Archive for the ‘Side effects of Suboxone’ Category

Barring Healthcare Professionals from Working while on Buprenorphine

While buprenorphine has been prescribed for many patients over the last 10 years, there’s still controversy about whether healthcare professionals should be allowed to work while on buprenorphine.

In an article in March 2012 Mayo Clinic Proceedings, Hamza and Bryson  cite studies that support their conclusion that medical professionals should not be allowed to work while taking buprenorphine as maintenance for opioid addiction. The authors say studies show that people taking buprenorphine have some impairment when performing safety-sensitive tasks that are required in practice as a physician. (1)

I read this article with great interest, since I have been prescribing buprenorphine and telling my patients they won’t be impaired while taking a maintenance dose. Wanting to know if I am misleading patients, I scrutinized the studies cited in this paper.

I’m not sure the authors’ conclusions are backed up by the studies they cite.

The most worrisome misinterpretation was the Schindler et al study. The Mayo study by Hamza and Bryson interpreted the Schindler study thusly: “significant differences were found between them [methadone and buprenorphine groups] and the controls.” But when I read the original study, the authors’ conclusion was really the opposite: “The synthetic opioid-maintained subjects investigated in the current study did not differ significantly in comparison to healthy controls…” (2)

Hmmm…I’m confused.

When I looked at other articles cited by Hamza and Bryson, I discovered that what I read didn’t match Hamza and Bryson’s conclusions of what I read.

Three of the studies cited in the Mayo article (Pickworth et.al., Jensen et. al., and Zacny et.al.) all looked at healthy volunteers who were given buprenorphine, then tested to see if they were impaired. In other words, these test subjects weren’t opioid dependent. All three studies showed impairment, and I don’t doubt it, because opioid-naïve subjects would be expected to feel a great deal of opioid effect with their first dose of buprenorphine. But studies of opioids-naïve subjects given buprenorphine don’t seem applicable to opioid-addicted patients on buprenorphine for maintenance.

The Rapeli et al study looked at methadone and buprenorphine patients in early recovery, so these groups would be expected to be different than those on established maintenance therapy.

Soyka et al compared opioid addicts on buprenorphine and methadone at 2 weeks, then at 8-10 weeks. This study also had a control group. The patients on methadone and buprenorphine had impaired cognition on testing compared to the controls, but they improved with length in treatment. This study was randomized but not blinded. This means patients and researchers knew who was on methadone, buprenorphine, and who was a control subject. Interestingly, in a later letter to the editor defending their conclusions, Hamza and Bryson mistakenly claimed the study was double-blinded, but clearly it was not.  Also the study was relatively small, since only 46 patients completed the study. The purpose of the study was to see if methadone was more impairing than buprenorphine. The authors of the Soyka study didn’t conclude the buprenorphine group was impaired to the point they were unable to work, only that they performed better than methadone patients.

One study, by Messinis et al, did compare abstinent heroin addicts on naltrexone with opioid addicts on maintenance buprenorphine, and showed the buprenorphine group had more cognitive impairment than the naltrexone group in cognitive functions. To me, this is the main study that speaks to the actual issue of impairment. It gives a basis to require more studies be done. However, the small size of the study, 18 patients, limits the impact of this study. (3)

The ideal study to resolve this issue would be a double blinded prospective study of opioid-addicted healthcare professionals who are randomized either to abstinence-base treatment or buprenorphine maintenance treatment. Then cognitive abilities can be compared at various times during recovery, like 3 months, 6 months, 1 years, and 2 years. Such a test is unlikely to be done, since most addicted professionals enter abstinence-based recovery, and have a high rate of success.

I do think medication-free recovery is the ideal. I acknowledge that’s my bias, even though I strongly believe medication-assisted treatment is a life-saving option. But then, medication-free treatment is the ideal for all diseases. If a patient can achieve good blood pressure control by changing her diet and exercise, I think most of us would agree that’s a superior outcome to taking blood pressure medication to achieve the same result.

Most doctors and dentists have the resources to afford the prolonged inpatient treatment needed for medication-free recovery. The monitoring required for continued licensure is additional leverage and accountability that most opioid addicts don’t have after leaving inpatient treatment. These factors produce excellent recovery rates in these healthcare professionals, much better than that achieved by the average opioid addict.

But no recovery works for everyone. If a healthcare professional has failed traditional abstinence-based recovery, but is able to do well on medication-assisted recovery with buprenorphine, is the data strong enough to say such a recovering person on a stable dose of buprenorphine can’t work in healthcare?

We must be careful about this decision. If the decision is going to be based solely on patient safety, and not on a bias against medication-assisted recovery, then healthcare professionals on opioids for acute or chronic pain must also logically be removed from the workforce, unless we can prove they don’t have cognitive deficits from prescribed opioids. And what of other medications, like benzodiazepines, which are more likely than opioids to cause impairment?

If professional monitoring boards rely on the evidence cited by this study to refuse to allow healthcare professionals on buprenorphine to return to work, they leave themselves open to accusations inconsistent safety standards if they allow other healthcare professionals to work while being prescribed opioids or benzodiazepines.

It would be a mammoth task to monitor every healthcare professional who is prescribed a controlled substance. But if a professional on stable a dose of buprenorphine can’t work safely, how can we assume a surgeon who takes legitimately prescribed opioids for back pain is safe to work?

Frankly I suspect most of the posturing about the dangers of healthcare workers on buprenorphine is really an attempt to remove medication-assisted recovery as a treatment option for healthcare professionals. I don’t know if the mayo article authors, Hamza and Bryson, have any underlying bias against medication-assisted treatments, or perhaps biases favoring abstinence as the only worthy treatment goal. I don’t know these two people at all. But my impression is that they have taken a sweeping position supported by shaky evidence. The studies they cite are evidence enough to call for larger studies, but don’t seem adequate in themselves to deny a potentially life-saving treatment to a healthcare professional.

  1. Hamza H, and Bryson E, “Buprenorphine Maintenance Therapy in Opioid-Addicted Health Care Professionals Returning to Clinical Practice: A Hidden Controversy, Mayo Clinic Proceedings., 2012, 87(3);260-267
  2. Schindler SD, et al, “Maintenance therapy with synthetic opioids and driving aptitude, European Addiction Research, 2004; 10(2):80-87acol.
  3. Messinis et al, “Neuropsychological functioning in buprenorphine maintained patients versus abstinent heroin abusers on naltrexone hydrochloride therapy”. Hum. Psycholpharm. 2009;24(7):524-531

Complications of Intravenous Buprenorphine (Suboxone, Subutex) Abuse

Endophthalmitis from IV drug use

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Since I started this blog, some of my readers have educated me about how frequently addicts use Suboxone and Subutex intravenously. I think some of these addicts have become blasé about the reality of complications that can occur from injecting a medication that’s not meant to be injected.

Like oral opioids, Suboxone and Subutex tablets and films aren’t sterile. Bacteria live everywhere, including inside an on oral medication. Since the medication is meant to be taken by mouth, these bacteria don’t harm the user when swallowed or used sublingually as intended. But when injected, these bacteria have the potential to cause catastrophic illness, depending on the nature of the bacteria.

Skin and bloodstream infections, endocarditis

Most commonly, we see cellulitis, a soft tissue infection, around the site of the injection. Sometimes the infection walls off and forms an abscess that usually must be drained. The infection can spread to the walls of the vein, causing angiitis. These infections can spread to the rest of the body, and can lodge in special areas that cause big problems. For example, endocarditis, an infection of one of the heart valves, occurs more commonly in IV drug users. It’s difficult to treat endocarditis, and requires lengthy antibiotic treatments. Sometimes this infection can destroy the heart valve and the patient may require surgical replacement of the valve. People can die from this serious infection.

Some of Singapore’s large population of intravenous heroin users switched to buprenorphine when it became available, but with that availability came an increase in complications from addicts who injected buprenorphine rather than use it as intended.

Researchers studied a series of one-hundred and thirty intravenous buprenorphine addicts that came to a Singapore hospital for treatment for infections. Of those, 31% had cellulitis. In nearly half of those patients, skin and blood cultures were positive for bacteria, most for Staph aureus. Twenty-four percent of the patients with skin infections eventually required surgical procedures, and the average length of stay in the hospital was eight days. (1)

A different study, also done in Singapore, looked at twelve consecutive patients admitted to the hospital with infective endocarditis from using buprenorphine intravenously. Eleven of the twelve patients had Staph aureus in their bloodstream, and five of them died. The average length of stay was 48 days, and multiple medical complications were noted. Three patients required open heart surgery. (2)

Fungal Endophthalmitis

Bacteria aren’t the only unwelcome travelers hitching a ride on a buprenorphine tablet. Fungal endophthalmitis is rare in people who have not had eye surgery, yet it is seen in intravenous addicts in general, and now specifically in addicts injecting sublingual tablets. At least four cases of endophthalmitis in intravenous users of buprenorphine tablets occurred within a year at one Australian hospital. These serious inner eye infections developed due to a type of Candida fungus usually found in the mouth. One of the patients admitted injecting a tablet that had been in her friend’s mouth for a short time, prior to diversion of the tablet to the patient. The oral candida species likely contaminated the buprenorphine tablet through this method.

In the 1980’s, a series of cases of candida endophthalmitis was seen in users of brown heroin. At that time, scientists thought the Candida came from lemon juice used to break down the heroin for injection. However, none of these four intravenous buprenorphine abusers used lemon juice. (3)

It is possible we will see more cases of fungal infections in patients who inject buprenorphine that has partially dissolved in another person’s mouth, due to the oral contamination of the pill.

Talc Granulomatosis

Tablets meant to be taken by mouth or sublingually (under the tongue) often contain talc as a filler. Heroin is sometimes cut with talc, to make more product to sell on the street. When these substances are injected, they can cause talc granulomatosis. Many addicts don’t get regular check-ups and most are reluctant to tell doctors about their IV drug use, even during serious medical problems. This condition is likely under-recognized because on the chest X-ray, talc granulomatosis looks like other interstitial lung diseases. The talc crystals lodge in the lungs, and cause an immunologic response. This in turn causes trouble breathing, dry cough, and low oxygen levels. Respiratory failure and death can occur in the worst cases, since there are no definite effective treatments. In some studies, patients with talc granulomatosis have improved when given corticosteroids, but tend to get worse again as soon as the medication is stopped.

Tablets meant to be used under the tongue aren’t sterile and aren’t suitable to be injected. Tablets diverted from patients who partially dissolve them in their mouths may be particularly hazardous due to contamination with mouth bacteria.  Addicts who inject tablets meant for orally use risk catastrophic health problems beyond overdose.

If you are an intravenous drug user, don’t fool yourself into thinking you’re safe because you use new needles and “works” each time. New needles do reduce the risk of contracting hepatitis and HIV, but oral pills still contain substances that were never meant to be injected.

  1. Ho et al., “Cutaneous complications among i.v. buprenorphine users,” Journal of Dermatology, 2009, Jan;36(1) pp22-
  2. Chong et.al., “Infective Endocarditis due to intravenous Subutex abuse,” Singapore Medical Journal, 2009 Jan;50(1):34-42.
  3. Alboltins et. al., letter to the editor, Medical Journal of Australia, April 18, 2005, Vol 182(8) p.427.

Taper Off Suboxone: Using the Films

When my Suboxone patients are ready to taper off the medication, I prefer to use the film. Since the film is no longer crumbling, patients can take sharp scissors or a knife and cut the films into smaller pieces roughly equal in size, ideal for a taper. Yes, I know the manufacturer says we shouldn’t cut the film or the tabs, because they have not done studies to see if the medication is equally distributed throughout the entire film or tablet. But cutting is a great way to taper, it seems to work, and everybody’s been doing it since Suboxone came out in 2003.

Most of my patients who successfully tapered off were on Suboxone at least two years, and did the work of counseling before attempting a taper. Most recent studies show high relapse rates if tapered too soon, probably because it takes time to get the essential counseling and make life changes that support a new life without drugs.

How long should the ideal taper take? It depends on the patient’s tolerance of opioid withdrawal symptoms. I’ve been telling patients four to six months is an average taper. I’ve been decreasing the dose by 2 mg every 2 weeks, until the patient is at 8mg or less. Most patients tolerate that fairly well, though patients differ markedly in their tolerance of withdrawal. At any time in the taper, if the patient starts feeling more withdrawal than they can tolerate, we can go back up a little, or plateau at a dose for a month or so.

Below 8mg, I reduce the dose more slowly, since each milligram is a bigger percent of the whole dose. I’ve been trying to decrease patients by 2mg every 4 weeks. This way when I see them every month, we talk about how they’re feeling, and if they’ve had a relapse (With any relapse to opioids, we go back up on the dose and work more on relapse prevention). For an 8mg film, this can be accomplished easily, by cutting the film into fourths. That’s a 25% drop in a month, or around 6.25% drop per week, at least at first. It’s common to have to stay on 4 or 2 mg for longer than a month.

Once the patient is down to 2mg, I switch to the 2mg film, and again have the patient divide it into fourths. I still try to drop by one-quarter of the film per month, meaning a half of a milligram decrease each month.

Sometimes we seem to get stuck at a dose. For example, I have a patient on a 2mg tab, which can be cut in half but is too small to reliably cut into fourths. He’s been trying to drop to 1mg but can’t tolerate staying at that dose for more than a day or two. So at his last visit, we decided he would alternate 1mg per day with 2mg per day. He did better with that, and now we are trying two days of 1mg and one day of 2mg, in a cycle every three days.

Then today, in my latest issue of American Journal on Addictions, there’s an article that throws a monkey wrench into my ideas around tapering.

This article has case reports of four patients who stopped Suboxone suddenly, unplanned. They were on doses ranging from 12mg per day to 30mg per day, and all four had only one or two days of mild opioid withdrawal, then felt fine.  The author concluded that these patients, “Showed no objective signs of opiate withdrawal following abrupt discontinuation of chronic buprenorphine/naloxone treatment…” The authors postulated that a prolonged taper might actually be harder on patients than stopping suddenly at a higher dose, based on these four case studies and other doctors’ impressions. Three of the four patients returned to buprenorphine/naloxone treatment when they had the opportunity, for fears of relapse, and the fourth was felt not to be appropriate for continued treatment with buprenorphine.

Could this be true? Might it be easier for patients to stop at a higher dose, rather than taper to a lower dose? Intuitively, a taper seems to be the best way to avoid withdrawal symptoms, but what if buprenorphine is different? It is an unusual drug. It’s a partial opioid agonist at the mu receptors, but it also has action on other opioid receptors. Might the action at other types of receptors be responsible for what was seen in those case studies? What about the monoproduct, Subutex?

The article’s authors conclude by recommending further studies comparing intensity of opioid withdrawal in patients undergoing rapid taper or sudden discontinuation versus patients undergoing a slower 28-day taper.

I’m so intrigued by these case reports that I’d love to see a large randomized trial to answer these questions. I have seen a few patients stop taking medication suddenly at higher doses and they said they didn’t have bad withdrawals…but then I have had many others who stopped suddenly and had terrible withdrawals.

Patients on Suboxone or Subutex, what do you think?

  1. Westermeyer, Joseph MD, et. al. “Course and Treatment of Buprenorphine/naloxone Withdrawal: An Analysis of Case Reports,” American Journal on Addictions, 2012, Vol. 21 (5) pp. 401-403.

New Health Care Laws: How Will They Affect Office-based Treatment with Suboxone?

Last week, one of my office-based buprenorphine patients asked me how I thought the new healthcare laws would affect my business. I’ve considered this question with a mix of anxiety and hope. Until we have more details, I’m not certain I’ll like the new changes. And of course since I’m a healthcare provider, I’ll look at changes differently than if I were an insurance executive.

I told my patient that it will be excellent for my patients in buprenorphine (Suboxone, Subutex) treatment who don’t have insurance now, and are paying out of pocket. My patient then remarked that I’ll be much busier, because more pain pill addicts will be able to afford treatment.

“No,” I said, “I can still only have one hundred Suboxone patients at any one time, so I can’t add any new patients.”

My patient was quiet for a moment and said, “So if an addict calls you because he just got insurance to pay for his treatment, you couldn’t see him anyway?”

“That’s right, unless I lost a patient for some reason, and had an open spot for him.”

“So even if addicts get insurance, they can’t use it? That’s crazy. Why does the government have that law?”

I explained to him about the newness of the DATA 2000 Act, and that some lawmakers were skittish about this program from the beginning. They were worried Suboxone “mills” would open, where hundreds of addicts were treated with little physician oversight or precautions.

Lifting that limit would be the easiest way to get more opioid addicts into treatment.

My private practice, where I treat opioid addicts with buprenorphine (Suboxone, Subutex), is a bare bones operation. Because of the one hundred patient limit, I have enough patients to keep me busy for one day per week. On the other days, I work at opioid treatment programs. I enjoy my own office practice because of the autonomy, and because I have some great patients that I’ve known for years. But at my own office, I make far less than half what I make at the opioid treatment programs.

I have the usual fixed overhead of rent, utilities, answering service, internet, etc., and most of the money I take in goes towards that. I have a part-time health care coordinator, who makes appointments for patients, calls them to remind them of appointments, does most of my office drug screens, screens my after-hours calls, handles the filing, copying and other record-keeping tasks, and deals with those pesky pre-authorization requests that insurance companies make. (She and the counselor have decided I ought not to be allowed to talk with the insurance companies, since I often erupt into profanity).Then I have the best LCAS (Licensed Clinical Addiction Specialist) counselor in the world who works with me on Fridays, doing individual counseling (he’s my fiancé). Since I don’t file insurance, but rather give the patient a receipt so they can file it themselves, I avoid that personnel expense.

And I don’t accept Medicaid or Medicare as payment for treatment. I feel guilty for admitting that, but I don’t think I could stay in practice if I accepted what these government programs pay for treatment. When I first opened my own office in 2010, I saw a handful of these patients for free, since trying to file and going through the necessary red tape isn’t worth the pittance these programs pay for an office visit.

So if my uninsured patients get Medicaid, I’ll have to decide how to deal with that problem.

It’s not legal for me to ask patients with Medicaid and/or Medicare to pay for treatment out of their pocket unless I opt out of those programs completely for a period of years. I can’t do that because some of the other treatment facilities that I work for do bill Medicaid.

So do I start taking Medicaid, with all its headaches, red tape and low re-imbursement? I don’t know. I don’t like the thought of it, but it will perhaps become a necessity. It will depend on reimbursement rates. Plus, I’ll be paid even less since I don’t have electronic medical records. Government programs have decreed that doctors without meaningful use electronic medical records will receive less money for Medicaid/Medicare patients than doctors with these programs.

I’m not against electronic medical records. I use them effectively at both of the opioid treatment programs. One program is completely paperless, and I like that much more than I ever thought. But in my small, one hundred patient office, I can’t afford any software for medical records. It’s not practical or feasible

Since I was trained and still am board-certified as an Internal Medicine doctor, I could fill my other days with primary care patients. I was talking to another doctor who was starting her own Suboxone practice, and she was wondering how to get by financially, only practicing Addiction Medicine. She too is a former Internal Medicine doctor. I suggested she could always do some primary care.

“Just shoot me in the head,” she said, summarizing my feeling exactly. I’ve never liked primary care as much as addiction medicine, to put it mildly.

Addicts are easier to deal with, and are often nicer people than the average soccer mom, demanding an antibiotic to treat her viral upper respiratory infection. But my biggest reason for preferring addiction medicine is that addicts get better. I never saw the big changes in health when I worked in primary care, like I do in people treated for addiction. Primary care feels like a step backwards. I don’t want to go back to treating non-compliant diabetics, and overweight people who won’t exercise. I’d prefer to keep my present patients, in whom I see an intense desire to get well.

I’m addicted to seeing the big changes that I see when I work in addiction medicine. I hope the new changes in healthcare will allow me to stay in the business of helping people change. Like the rest of the U.S., I’ll have to wait and see.

Suboxone: Miracle Drug or Manacle?

Yesterday in my office, I saw patients for whom I prescribe buprenorphine (better known under the brand name Suboxone). It was not my typically pleasant day. Usually, I see the positive changes occurring in the lives of my patients: they are getting families back, getting jobs or better jobs, getting health and dental care needs addressed, and overall feeling happier and more productive.

 But yesterday I had two patients who were bitter about being on Suboxone. Both were having great difficulty tapering off of Suboxone. Both had also been reading materials on the internet that described the hopelessness of ever tapering off this medication.

 This frustrates me for several reasons. First, not everything you read on the internet is correct. Second, people don’t appear in my clinic requesting Suboxone for no reason. All of my Suboxone patients were addicted to opioids before I ever prescribed Suboxone. Even assuming no patient ever gets off Suboxone, it’s still so much better than what they were doing before. Third, I’ve never said it’s easy to get off Suboxone. It can be done, but it’s still an opioid. When you stop opioids, you will have withdrawal. There’s no way around that. 

Overall, most people say withdrawal off Suboxone is easier than other opioids. But people and their biochemistries are different, and I accept that some people have a worse withdrawal than other people. I’ve had a few people say methadone withdrawal was easier than Suboxone withdrawal. I have to believe that’s their experience, but I think that’s unusual, and not the experience of most people. 

Some doctors think patients on maintenance medications, like methadone or Suboxone, should always stay on these medications, given what we know about the rates of relapse and even death for patients who leave these programs. And some patients have continued sub acute withdrawal symptoms for weeks or months off opioids, and just don’t feel right unless they are on maintenance medications. These people seem to do better if they stay on maintenance medication. 

And on the other hand, many people are able to taper off opioids and remain off of them, and lead happy, healthy lives. I keep thinking about two groups of recovering opioid addicts who do well off of all opioids, on no maintenance medications: members of 12-step recovery groups, and recovering medical professionals.

 Off the top of my head, I can think of a dozen recovering opioid addicts who are members of Alcoholics Anonymous or Narcotics Anonymous, and who aren’t on any maintenance medications. They feel fine, and have been abstinent from opioids for years. If you don’t believe me, go to an open Narcotics Anonymous meeting. Ask the recovering addicts there if they have been addicted to opioids in the past. Chances are that around a fourth of the people you talk to are recovering from opioid addiction. There may be a few people who are on methadone or Suboxone, but many are completely free from opioids.

 Look at doctors in recovery. Opioids were the drug of choice for many addicted doctors, and they are “real” addicts, having used remarkable amounts of opioids before getting into recovery. But doctors have one of the highest rates of drug-free recovery. This isn’t because we are so smart or special, or because we have Charlie Sheen’s tiger blood. It’s because we are held tightly accountable by our licensing boards. If we want to practice medicine, we have to participate in recovery. Licensing boards often hold our licenses hostage unless we do the work of recovery. This may mean three to six months of inpatient residential treatment, after a medical detoxification. It may mean four recovery meetings per week for the first five years of recovery, along with monthly random drug screen, and a monitoring contract for five years.  (1,2)

If every addict seeking recovery could have that degree of treatment and accountability, I suspect relapse rates would be uniformly low. Sadly, that’s just not possible for most opioid addicts, because of financial constraints, and because there’s less leverage with most people than with licensed professionals. 

Not all opioid- addicted doctors do great off opioids. Many have multiple relapses, and would probably be much healthier and happier if they got on maintenance medications like methadone or Suboxone, but isn’t allowed – at present – by the licensing boards in most states. Again, one type of treatment doesn’t work for everyone.

 My point is that it is possible for many people to get off Suboxone, and live a happy drug free life. And for other people, lifelong maintenance is probably the best and safest option. At present, we don’t have a way to predict who might do well off of Suboxone (or methadone). We do know that a taper should be slow, and probably takes four to six months for a taper to give best results.

 I believe in Suboxone. It’s saved many lives, just like methadone has. I wouldn’t prescribe it if I didn’t know it works. I think what I’ve been hearing and reading is a normal backlash against the unrealistic expectations many people had for Suboxone. It’s been called a miracle drug, but it’s not. It’s still an opioid, and there is still a withdrawal when it’s stopped. It’s a great medication for many people. It can allow many opioid addicts to get their lives back and enjoy a normal life, except for having to take a daily dose of Suboxone. But isn’t that still drastically better than active addiction? 

  1. Ganely, Oswald H, Pendergast, Warren J, Mattingly, Daniel E, Wilkerson, Michael W, “Outcome study of substance impaired physicians and physician assistants under contract with North Carolina Physicians Health Program for the period 1995-2000,” Journal of Addictive Diseases, Vol 24(1) 2005.
  2. McLellan, AT, Skipper, GS, Campbell, M, DuPont, RL, “Five Year outcomes in a cohort study of physicians treated for substance abuse disorders in the United States,” British Medical Journal,2008;337: a 2038.

Side Effects of Methadone and Suboxone: Constipation

When I ask my patients about side effects of methadone and buprenorphine (active ingredient in Suboxone and Subutex), the most common one they report is constipation. Nearly all people on any opioids have constipation. This is because the bowels contain opioid receptors, and when they are stimulated with opioids, the bowels relax and don’t contract as much.

So what can be done?

Of course, drinking more fluids will help. Then, try adding more fiber to your diet. Either eat more fresh fruits and vegetables, or get some of the fiber-containing agents. Some brand names include FiberCon, Metamucil, and Citrucel.

If that doesn’t get things moving, try adding a stool softener. If no results after all of these, consider trying the Miralax powder. Some people need to take it on a regular basis to keep their bowels moving. Some patients use a teaspoon of mineral oil every morning to keep them moving.

It’s a good idea to see a primary care or gastrointestinal doctor at least once, to rule out causes other than medication. If you have blood in your stool, weight loss, or a family history of colon cancer, we don’t want to ignore the possibility that something more serious could be causing bowel problems.

And anyone over 50 years old is due for a colonoscopy, anyway. (They really aren’t too bad. I had one last year and it was fairly easy.)

Methadone and Suboxone Can Cause Sweating

All opioids can cause sweating and flushing. But methadone is perhaps worse than the other opioids, since we use doses high enough to block opioid receptors, to get the maximum benefit from methadone in the treatment of opioid addiction. Buprenorphine (active ingredient in the brand Suboxone and Subutex) can also cause sweating, but since it’s a weaker opioid, people don’t seem to be as badly affected by it.

 We don’t know exactly why opioids make people sweat, but it is related to opioids’ effects on the thermoregulatory centers of the brain.

 Excess sweating can also be caused by opioid withdrawal.  If other withdrawal symptoms are present, like runny nose, muscle aches, or nausea, an increase of the methadone dose may help reduce the sweating.

 At least half of all patients on methadone report unpleasant sweating, but some patients have sweats that are more than just inconvenient. These patients report dramatic, soaking sweats, bad enough to interfere with life.

 First, non-medication methods can be attempted. These methods include common sense things like wearing loose clothing, keeping the house cool, and losing weight. Regular exercise helps some people. Talcum powder, sprinkled on the areas that sweat, can help absorb some of the moisture. Antiperspirants can be used in the underarm area, but also in any area that routinely becomes sweaty. The antiperspirant can be applied at bedtime so sweating won’t interrupt sleep. There are prescription antiperspirants, like Drysol or Xerac, but these sometimes can be irritating to the skin. Avoid spicy foods, which can also cause sweating.

 Make sure the sweating isn’t coming from any other source, like an overactive thyroid, and check your body temperature a few times, to make sure you don’t have a fever, indicating the sweating could be from a smoldering infection. A trip to the primary care doctor should include some basic blood tests to rule out medical causes of sweating, other than the dose of methadone.

 Some prescription medications can help, to varying degree, with sweating.

 Clonidine, a blood pressure medication that blocks activation of part of the central nervous system, blocks sweats in some patients.

 Anticholenergic medicines, drugs block the effect of the neurotransmitter acetylcholine in the involuntary nervous system, block sweating. Anticholinergics tend to dry all secretions, causing such common side effects as dry mouth and dry eyes. These medications can cause serious side effects, so they must be prescribed by a doctor familiar with the patient’s medical history.

 Some examples of anticholinergics include oxybutynin (also used for urinary leakage), bipereden (used in some Parkinson patients), scopolamine (also used for sea sickness), and dicyclomine (used for irritable bowel syndrome). All of these have been used for excessive sweating with various degrees of success, in some patients.

 For unusually bad situations, Botox can be injected under the skin of the most affected areas, like armpits, palms and soles. Obviously, this is somewhat of a last-resort measure.

Patients affected with severe sweats, unresponsive to any of the above measures, need to decide if the benefit they get from methadone outweighs the annoyance of the side effects. In other words, if being on methadone has kept them from active drug addiction, which is a potentially fatal illness, it would probably be worth putting up with sweating, even if it’s severe.

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