Pharmacist Steve pls if you have time

[Maria]

Hi Steve,
I've been taking Methadone 10mg for nearly 10 years now for CLBP and I have wanted to get switched to Suboxone and either use it as a maintenance drug or try something lighter than Methadone as my L5S1 disc has autofused and I think I have less pain going on (tho am not sure if I have that much less that I don't need what I'm taking). I still have an L4 disc that's bulged and problematic at times and an L3 annular tear. I'm not without pain I'm sure just don't know to what degree things have changed.

My PM works in a practice that doesn't want him to "detox" patients from that office so he's not motivated to be able to prescribe Suboxone. I have a good rapport with this PM and have utilized his services since 2005 so don't really want to make a switch.

Now the question~ I've tried to decrease my dose of methadone ever so slightly but I find that the GI issues are extremely difficult to deal with and even get out the door to walk my dog on a regular basis.

When I ask my PM about this he really has no suggestions and I wonder how can he be prescribing this drug and not be able to recommend how to get off it (he just says very slowly over a 3 month period).

I can't even bring my dose down to 7.5mg/day without feeling pretty overall horrible. Do you have any recommendations on how much to decrease the dose over what amount of time and/or some GI meds recommendations to combat the nausea and keep the gut function going (I use Senakot S 4 qhs and PEG 3350 17 gms/daily for this purpose to date)?

My PM advises me he can refer me to a treatment center for detox but I don't want to go thru this as I only have a physiologic dependence and no abuse issues with substances. I don't think WC would pay for such a stint and I think it very unnecessary in my case. ** I stopped taking 1800mg Neurontin after 12 years back in Aug this year and also have stopped using Fioricet on a near daily basis for the last 5 years (now only take for migraine which has been only twice since Sept).

[Pharmacist.steve]

"coming down" from any opiate needs some supportive measures. prescribers have to be certified to prescribe Suboxone and can only oversee up to 100 patients at a time. The cramps that you are experiencing is typically one of the first issues to deal with trying to get off a opiate. There is no way that you are going to do a slow taper with oral tablets... might get your doc to prescribe the liquid and you do the taper with a dropper/syringe... so that you can cut the dose by ...say.. 5% at a time... dropping from 10mg to 7.5 is a 25% drop... the next step 7.5 to 5 is going to be a 33% drop and the next is going to be 50%. How long it will take between each step is individualized.. just like the intensity of your pain can only be determined by you... and only you can determine if you are ready for the next step-down and if your "guess" of being ready is wrong.....you should be able to step back up and try again at a later date and/or do a partial step up to see how things go. that should keep the need for other supportive measures to a minimum.

[Maria]

Pharm.Steve,
For the suggestion of the oral drops ~ I never thought of that. That does sound like a much simpler/better way to decrease with precision and not so drastically or apparently drastically to my system/mind/body.

I see my PM tomorrow so will inquire with regard to the liquid form. Maria