Buprenorphine MED Poll

[101N]

What is the morphine equivalence of 8mg buprenorphine SL? Site sources if you have them.

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[drusso]

There is no straight conversion. Needs to be individualized to the patient. The elderly to stabilize on lower doses.

http://www.painphysicianjournal.com/current/pdf?article=MTcwNg==&journal=68

http://www.suboxone.com/content/pdfs/prescribing-information.pdf

 

[101N]

CDC 2016 8mg SL buprenorphine = 30mg oral morphine

 

[drusso]

CDC 2016 8mg SL buprenorphine = 30mg oral morphine

Ex Cathedra. I'd like to see the references for that. 8 mg SL in a rheumatoid patient with stomatitis is so different than 8 mg in a CP patient with sialorrhea.

It would be a mistake for a trainee to marry a conversion chart. All of them are just guides. Everyone treats patients not conversion charts.

 

[Aether2000]

Agree....charts are not accurate. For instance, many charts list a direct dosage equivalent conversion factor from other opioids to methadone. This does not take into account methadone is a hepatic self inhibitor, making the conversion factor much lower at higher steady state doses. Similarly for buprenorphine, since with 3mg/day, 50% of the receptors are occupied, at 12mg per day 80% of the receptors are occupied, and at 32mg a day 85% of the receptors are occupied. This flattening of the curve strongly suggest a ceiling effect so dosage equivalency of buprenorphine with other opioids cannot possibly be linear.

 

[101N]

I don't debate the fact that buprenorphine's MED calculation is non-linear. Neither is MTD. The question was what is the MED of 8mg SL.
CDC - and canine/feline vets - all agree it's about 30MED.

I think > 90% of the mu receptors are occupied at 16mg buprenorphine.

 

[Aether2000]

Actually the original question did not mention the dose of buprenorphine.....
It comes in 8mg and 4mg tabs as generic buprenorphine, and in several other dosage combinations with naloxone...
But I understood your implied dosage

 

[drusso]

I don't debate the fact that buprenorphine's MED calculation is non-linear. Neither is MTD. The question was what is the MED of 8mg SL.
CDC - and canine/feline vets - all agree it's about 30MED.

I think > 90% of the mu receptors are occupied at 16mg buprenorphine.

It still begs the question, "What does that mean?" The receptor activity/profile is different enough from full mu agonists that I don't think you can compare apples to apples. I always start low 2 mg induction dose and go slow and never titrate over 24 mg QD. In my experience, if you're tolerant to less than 60 MED then buprenorphine is usually not a successful drug.

 

[olafa]

.

 

[101N]

It's a good discussion to have. While the analgesic power of bupe SL @ 8mg is equivalent to 240 MED it doesn't give anywhere near the euphoria.
Patients who are seeking euphoria, or just accustomed to it as 'benefit' of their drug, often claim 'bupe' doesn't help their pain at all. I think some
of these folks are looking for the euphoria beyond pain relief. Hence why the vet literature is important. Dogs and cats don't lie and they don't seek
a high.

 

[101N]

So, where does the analgesia ceiling effect start to kick in? If 8mg bupe = 240 morphine does 16mg bupe = 480 morphine?
We all know it plateau's some where, what does the curve look like? Why can't a 960MED patient be induced with 32mg of
bupe?

At what dose does bupe plateau?

 

[Aether2000]

Theoretically, it should plateau when the receptor occupancy/dose curve becomes a plateau- which occurs at about 16mg. This, in conjunction with the long half life explains why the recommended dosage is no more than 16mg per day.

 

[101N]

I agree. You are logical. But I've converted at least 3 people on > 480 MED to bupe 16mg/d with no drama?

 

[deleted185747]

It's a good discussion to have. While the analgesic power of bupe SL @ 8mg is equivalent to 240 MED it doesn't give anywhere near the euphoria.
Patients who are seeking euphoria, or just accustomed to it as 'benefit' of their drug, often claim 'bupe' doesn't help their pain at all. I think some
of these folks are looking for the euphoria beyond pain relief. Hence why the vet literature is important. Dogs and cats don't lie and they don't seek
a high.

I'm pretty sure dogs and cats will seek a high. In rat experiments, the rat pushed the button which activated dopamine receptors at the expense of food and water. The rat starved with a hand on the dopamine button.

 

[101N]

I'm pretty sure dogs and cats will seek a high. In rat experiments, the rat pushed the button which activated dopamine receptors at the expense of food and water. The rat starved with a hand on the dopamine button.

Monkeys too. But these were opioid naive. No exposure, no high seeking.

 

[Aether2000]

Perhaps we could somehow use the presence of euphoria vs none with buprenorphine to stratify the type or degree of chemical dependency.....

 

[101N]

Euphoria can be measured in animals and there is one study comparing the release of dopamine with oxycodone vs morphine. But, most opioids have not been studied or compared.
Probably the easiest way to study it is by reading the bluelight threads.

 

[Aether2000]

Those are some of the most amazing human experimentation studies published!