboxone was initially developed during the "make an abuse resistant opioid" phase that pharmaceutical companies went through, and ultimately, it was deemed to be a better opiate replacement drug than it was a painkiller. However; regardless of where you look online, includine medical journals, you will not find the actual study itself. I was fortunate enough to read the articleAll while Suboxone was still in it's infancy, and Reckett-Benckiser was it's manufacturer. What happened with Suboxone is nothing new. Anyone who remembers the early days of Viagra should remember that the drug was trialed as a pulmonary hypertension drug, but was later marketed as an erectile dysfunction drug after patients reported they were obtaining erections that they previously could not achieve. So, we went somewhere along the lines of 5 or 6 years with Viagra being exclusively used, on-label, for ED. My grandmother had to take it for pulmonary hypertension, and it was an absolute Godsend for her, and may have even prolonged her life by many years. After the ED market cooled off, along comes a brand new drug, Revatio, made by Pfizer, and contained the exact same ingredients, in different strengths, as Viagra.

Pharmaceutical business is an absolute racket. Right now, there are three buprenorphine/naloxone combination products on the market that absolutely should be used in pain management for select individuals. Those drugs are Suboxone, Bunavail, and Zubsolv.  Every one of those medications listed contain buprenorphine in milligram strengths, not micrograms. I have heard some claim that these drugs are not ideal for pain management because of the naloxone. Well, the naloxone is negligible and has no effect when taken as directed and not tampered with. One other thing I do not understand is why the drugs that are approved for pain management contain 1/1000th of the strength of their naloxone containing counterparts. Do you really want to give a recovering addict more of a drug than necessary. It seems like backwards thinking to give someone with a known history of abusing narcotics a higher dose of a narcotic than you would give the legitimate chronic pain patient. Perhaps I am missing something, but I have searched all over and can find nothing that makes any sense to me regarding the disparity in dosage formulations.

One thing that I have heard is that "less is more" with buprenorphine. Well, that's BS. There is never a time where less is more. Giving a pain patient an absurdly low dose of buprenorphine and expecting them to achieve pain relief is illogical thinking. When taken by itself, as in, not mixed with benzodiazepines, Suboxone is a much safer drug than many of the pain relief drugs on the market today. The overdose deaths that I have read about that were the result of Suboxone ingestion always included at least one of the following: 1. a benzodiazepine taken by the victim that was not prescribed to him/her, and the dr did not know about the patient's bzo abuse. 2. The victim who overdosed from Suboxone was not actually prescribed Suboxone, but received it from a friend, and 3. The Suboxone patient was found to have alcohol in their system as well as Suboxone. 

With all the above being said; I still feel that simply because a patient is on a benzodiazepine should not preclude them from being on Suboxone. A patient's history should be looked at prior to prescribing Suboxone, and the dr should know whether or not the patient has been on a benzodiazepine medication long enough to be accustomed to it, and should be able to mitigate the risk of overdose from ingesting both substances. I am not saying that accidental overdeaths do not occur. In fact, when I first started taking Suboxone, I did not take my Xanax XR for three days because I felt as though I did not need it since the pain was controlled. When I did resume taking it, I only took 1 tablet per day, instead of the two I normally took. Simple common sense can save lives, people. 

I'm just frustrated as heck right now. I'm getting no relief from my current medication, and can not find a pain doctor who treats pain with Suboxone in Indiana, aside from the one I was kicked out of. Yet, online, I see many people post that they are taking Suboxone/Zubsolv/Bunavail for pain, and it just burns my backside. If anyone out there is from Indiana, and knows of a pain doctor who treats pain with Suboxone, feel free to PM me. I never, ever ask for anyone to solicit info to me, but I'm beyond desperate at this point, and completely fed up with my current pain doctor, and his inability to listen to anything I have to say. 

 

goat
User offline. Last seen 12 hours 29 min ago. Offline
Moderator
Posts: 4991
re/

https://projects.propublica.org/checkup/drugs/2017/states/indiana


 i am pretty sure you did a intenet search.   I know nothing about suboxone.  good luck brother

Njshoregurl
User offline. Last seen 44 weeks 6 days ago. Offline
Member
Posts: 4
That's what husband was

That's what husband was prescribed - BELBUCa for his back (he has extensive damage on back and knee)
Was in pain Med's and doc decides- OH every patient is now going to be on belbuca?!
He needs to find a doc in NJ/PA area this scares me now- for him! Wow! HE did get his mess this month and dropped the belbuca off--- but?? I told him find a dr-

gtrplayer
User offline. Last seen 1 week 3 days ago. Offline
Moderator
Posts: 2934
Thanks, Goat.

Hey bro, after you read this, lets unpublish it so that it doesn't "bump" a thread nobody cares about. I'm only leaving it published now so you will see this.

Propublica is actually the site I used when my family Dr said, "Find a Dr, and I'll refer you." Never knew it was the patient's job, but, what do I know.

The problem I found with that site is that it appeared, to me anyhow, to list only Medicare related expenses, and nothing in regards to Medicaid, or even private health insurance. Being as how I'm practically broke at the moment, I'm not going to be going to a Dr who doesn't accept ANY insurance, and proceeds to bill $350 for the first visit, followed by $200 every subsequent visit. 

I realize that this drug, per FDA's approval, is truly only intended for a niche market. That being said, I find it ironic that our politicians B and moan about our "opioid crisis", go out of their way to inact laws restricting opioids for everyone except those with terminal illness, or cancer pain- yet they know how safe this drug, when used by itself and absent from someone intentionally misusing it in some form, or taking benzodiazepines they aren't prescribed nor have familiarity with, truly is. Someone looking to abuse an opioid surely isn't going to choose Suboxone, or any buprenorphine products for that matter, simply because what those users are attempting to get just will not happen. For an opioid naive individual? Perhaps. Yet, unlike Norco, the seemingly new "go to" pain medication handed out by all pain management doctors regardless of the pain, cause of pain, or severity of the pain; after a certain amount of mg's, there's no real reason to take more. They aren't going to feel more effect after X dose, regardless of how much they take. Now, they may die, but Darwinism tends to get it's victims for the betterment of most of us.

gtrplayer
User offline. Last seen 1 week 3 days ago. Offline
Moderator
Posts: 2934
No idea on the triplicate post

Sorry, Goat, and fellow Pharmer members and guests. I did not mean for this to post in triplicate. Only thing I can figure is that, while my wifi was skipping for whatever reason, this became the result. Unfortunately, if I were to delete any one of the two extra posts, the original message would also be deleted. I want to leave the original response to Goat up to make sure he sees that I was not ignoring him- I simply glossed over it and missed the link he gave at the time. The post(s), all three of them, will be unpublished once he gets the chance to see my acknowledgment of his post. For some reason, I have been trouble unpublishing my own post from my smartphone (dosen't it sound pretensions when someone says smartphone versus cell phone?) Either way, the triple post is my fault and I apologize to the Pharmer family. 

Before I hit send, anyone want to place a friendly bet as to whether this posts once, or three times???

Let's find out together... 

Rocker Dan
User offline. Last seen 17 hours 27 min ago. Offline
Member
Posts: 154
cant get my drug

Dear gtrplayer it seems like this unreal movement to alter what helps us is still in full swing some places.I went through all kinds of minor changes but now am back to semmi normal as far as my medication goes.I was put back on a smaller yet decent ammount of Diaezapam after my doctor said I was driving him crazy so I now live with the changes.But I  feel for you and others who after so many years are forced to choose between pain meds and Benzos!I AlsoI  lerned self control and never run out of my medicnes early anylonger.So we live and lern,I sure wish you the best in your search for a happy medium,Peace,RD

gtrplayer
User offline. Last seen 1 week 3 days ago. Offline
Moderator
Posts: 2934
I appreciate the reply

Thanks, RockerDan, for sharing your story and posting encouragement. My major problem stems from the fact my primary dr wants me to be seen by a "specialist" for everything. I can agree that the pain specialist is needed, and wouldn't ask him to treat my pain. However; the last time I had an appointment with him, he told me to find a dr who prescribes Suboxone for pain, and he would then refer me to that dr. Well, believe it or not, doctors offices do not tell you over the phone if they do or don't prescrobe a certain med. I could have told my family dr that before he even finished suggesting me trying to find one. 

Now, to make matters worse, the psychiatrist he sent me to for medication maintenance (prescribe my Klonopin on a monthly basis) tells me she can't rx any klonopin to patients on narcotics due to a law that went into effect January 1, 2017. My problem with this is, it's not true. I have read the mind numbingly boring letter sent to physicians advising them on coadministraton of benzodiazepines and opioids. Not one time did it say "you may not rx nerve meds if a patient is on opioids", or vice versa. What is DID say, was that they urge doctors to more carefully weight risk vs benefit to rx'ing both class of drugs to the same patient, on a case by case basis. To make matters partially worse, she saw that I had been treated for adult onset ADD caused by a traumatic brain injury from a crash, and read where I had 3 car accidents since being off ADD treatment, which were totally my fault. Not texting and dribing type of not paying attention, but just "thought distraction." So now I am on Vyvanse, which works great, and always has. However, I can barely write my signature on receipts, or even write with a pen in general, because I shake too bad. The ADD meds work to keep me focused, but also causes the anxiety to get worse. 

And while I typically do not share my emotions on this page, I can not help but be 100 percent honest when I state that I am feeling absolutely overwhelmed, frustrated, disillusioned, and disheartened. I hate what I am about to say, because I don't want people responding with "pity" posts. What I say next I say just in order to remain 100% honest with anyone who may value what I write. That being said, I truly feel like these misinterpretations of guidelines are a way to cause some of us to commit suicide, and reduce the number of patients that need these medications. I can tell you, without my klonopin, I am usually so on edge I stay by myself and barely venture out. Yet, if I choose to continue the Klonopin, and discontinue the pain meds, the pain alone will cause suicidal idiation.

IMPORTANT NOTE: I do not advocate suicide, nor do I support it as a justifiable solution to a temporary problem. I urge anyone with suicidal thoughts to seek treatment, or an evaluation at the very least. However, what do you do when you are confronted with a permanent problem, to which solutions exist, but can not receive the treatment? In all honesty, I'm kind of done caring anymore. It seems so stupid to try to seek treatment when all you run into are locked doors.

gaucho
User offline. Last seen 9 weeks 4 days ago. Offline
Member
Posts: 189
Belbuca? UNDER 200mcg/tab?

I imagine (since I am in Scotland and have been described as a "walking BNF") that BELBUCA is an American buprenorphine brand. I have never heard of, far less seen, ANY buprenorphine tablet in dosage of under 200mcg - the standard start dose for moderate to severe - in opioid-naïve patients - pain. There ARE (mainly in Asia, in particular Pakistan and Thailand) IV vials of less, but not for the normal RoA - sublingual - which delivers the highest bioavailability;  I haven't heard of anyone in hospital receiving any less than 200mcg IV here in the UK, lower dosage being considered TOO low for successful analgesia, even in a country like this where even OxyContin 120mg tabs are seen by most doctors as reserved for cancer and other painful terminal conditions (I was titrated to 120mg bd in 2002 yet, because of the culture of opiophobia amongst dosctors graduated after c.1995, and despite my conditions being progressive, I am forced to spend money on extra analgesia beyond my Rx, now being given a paltry 80mg daily, which is hardly enough to dull down my pain.)

There are companies whose IV buprenorphine - patent proprietary brand SUBUTEX, SUBOXONE being a specialised med which contains naloxone, a partial to full agonist intended for withdrawals from opioid dependence as the combination blocks the mu-opioid receptors' affinity for the pleasure principle of opioids, in short meaning that anybody using, say, morphine diacetate whilst the combination is in their system, will not experience any euphoria but WILL benefit from analgesic action. The big problem is that, if taken within 12 hours of a regular analgesic, you are likely to go straight int o a withdrawal syndrome.

A standard in some countries is 300mcg, 50% greater than PhEur, BP, USP, IP &c. recommend. Note brand BUNEX, sold in PK, Afghanistan, India and Nepal.

As a sideline, there is no way - absolutely non-negotiable - that I would EVER agree to having my 6mg clonazepam daily stopped on the spurious pretext of some invented clonazepam/oxycodone mix being banned. That in fact takes away the doctor's freedom, guaranteed in the Hippocratic Oath, to relieve suffering. Yes, when my Rx is entered into the computer, a warning does appear saying that there is a possibility of interaction, but considering that I have been using BzDs since 1976 and opioids (legally) since 1994, having never experienced a single side effect from either, the doctor  should not change what they consider best practice (even if that definition is a LOT narrower now than in the 70s and 80s) as long as my Rx is to my benefit with no perceived risks at all. I can not believe that any such 'law' could ever be enacted as it would remove the doctor's opinion of the best Rx for the conditions presented. If you take Vyvanse (lisdexamfetamine, availanle in the USA only) I am not in the least surprised your anxiety is worse and you should be on an acute med, not a prophylactic like clonazepam - alprazolam would be my choice. By all means, if your anxiety is as bad as a panic disorder or a phobic, especially thanatophobic, problem, stay on at leat 6mg clonazepam daily but use the much gentler ADDERALL for ADHD. Your doc sounds as if s/he was never properly educated in GP prescribing at all and I would seriously consider changing.

Some of the above answers are superb but miss out on those important points. In such a litigious society as the US, that could be dangerous.

You are the first person I have ever come across who is being prescribed such a HUGE buprenorphine dose, 40 x the standard for pain, and not dependence, and as a result have a little difficulty in understanding why you ask what you do and what you actually expect; what you SHOULD be being given is something made specifically for analgesia and not for handling withdrawals from recreational or iatrogenic dependence on opioids.

I would be in a better position to answer you in terms of pure pharmacokinetics and dynamics and to suggest what you SHOULD be asking for (frinstance why the ???$* should you be given anything containing naloxone if the doctor does not suspect or KNOW that without it, you would be using other strong opioods like dextromoramide, diacetylmorphine or oxymorphone - even the now-commonly found fentanyl hydrochloride being shipped to the West in huge quantity from China for inhalation or insufflation - that is the ONLY clinical reason to prescribe such a combination, the dosage of buprenorphine being something no doctor of my knowledge would ever prescribe for pain of any degree.

As a matter of interest, what are your pain scores on the Glasgow or other standard scale?

This is a question purporting to ask about one thing but which offers up more additional questions than answers. As a counsellor/therapist, I should prefer to get to the bottom of this strange and possibly unique prescription, which sounds like it is something suggested by a patient to a doctor in his/her personal employ than any normal Rx.

I am not, by that, suggesting any illicit deal between professional and patient, but do have many misgivings about your situation and the solution that appears to be (for how long?) yours, and not a qualified prescriber's!

Nobody should require any more than 500mcg buprenorphine WITHOUT naloxone for pain without being switched onto something more suitable for your pain levels.

Finally, Suboxone is (12 yrs) relatively new. TEMGESIC (orig 200mcg painkiller) dates from c.1975 and Subutex (buprenorphine without naloxone) from early 80s, & has NEVER  been licenced for use as an analgesic - any doctor so doing is putting his/her licence to prescribe in danger. It is licenced SOLELY for treating opioid dependence, as in the opposite manner, dipipanone may NOT be used for dependeence, only pain, and [filtered word] HCl may NOT be used in any dependence tapering programme, they must use amfetamine (usually dextroamfetamine sulphate SR 15mg) which acts upon different receptors in the brain, which is why [filtered word] dependence is the most difficult to treat & has the highest recividism rate of any addiction bar tobacco. Only doctors with special licences may prescribe these for such usage. And there are but a handful in the entire Western world!

gaucho
User offline. Last seen 9 weeks 4 days ago. Offline
Member
Posts: 189
Peruvian Marching Powder??? Rx by Teva, Ranbaxy, Mallinckrodt.

My final 2 paras above make no sense whatever if the crucial word, a perfectly legal Rx drug, is filtered. Just to let you all know without hitting another filter!

Gaucho, talking professional, legal, prescription drug used in well over 50 Western countries. Mainly by optometrists but also by suitably licenced doctors for dependency and ANY doctor for other, anaesthetic purposes.

It is a lot more commonly prescribed than many think, my own local Health Board having listed Rxs amounting to well over 250g in 2015-6.

gtrplayer
User offline. Last seen 1 week 3 days ago. Offline
Moderator
Posts: 2934
I see your post, and had a

I see your post, and had a response typed but fat fingered it on my phone. I'll repost it tomorrow.

gtrplayer
User offline. Last seen 1 week 3 days ago. Offline
Moderator
Posts: 2934
My experience with Suboxone for pain

Okay, now that I can type correctly, I can better answer your questions in regard to my experience being on Suboxone for pain, as well as what discussions were made prior to me asking to try it for my pain. 

Brief backstory; I saw my pain management group in 2009 for the first time, and was only taking Lortab 7.5/500 at the time. This pain management group kind of prided itself on the fact that they were not a "pill mill", even though, they kind of were. On my first visit, I saw 3 different doctors. The first guy was an internist who would be responsible for my medications. The internist read my MRI report, and said that they generally do not like to keep patients on a short acting narcotic due to "rebound pain." However; on the new patient quetionairres, one of the questions was "What type of pain relief are you hoping to achieve?" I answered that, since I was still young'ish at the time, 28 years old, I wanted to minimize the pain intensity without having to be placed on a long acting pain medication, and ideally, would like to get enough relief that narcotics were not necessary. I had a very valid reason for that answer. My grandmother, who was in her early 80s, had just been admitted to the hospital for congestive heart failure. However; she had also been taking Percocet like a crazy woman, or so it would seem. Come to find out, the reason she was not getting pain relief for any amount of time was because something in her heart was causing her liver to shut down, while she was already in chronic kidney disease, and due to these complications she was not breaking down her Percocet. Basically, she took the medicine but never processed it. The first night that she was admitted to the hospital to treat her CHF, she had a massive overdose, and it scared the living daylights out of me. She hallucinated. She vomitted profusely, and was more or less zombified for the first two days. The next three days were even worse, as she went into a huge withdrawal. It was painful to watch, and I made the decision then (knowing that my back was bad due to a car accident) that I would never let myself be placed on Oxycodone. Not that it was an issue because my pain management group prescribed everything except Oxycodone. 

The internist switched my Lortab, to Norco, and told me that even though they dislike having patients on IR narcotic medication, he agreed with my overall assesment, and reasonings, for not wanting to be put on a long acting medication. After I saw the internist, I saw the psychiatrist. The psychiatrist basically just wanted to make sure that I was not seeking pain medications as a means to dull emotional pain, and it was a very corny 45 minutes with him. After he signed off on my pain treatment plan, he had me meet with the interventional pain medicine doctor. The interventional guy was supposed to be the guy who just did shots, but he ended up prescribing Avinza to me, with the psychiatrist and internists approval, and I just felt absolutely horrible. 

I would say 80% of my feeling awful was the fact Avinza just turned my stomach into a rock, and it was unpleasant. The other 20% of me really hated the idea that I was on morphine. I only stayed on the Avinza for about 3 months before calling my nurse practitioner and telling her I could not tolerate Avinza, and I was going to discontinue it. I had a prescription for a 4th month that I returned to her, and I think that was a turning point for the trust relationship we eventually formed. She realized that I did not want "more" drugs. I wanted more relief, with less side effects. However; this also meant (remember this is 2011 or so by this point, long before the "epidimic") that their next medication adjustment would most likely include either Methadone, or Duragesic. 
By chance, I happened to have an appointment scheduled at a surgery center with the interventional pain doctor, and I overheard the nurses asking other patients "1 to 10, what do you rate your pain", and "What medications have you taken today?" I noticed that one whole side of the surgery center was for the dr who was doing my shots, and also noticed that most of them said they only took their Suboxone for pain. This was where I first had the inkling about Suboxone, and I began studying it almost ad-nauseum. However; I have to explain something about the doctor who would become my prescribing physician, the psychiatrist.

The psychiatrist was a regular psychiatrist. He was also a 1/2 partner in the business. He began touting Suboxone as a miracle drug, and after what information I was able to ascertain, it seemed to be a far better option than allowing myself to be placed on Methadone or Duragesic. This psychiatrist also had the proverbial "God complex". He thought he was smarter than everyone else, and he wanted to make sure that you understood, as a patient, you were to gather as much information as possible about a proposed treatment plan in order to have the best results. I can not fault him for that. However, he was doing a lot of extremely off-label treatment of pain. This is also the guy who would eventually kick me out of the practice for refusing to discontinue my Klonopin, after 9 years. Anyhow, this guy swore by Suboxone, would not prescribe Subutex, and even began treating patients not already on opioids with ULDN (ultra low dose naltrexone). 

I do not know if it matters, but this psychiatrist was Russian, received his medical training in Russia, and did his residency in Georgia. Which would not be an issue if he didn't become so smug. He eventually tired of his partner prescribing full opioid agonists, and filed for bankruptcy, causing the practice to dissolve, only to re-emerge as a new practice with him 100% the owner. I was on Suboxone by the time this happened, and honestly it was a great pain medication that did not give me the false sense of well-being, or stomach issues that even Norco had given me. Should Suboxone work for pain? Not if you believe that everything you read is gospel. The fact is that the naloxone that is part of the ingredients remains inactive as long as the pills (later, films) integrity was not compromised. In short, the buprenorphine was the only ingredient that was ever activated, and it worked wonders for me. I know that most chronic pain patients will not admit it, but we do reach a point where we have little miniature withdrawals once our body becomes accustomed to the medication. I never had this issue one time while on Suboxone. I felt great, was in relatively low amounts of pain, and I knew that the medication would last. I was actually prescribed 3 8/2mg tablets for pain. All of my prescriptions read, "take one tablet sublingually 3 times daily for pain management."

I have managed to lose my own train of thought, but this should be good enough for one night to read. Sorry that I can not answer the Glasgow scores question. I've never encountered that test that i know of. All I have ever said is it rates an X out of 10. 

Belbucca is a buprenorphine film that is approved for pain management that requires around the clock opioid therapy.

I will post more after I have time to think.