replied 6 years ago.
Thank you so much for your compassion. I have had a lot of bad luck with doctors over the past year and yet somehow all the docs I interact with on this site are not only qualified and helpful, but also incredibly generous with their time and patience.
I have had aches and pains and a general feeling of feverishness (without an actual fever oddly, I take my temp whenever the bad times hit), and very mild stomach upset - mostly just loos stool no real nausea so far. But the worst symptom BY FAR has been restless leg syndrome, except it's not just my legs. It feels like every nerve in my body is firing and my whole body is irritated causing me to flex all my muscles ever few seconds for attempted relief.
I asked a question toward the beginning of this ordeal and received a response from a wonderful doctor with whom I continued to communicate until yesterday. I hope this isn't breaking some kind of boundary, but in lieu of having to start from the very beginning, I'm going to copy and paste the thread of questions and responses with Dr. Chip so you can get a better idea of my situtation. Be prepared, it's long, but now that 150mg Nucynta and .125mg xanax has finally kicked in I should have a couple decent hours during which I can type back to you. Once it gets extremely bad, even a task as simple as typing is brutal. Ok, here's the scoop:
I don't know if I should submit this to "Medical Experts" or "Health Experts" but please ONLY RESPOND IF YOU ARE A DOCTOR WITH A THOROUGH UNDERSTANDING OF THE DRUGS NUCYNTA AND SUBOXONE.
That said, I see a pain specialist who is helping me ween off Suboxone (been on for 14 months, initially to help with physical dependency on hydrocodone - used strictly for pain - and continued for supposed pain relief properties for my chronic pain), and onto Nucynta. Theoretically I will eventually be able to take Nucynta as needed, and not every day like with Suboxone. Per the doctor's instructions, I stepped down from Suboxone by half every day until I was down to zero yesterday (starting from 10mg). This pain specialist - the best around - is a doctor you have to wait at least 2 hours to see, and then you get 5-10 minutes with at most, so when he responded to my question about whether this would be too fast a taper and would cause withdrawal, he said "you will have the Nucynta, which will help with the withdrawal."
The withdrawal hit hard last night with cramping, flu like achiness, restless nerves and stomach upset. I took one Nucynta since it had been well over 24 hours since my last Suboxone and within about an hour I felt MUCH better. I tried to reach my doctor after hours but not only was he not available to be paged, but it turns out he's on vacation for two weeks with NO ONE on call for him! The dosage I was prescribed of Nucynta is one 75mg pill every 6 hours as needed. In order to fight off the withdrawal from Suboxone, I've had to take one every four hours, and the last half hour is usually a tough time. I spoke with my doctor's medical assistants who were in the office today and one of them said not only should I not get withdrawal from Suboxone (yeah right, I knew this was coming based on every message board I've ever read with anecdotal posts from people like me going off Suboxone), but if such withdrawal is experienced, Nucynta shouldn't help because it's not an opioid. I've since researched online and found that while perhaps not strictly an opioid, Nucynta does have some opioid qualities. The medical assistants did, however, assure me that taking one Nucynta every 4 hours was safe. While not my primary question, I am wondering exactly how much/how often is safe since the withdrawal is getting worse.
It sounds like maybe the most logical approach I can take is to go back on the Suboxone (I have a month's supply) and ween much more slowly, waiting to taper completely until the doctor is back in town and I can speak with him directly. My question is this: HOW LONG AFTER TAKING A NUCYNTA IS IT SAFE TO TAKE SUBOXONE? The last thing I want is to have an extreme withdrawal reaction like what happens if you take suboxone within 24 hrs of an opiate, but I don't see how I could keep from taking either Nucynta or Suboxone for 24 hours since every time the Nucynta starts to leave my system (every 3-4 hours) the withdrawal symptoms come back worse than before.
Forgive my longwinded explanation, I just wanted to be as specific as possible since we can't speak directly. I would go to my GP but as wonderful a primary care physician as he is, he - like every other non-Suboxone prescribing doc I've encountered - had to look up Suboxone just to see what it was when I listed it among the medications I'm taking. For your information, I'm also on 20mg Lexapro, 1-2 mg Chantix (trying to quit smoking, not going so well since the withdrawal hit), 20mg prevacid, the Nuva Ring, Metformin 1500mg ES (for insulin resistance/PCOS, not diabetes), and Benicar for hypertension (hopefully I'll get to go off that when I'm smoke free).
Here are the questions I need answered:
- How long after my last dose of Nucynta is it safe to take Suboxone, for the Suboxone to work effectively and relieve the withdrawal rather than bring on extreme withdrawal?
- HOw much Nucynta is safe to take how often?
- Is it safe to take these two drugs together, or within hours of each other?
OK--I work in this area. So long as you are in withdrawal for at least 24 hours after stopping the Nucynta, it should be OK to restart the Suboxone. If you still get sick after that, you'll need to wait, say, another 24 hours before attempting the Suboxone again.
Wednesday, August 11, 2010 7:57 PM EST
But so you're saying I have to wait 24 hours from the last Nucynta? I honestly don't think I can do that. I know I'll break down and take another Nucynta, and maybe another after that if it keeps getting less and less effective in helping with the increasing withdrawal, well before 24 hours. I took the last Nucynta 4 hours ago and this time it barely took the edge off, making me wonder if the withdrawal is getting worse and worse as others have intimated it did with them. I'm trying to clarify. Will it make me sick to take Suboxone before 24 hours from the last Nucynta? My doctor's assistants kept saying it's not a narcotic, it's not an opiate. So why would it make me sick to go back on Suboxone now?
From Dr. Chip:
Sorry for the delay. Nucynta is an opiate receptor agonist, so, in essence, it acts like an opiod whether it's called one or not. It may not make you sick to combine the two, and, any moderate stage of withdrawal may indicate that your body will accept the Suboxone without a problem. It's worth a try to take the Suboxone while you're experiencing any amount of moderate withdrawal, and, perhaps, at worst, the withdrawal won't be exacerbated, just not helped very much.
Do you have any idea how long suboxone withdrawal can last (at most)? I made it through the night with Nucynta and Advil and haven't taken Suboxone so considering I know going off Suboxone gives me withdrawal symptoms, I'd like to see if I can make it through rather than go back and have to do this all over again. I'm just terrified of how long this could last. Some of the horror storries around start "it's been 5 months and every day is still worse than the last..." I will accept your answer after sending this, but I hope you'll be kind enough to answer this last question. There is a serious derth of good pain doctors with a knowledge of Suboxone - at least in my area - who don't qualify every Suboxone patient as an addict. It is nice to get the straight story from someone who knows what I'm taking about. Thanks for your previous answers. -Cara
OK. I run a drug and alcohol rehab, so I'm "tuned in." Let me ask first, why the switch from the hydrocodone to Nucynta?
OK, (and btw I would have "accepted" your answer already but I'm afraid it won't let us keep replying. I will definitely pay you for your time) First I was on Norco 10/325 for about three years for chronic back pain (2 herniated discs and bunch of other stuff revealed via MRI) as well as extraordinarily painful menstrual cramps (maybe due to ovarian cysts, maybe not). I never abused it and because I didn't take it every day I didn't become dependent....until May/June of 09 when I had a bout of pain that lasted weeks and weeks and I was taking the pills every day. Then I noticed I was going to run out of pills so I tried to go without for a couple days despite my pain. That was my first experience with opiate withdrawals, and it was rough. I immediately went to an outpatient detox where they recommended I take suboxone to help with the withdrawal. After about a week the doctors at that clinic said I could either taper off the suboxone or continue using it for my pain. I was scared of having nothing for pain but OTC meds that had never even touched the pain, so I went with continued use of Suboxone.
Between June 30th 2009 and about a week ago I was prescribed a dose of 12 mg suboxone per day. I didn't always remember to take all of it but I NEVER went over that amount. After suffering a pinched nerve in April I acknowledged what I had already begun to suspect, that the Suboxone didn't do much for severe. I never wanted to be on something every day anyway. My fiance and I want to have kids in the next year or two and that gets pretty complicated when you're on suboxone (i know about subutex but I just wanted off the roller coaster). I found this pain specialist who prescribed suboxone (not for me, but I liked that he had an understanding of the drug) who helped alleviate my extreme nerve pain with an epidural, and then suggested Nucynta as a way to get off Suboxone since that was what I wanted. As I said previously, he indicated that if I went down by half every day, the first day I took zero Suboxone I could take a Nucynta and that would alleviate the withdrawal. It did at first, and then it didn't work as well yesterday. This morning it has been over 6 hours since my last Nucynta and I am feeling a bit better overall with the withdrawal stuff (less of that achy, I-want-to-jump-out-of-my-own-skin feeling), but I have a MASSIVE headache which I know for sure is from the Nucynta. Occasionally I got similar headaches from the Norco back when I was prescribed those. I've taken two anvil for the headache, not wanting to take more because my liver's probably already working double time with the Nucynta.
Full disclosure: I did my share of doctor shopping when I was on Norco's because most doc's I saw assumed I was drug seeking rather than pain relief seeking. I never took them for anything but pain. I went to AA and NA meetings regularly for about 10 months after getting off the Norco and it was helpful for a time, until it just didn't speak to me. I did have a sponsor, but I gotta tell you she was more screwed up than me. I'm a huge believer in support networks and if I thought I needed more help I would absolutely go back to meetings. I don't have cravings for any type of high. I just want to control my pain without getting physically dependent on yet another drug and have to go through this all over again. Another big reason to go off the suboxone is I'm so tired of being treated terribly by doctor after doctor after counselor after medical assistant (I've been to a total of three Suboxone docs, including the one in the treatment center. The second kept moving her office and seemed sketchy so I switched to a clinic with a longer term rep.) who not only pigeonhole me as an addict, but as such, treat me as someone who is constantly on the take, always looking for a way to do something criminal. It's insane! I have had a zillion urine tests and ALWAYS test clean because I don't mess with drugs. I don't even like to drink so that's not an issue either. Smoking's my only vice but I have found that trying to quit that while suffering withdrawal is just too tall an order.
Wow, sorry once again for my lack of brevity. I guess it's just so rare to get to communicate with an actual doctor who seems to genuinely want to help and listen, rather than just box me up into some category and put me away, not to be dealt with until the next urine test.
OMG, you asked why the switch from HYDRO to Nucynta, not Suboxone! Oy Vey, forgive me, I'm working with very little sleep here. The answer is that the pain specialist seems to think Nucynta isn't AS physically addictive as hydro, and he says in his experience (or more aptly his patients') Nucynta can provide a similar level of pain relief. Ok, in lieu of writing the Great American Novel here, I'll stop typing and await your response. As I mentioned before, this highly reputable (and highly arrogant, but hey, it's the American health system, I'll take what I can get) pain specialist is on vacay for two weeks with no one on call for him. I have a therapist (cognitive behavioral, with lots of ADD/ADHD experience...did I mention I have intense ADD? Like you couldn't tell from my writing style, lol!), who I will see this afternoon, and perhaps she can recommend a course of action. But right now, if I can make it through the withdrawal I don't want to start this whole cycle over by going back on Subox UNLESS you think weaning super slowly would avoid most of the withdrawal, or if you think there is a real medical need for me to wait until my doc is back in town (provided I could even get in). Yeah, I guess I was just kidding about finishing this message a couple paragraphs ago. Sorry :)
No problem with the novelette, and we can continue on this for as long as you like, or, if later on, you have other questions, you can just address them to me. First--my definition of addiction is loss of control. The alcoholic says, "I'm not going to drink," or, "I'm only going to have a couple today," and, then, they break their promise to themselves. Same with addicts, and if the broken promises accumulate, they have a problem. It doesn't sound like you fall in that category. Weaned slowly, there should be little or no withdrawal from Suboxone. The problem with genuine pain patients who are not addicts but who don't want opiates is what are the alternatives, and, hopefully, Nucynta will work for you (I would be a little concerned that, just like Suboxone, Nucynta may be relatively contraindicated in a woman who's planning to become pregnant, so you should check with an OB about that). The point about withdrawal is that it always everntually ends if you can hold out, and meds like clonidine and modest doses of a benzodiazipine may help. BotXXXXX XXXXXne--the alternating of Suboxone and Nucynta is worth a try, and if, after restarting Suboxone after going into withdrawal from Nucynta, all's well, then no harm's done. This is more of an educated hunch--like most of the practice of medicine--let's try this and see if it works--didn't?--OK let's try this........If that hasn't covered everything, don't accept my answer--just continue with the dialogue.
Wow, you're the greatest, Dr. Chip! If it weren't for the fact that your advice comes from an obvious understanding of these medications, I would seriously question your credentials because your attitude, the time you're willing to give me for such a low cost, and your compassionate approach is the antithesis of every experience I've had with doctors over the past couple of years. Ok, so here's what I'm thinking. Right now I have no withdrawal symptoms. I took one 75mg Nucynta a few minutes ago because if the good morning I'm having takes a turn for the worse, I'll still need to drive to my therapist in an hour and a half and that will be right in the window of Nucynta's effectiveness for me. With the support of my fiance, Ben, I have pretty much decided to stick it out as long as the withdrawal doesn't get much worse. It had been almost 8 hours between doses of Nucynta before I took another so I am cautiously hopeful that the worst is over. Do you know anything about the likelihood of becoming physically dependent on Nucynta? The pain specialist seemed to think it was a better option than Suboxone, but I can't remember if that was just because it actually helped with pain or if it's not as addictive as well. ------------------------------------------------------------------------------- Yikes, I meant to send that before my therapy appointment and even though it's been a bit better today I crashed as soon as I got home and just got up and dealt with a bit of life before I realized I never sent this. I'm sorry, I promise not to bail without paying you for all your help and time. I have taken 1-1.5 Nucynta every 5-6 hours today and once it kicks in I feel much better for about 3-4 hours. I just keep praying that I'm over the hump and some fresh hell doesn't await tomorrow. I really thought I was done with all this last year. Lovely. Anyhoo, get back when you can, but nothing urgent this second. I'll edit if anything big comes up. Thanks a million Doc, I mean it. -Cara
I just Googled Nucynta and it's listed as a Schedule II narcotic--on an "abuse potential" level with Percocet, Methadone, Dilaudid, etc. I am assuming that, for that reason, yes, it can be addictive--although, since I don't think you are an addict with the "gene" as I call it, you won't abuse it. As an opiate, though, withdrawal is a possibility. The Suboxone's Naloxone additive makes it relatively abuse-proof and also probably doesn't allow the "high" that opiates give addicts. In essence, you're trading one opiate for another, so if the withdrawal part bothers you, the potential is still there. At the same time, it's no fun to be in pain, so taking a pain medication is no sin for those with legitimate pain problems. Your option is nonnarcotic pain medication if the withdrawal potential worries you, and that might not be enough relief to make life worthwhile. I'm leaving the office for home, but, in an hour, if you have more to ask, please do.
Thanks Dr., I'm still waiting for it to kick in now. After about 6 hours without, it seems to take a bit longer to help with the withdrawal (meaning the longer I wait in between Nuc doses the longer it takes to work again). My hope is that since it's not necessrily an everyday type drug - as suboxone was prescribed to me - I'll be able to use the Nucynta as needed for severe pain, which hopefully won't last so long as to cause physical dependency. For instance, if I get another pinched nerve, I would try to get in for an epidural as soon as possible, and only use the Nucynta subsequent to the shot. On the other hand, if the withdrawal lasts much longer it will have been who knows how many days of the Nucynta every 4-8 hours and perhaps that's enough to cause the dependency I so despise. With Norco, I get it. I only ever took it for severe pain, but it had some euphoric effects in addition to the pain relief (not as euphoric, I'm told, as it is for people abusing it without any pain). I've never indulged in a mind altering substance I couldn't stop using on my own (yes, I experimented a bit many years ago in college, but soon tired of the party lifestyle in favor of an actual life), but I still made sure there were other people in my life with whom I checked in on a regular basis regarding the use of such a heavy duty drug as hydrocodone. I'll never for the life of me get why every doctor I saw for suboxone treated it as such a defcon 5 situation since it tastes horrible, didn't do much for my pain, and had absolutely no euphoric effects, unless you count the euphoria of taking away withdrawal. I always ended up feeling like I had to work so hard to prove I was doing nothing wrong that it almost felt as if I was. Of course I understand that this attitude is passed down from the DEA, whose control of Suboxone seems outlandishly hypocritical given how easily people seem to be able to get the whichever opioid they got addicted to/dependent on in the first place. The especially degrading part was that even if the doctor/assistant/counselor/urine-test-giver had reason to believe I was a full blown addict who only ever took pills to get "high," wouldn't the fact that I was on Suboxone indicate a serious resolve to be free of the drugs? Sorry, I could go on all day about the mistreatment I, and others like me, endure just so they can do the right thing. It never seemed to count for anything to any of those docs that I didn't run out of money, get in trouble with the law, or lack a source for the hydrocodone. I checked myself in the very day I realized there was a dependency, KNOWING I would have no relief for serious pain beyond OTC meds. Anyway, I can't thank you enough. I'm going to try to get through this with a minimum of Nucynta and hope I don't have to go back on the Suboxone and start this whole thing over again. You have MORE than earned the money I'm paying, and believe me I'd pay more if I could. I hope there's a way to get you again if I have more questions in this vein, but since I feel I might be (crossing my fingers, knocking on wood, throwing salt over a shoulder and spitting twice) out of the woods, I can't in good conscience keep you "on call" with no payment. I will definitely be leaving you very positive feedback so that others know you are not only an extremely qualified professional, but maybe more importantly a real Mensch (high compliment in Yiddish, though not the prettiest sounding word). Thanks again for everything, and I hope not to have to be in touch soon, lol! All My Best, Cara
Thanks for the kind words, and I'm glad you didn't think I was mishugina (got no idea how it's spelled) or a nebbish!! Seriously--let me know how you do, and if you have any other medical questions, just call on me. You're right, we don't make a lot of money on JA, but I do it more for the "fun" of it, if you will. I fully agree with you on the whole drug thing--the federal government should get out of us M.D.'s hair and let us do our job, and it's the bad apples out there that make it hard for the good apples like you to get good pain management and relief. I take comfort in my pain patients that thank me with tears in their eyes for giving them back their lives by making them hurt less. I also think addiction is a disease, and I've worked in that field for years--it's
a much more difficult disease to work with than most, but the rewards can be astronomical. Take very good care of yourself. Chip
Hi Dr., it's been incredibly bad this morning. way worse than it has up til now. ONly this second am i able to type and i'm rocking back and forth as i type - on 150mg Nucynta and whatever half of .25 of Zanex equals. I am extremely concerned about what happens in 4 hours when everything comes crashing down again. I don't want to risk overdose by taking too much Nucynta, and of course it's so new there's not a ton of info about what that dose might be or if I can even be mixing it with a small amount of Zanex. I found out Nuc has sri properties with seratonin and norepinephrin and i also take 20mg lexapro daily. this is something my happily vacationing pain doc knew, so I'm praying there's not problem there, or higher potential for overdose. I would very much like to avoid the emergency room because I can't imagine what they would do other than treat me as an addict, IF they even had anyone on staff who knew shit about these drugs. I'm sorry to keep bothering you, it's just that I can't handle telling the whole story again. Please reply as soon as possible. I wrote this yesterday when I was feeling better than today: I tried asking this exclusively of you but got another expert instead. I'm sure she's qualified but it's so physically and emotionally draining going over all the same info with someone new, plus I've developed a report with you. Sooo, IF YOU'RE NOT DR. CHIP PLEASE DON'T RESPOND. THANKS! Do you know how long Suboxone withdrawal can last? I'm looking for a general range here so I can sort of say to myself "I know at the very least this will be over by _______ ." Also, does dependency on Suboxone, and the fact that Nucynta is offering such a large measure of relief (if only for a few hours) indicate that I will most likely be physically dependent on the Nucynta by the time the Sub. withdrawal ends if I keep taking it ever few hours? Thanks Dr. Chip. No better today, but no worse. -Cara