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    Old 08-06-2003, 01:18 PM   #1
    Grinolla
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    Post HELP re Bup finale to MS Contin taper (????)

    >Once you've plateaued, then the doctor can start tapering you down
    >about 2 mg (or less) every two weeks

    To all, especially Very Lucky/Mr Hope: (incl. message to Oldtimer)

    I have been reading several threads re Bup with major interest, as I do not have a dr with either experience or patience with questions and a complicated situation to which his training does not apply, as he keeps reminding me (did I listen? Nooo; he was so gung-ho at first that I did not appreciate the significane of "I have NO experience.") In any case, I was an intractable pain pt for the better part of the last 30 yrs. But the source of this symptom of my disorder regresses as women enter middle age & estrogen decreases. So, I am now trying to get completely off the MS Contin I've used to treat my pain since '97, ultimately by way of Subutex. And I've been tapering for the last 6 months and am down to 105 mgs, the equivalent of about 35 mgs of methadone, maybe 60 mgs Oxy & 10.5 Vicodin, so far. I began at several hundreds of mgs more, at first just to see if/how far my pain had regressed. Now it appears I can go all the way, but time is of the essence, for reasons including, but by far not limited to surgery both desparately needed & funded by a group insurance plan likely to be terminated at the end of this calendar year. And I had planned to switch to the Buprenex, now Subutex when I got down to the equivalent of 30 mgs methadone (90 mgs MS) and then just stop that within a week since I thought it did not build physical dependence, especially in such a short time.

    However, last week, the dr I consulted specifically for this purpose, offhandedly mentioned the need to taper from Bup itself, at a rate of 10%. But he was on call and even more unavailable for follow-up questions than usual. Since I have been reading the same story here, especially VeryLucky's comment excerpted above, I have begun to urgently wonder whether I could taper the MS itself just as quickly (or slowly) and perhaps even experience less withdrawal, something I have yet to do, than if I used the Subutex for the final 100 mgs as planned. It is difficult to taper below that point because the lowest dosage is 15 mgs, and, as a % of total dosage, each reduction after 105 to 90 (30 mgs meth) respectively represents 20%, 25%, 30%, 50% and then 100% from 15 mgs to zip. Yet, I dropped from 150 to 135 to 120 and, as of last night, 105 with just 4-5 days on each dosage w/ little or no problem. I also used to stop around the clock vicodin (5 mgs) every month for the days my pain was bearable with hardly noticeable symptoms. If I am able to get down to 60 mgs by my September appt., then I will be also at the same dosage. (60 mgs hydrocodone, also 25 mgs meth, etc.) Would the long-acting nature of morphine make a big difference? Or the nature of the substance itself?

    So, long story short, my primary question concenrs whether I will have to taper from the Subutex as well, and if so, how long will THAT take? 10% every day, week, more? And is that a physical issue or psychological one or both? Another complication is that I still have pain requiring medication 5-8 days per month at the moment, so I had scheduled the Bup or Sub switch for the first week of it. But if I am not off of IT by the end of that month, I will be in big trouble. And there is just so much needing doing between totally finishing the taper and surgery, which involves 6 weeks of IV antibiotics and tons of tests. All that & more, including the need to make plane and motel reservations for my Dad, who is coming in to help me thru whatever, all combine to make my need to decide what to do and exactly when to do it all the more urgent.

    In short, HELP!!!

    VeryLucky, I am directing my message primarily to you because I trust your information and experience, plus we share something else very important in common. Clue: "including, but not limited to." As a professional nitpicker, I also feel compelled to point out that Suboxone contains naloxone, not naltrexone, a BIG difference. And Oldtimer, if you are reading, why do you think you are an addict, rather than a pain pt? Because you will never legally qualify for Suboxone maintenance unless you meet the DSM criteria for opioid dependence and it certainly does not sound as if you do from reading your posts. Some people need meds; it does not mean that you are a failure or "relapsing'" because you keep taking them. Addiction is a whole different beast than appropriate treatment of pain, anxiety, depression or fear of withdrawal due to physical dependence. Just in case, it is also not misplaced shame about taking/needing meds, something I know all too well. Or did.

    In any event, any and all input desired regarding my dilemma and the details of a Bup taper. Thanks much in advance.

    [This message has been edited by Grinolla (edited 08-06-2003).]

     
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    Old 08-06-2003, 01:48 PM   #2
    eeyore714
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    My interest was sparked by something you said...that Suboxone contains naloxone, not naltrexone and that there is a big difference. Would you mind elaborating? If I remember correctly, naltrexone is what is in ReVia, and that blocks the effects of any opiate you might take, correct? So now I'm confused about what naloxone does, if they are completely different. thanks for clearing this up for me, if you can!

     
    Old 08-06-2003, 05:22 PM   #3
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    yes youll have to taper...i was on buprenex injectable for almost 4 years..if you abruptly stop it after awhile youll come down hard and fast...w/d's are different for everyone but i hurt..

     
    Old 08-06-2003, 05:59 PM   #4
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    Eeyore, I'll elaborate tomorrow, though your understanding of the workings of Revia as naltrexone is correct. Naloxone is merely a short-acting, weaker version that is usually combined with agonists and is virtually, if not always, inert unless injected. Or used on top of agonists. I am not sure there is much to add in the addiction context, but naltrexone has many little known medical benefits, some of which remedy the adverse endocrinological effects of long-acting opioids. And it is somewhat technical, so please stay tuned.

    And, Chef, I was fully aware that long-term use of Bup required taper, like any other opioid. But why would a taper be needed after only one week? And my primary question concerned the rate of taper. I am trying to determine whether it will take me as long to taper from Bup as it would for me to just keep on plugging with the MS Contin. I thought of using Bup in the first place because I believed that it would be quicker in that I could switch and then stop, all in a week or so. Again, I know it builds physical dependence with time, but ONE WEEK? And how long of a taper if you might know based on my intended usage?

    In any event, thanks for your response as well as in advance for any additional light you may shed.

    [This message has been edited by Grinolla (edited 08-06-2003).]

    [This message has been edited by Grinolla (edited 08-06-2003).]

    [This message has been edited by Grinolla (edited 08-06-2003).]

     
    Old 08-06-2003, 07:35 PM   #5
    verylucky
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    Grinolla,
    Sorry about the delay in responding, I just got in from mowing the grass. I believe you are asking if the bup might possibly assist and/or expedite the taper/withdrawal process from the MS Contin you have been taking. If I've missed the boat, spell it out for me again.

    My understanding is that the bup can, in fact, make the withdrawals much easier if you switch over to an equivalent dose of the bup as you are taking of the other opiates. Even though you may only take the bup for one week, you will still have the W/Ds because the opiate receptors in your brain that have been flooded with the opiates are being hit with an entirely different animal, but an animal nonetheless. But, again, my understanding is (and it's all anecdotal and what I've been able to glean from research I have done on the web) is that the bup will make the W/Ds much more bearable but it will not entirely take them away. The half-life of the bup is way out there so it makes a tapering plan much more doable than with most of the opiates (even the relatively long-acting ones like MS Contin -- assuming you haven't been chewing them up, shooting them or doing something else to speed up the process).

    It sounds like you are definitely dependent, but do you think you are an addict? I had too ask because the bup will also work better in those that are not chasing the euphoria because that is not a side-effect after your optimum dose is found and, even until then, it is only a minor effect -- not something you would chase if you are an addict.

    I would like to hear what some other folks have to say about Grinolla's question because I might not be all that objective considering I am very Pro-bup right now because of the experiences I'm having. Specifically, the fact I have NO thoughts of using or cravings. That is something I didn't know was possible for me to experience.

    Grinolla, I hope this helps a little and if I have totally misunderstood your question, please spell it out for my like you would to a first grader because I'm not the brightest bulb in the bunch.

    Keep us posted.
    verylucky

     
    Old 08-06-2003, 08:55 PM   #6
    verylucky
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    Grinolla,
    I can't hold my eyes open any longer but I will check this board as soon as I get to my office in the morning. You have really piqued my curiosity. We have something important in common and "including, but not limited to" is a clue? Hmmmm. I'm totally stumped. Does Voir Dire mean anything to you? Give me another hint.

    Have a good evening and, hopefully, I will talk to you tomorrow.

    verylucky

     
    Old 08-06-2003, 09:21 PM   #7
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    >I hope this helps a little and if I have totally misunderstood your question, please spell it out for me

    Verylucky,

    You hit the nail right on the head in understanding the gist of my concerns right off the bat. That belonging to the Cubs, not the Cards, of course. ;-)
    Thanks much for your response.

    Only problem is that I was heading to bed when I discovered it, and will fully digest your feedback, while adding more explicit information in view of your questions that might render my situation & concerns a tad clearer when I respond tomorrow. Especially with respect to the timing or rate of the Bup taper, which constitutes my primary consideration.

    But I would be struggling to type as well as to stay awake, without coming close to doing your post the justice it deserves, if I tried to address it tonight. I just hope that the 'lil bit I did just write made *some* sense! So, please stay tuned, and thanks again for caring.

    Grinolla

    [This message has been edited by Grinolla (edited 08-07-2003).]

     
    Old 08-06-2003, 09:50 PM   #8
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    >Does Voir Dire mean anything to you? Give me another hint.

    I did not see your pre-sleeping post before responding in kind or to the foregoing. I think you've got it with the voir dire, though another hint could not hurt. Hmmmmm. "Future Interests" ring a bell? Maybe an ancient sound, but at least the term may be familar. I was about to sarcastically identity it as something we ALL use every day <cough, cough>, but who knows? I *have* done voir dire a few times several years ago, escaping it thanks to settlement on most other occasions. But I again believe that, awake or asleep, we've reached a meeting of minds on this issue at least.

    Grinolla

     
    Old 08-07-2003, 05:44 PM   #9
    verylucky
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    Hey Grinolla,
    I expected to see you on here today. Everything okay?
    verylucky

     
    Old 08-07-2003, 05:58 PM   #10
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    I am not an attorney but I do know what voir dire is. Just had jury duty.

     
    Old 08-07-2003, 06:01 PM   #11
    Grinolla
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    >I expected to see you on here today. Everything okay?
    So did I. Thanks for asking. Things are okay, but could be better, as explained in the post I was almost about to send when I happened to notice yours. So, instead of starting from scratch, I'll quote myself:

    <<Geez, verylucky, I think I have asked for continuances 5 times already!! Not all from you, at least. But here comes one more, along with yet another hint That drop to 105 mgs after just five days was the first one that noticeably affected me since I began this process in March, so I've been quite a bit under the weather for most of yesterday and today as a result. And need to catch up on my sleep. I AM almost finished with my reply, addressing the issues you raised and then some. But this perfectionist and sleep-deprived person at the moment needs yet another day.

    I also spoke with my pharmacist at length this evening and he thought that tapering after only one week was craziness., but he really has no clue. And the MS is covered, while the Bup plan was all my idea, and self-supported as well. And I would not qualify for coverage anyway. Not fair!! I obviously need more facts to decide, and he loaned me his pharmacy's copy of all the info he was able to obtain from professional websites re Suboxone and Subutex. I am also still eager to follow thru with and make my intial plan work, especially if the MS reductions from here on down become much worse & require weeks or even longer in between. After all, don't hospitals use Bup for the purpose for which I intend in less than a month? I've heard it can be done in two weeks. Anyone know?

    While your post was quite helpful, for which I again thank you, you need more from me to hopefully answer my question(s). So, sorry about the delay. And I may be getting ahead of myself here, but do not worry about objectivity. I am just happy for you & your family that the med has been so helpful. That, to me, does not make you biased; it just represents your experience. And I will only be using Subutex for taper or detox and am seeking as much info as I can possibly get to enable me to make a decision. It also does not appear that anyone else has anything to add that might help me resolve my dilemma anyway. Oh well.

    Have a nice evening and hope to talk with you soon. Grinolla>>


     
    Old 08-08-2003, 07:16 PM   #12
    Grinolla
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    verylucky wrote:
    <<My understanding is that the bup can, in fact, make the withdrawals much easier if you switch over to an equivalent dose of the bup as you are taking of the other opiates. Even though you may only take the bup for one week, you will still have the W/Ds because the opiate receptors in your brain that have been flooded with the opiates are being hit with an entirely different animal, but an animal nonetheless>>

    Great explanation! It puts what I expected into words that I can use in explaining to others what I plan to do. But finding the equivalent dose is a trial and error process, is it not? And what I did NOT expect and am concerned about is the taper from the Bup itself or how long it may take. When Bup was first promoted on chronic pain boards 6-7 yrs ago, it was "sold" as the sole opioid that did not produce ANY physical dependence. Well, we all know that is not the case, but my question still is how much dependence can there BE after just one week? As I wrote in another post that may be clearer than this one will become, it makes NO sense to spend 10x as much time withdrawing from a substance than the amount of time I will be taking it.

    But I have yet to get any idea of what my dr may have meant when he indicated the Bup would be reduced by 10%. Would that be 10% per day, week, more? I also have no clue from what dosage I will be tapering, except that I know Subutex comes in 2 and 8 mgs and that it is not a "more is more" kind of thing. so I don't know if one can take more than 8 mgs in a day, but reducing 10% of 8mgs per day still could be a month or more. Unless it could be just 1 mg a day or 10% of the total a day would still be more than 10 days. I also wonder if dosage depends on how much one is taking when "induced" and/or how long one waits. So, I am trying to get as low as possible before my appt now scheduled for 9/02, in addition to just continuing my taper, to reduce the amount I will need and the withdrawal that may await regardless of the decision I make.

    May I ask at what dosage of what substance or med you switched from & how long you waited before the "induction"? And what you experienced? (sorry if I missed or do not recall it) is that equivalent dose what it takes to cover the MS Contin or morphine still in my body w/o inducing acute withdrawal? Or perhaps any? I have gone 24 hrs without when I forgot the lion's share of daily meds 2/4 nights. And while it was iccky, like a mild virus, I am all too used to those. I was also taking more than 200 mgs more at that time than I now am. But 72 hrs really scares me, what seems prudent given the time-release nature of MS Contin, much longer-acting than Oxy. (taken 2x v. 3x daily)

    Yet my pharmacist tried to explain how it is not really long-acting, at least not once released from the "time releasing matrix." But I am confused about how/when that happens and how it affects the process as a result. He claimed that it would not stay in my body as long as naturally long-acting methadone, but this too confusing to me. And hopefully not too confusing for you as well. I realize I am asking a LOT of questions and more are en route, but any answers are better than none. I really appreciate any time you can devote to helping me with the info I need to resolve my dilemma. My dad already has plane reservations, but I have yet to make the motel reservations because of my ambivalence. And that could render his whole trip pointless. No sane person leaves Seattle for the Midwest in August anyway.

    <<The half-life of the bup is way out there so it makes a tapering plan much more doable than with most of the opiates (even the relatively long-acting ones like MS Contin -- assuming you haven't been chewing them up, shooting them or doing something else to speed up the process).>>

    I am a bit confused on the comparable half lives and their implications for tapering. But no, I have never taken meds in any way but by mouth. How would or could taking them in other ways speed up the tapering process anyway? By producing withdrawal? I never even thought MS was possible to abuse by ANY route until I encountered Mr. MS Contin. Not only is Oxy 2x as potent, but almost all of it goes directly to the brain, while most of MS is excreted. I imagined that perhaps, if one's body were opiate-naive or s/he chewed 500 mgs at a time, then maybe they'd experience side-effects.

    <It sounds like you are definitely dependent, but do you think you are an addict?>

    I am no doubt physically dependent after well over 6 yrs of several hundreds of mgs daily, but not an addict. I am one of the majority who experience the initial side-effects of opioids as dysphoric, not euphoric. And have always hated them, gritting my teeth and almost losing my job until they passed with the MS.

    <<I had too ask because the bup will also work better in those that are not chasing the euphoria because that is not a side-effect after your optimum dose is found and, even until then, it is only a minor effect -- not something you would chase if you are an addict>>

    Are you suggesting that the Bup would work better in taper or detox, or are you referring to maintenance? And would the optimum dose represent that at which I have the least withdrawal and from which I can begin tapering? Is it the same or different from the equivalent dose? If you are referring to maintenance, then I am even more confused, because my plan was just to switch and stop, all within a week to 10 days. It was only after that offhand mention by my Bup dr, for the first time & after wasting $400 on him, that I'd need to reduce the Bup itself by 10%, followed by my reading here, especially your excerpted post that I began to wonder whether my plan was even doable. I still have trouble understanding why I could not just stop after a week, unless my body still needed to get rid of left-over morphine. A week does not seem long enough for my body to adapt to the presence of that new animal. But, assuming it is, how long would it, could it take? Not that anyone has the relevant facts, but still . . ANY estimates???? (as I asked already, I suspect. Sorry

    Good thing I waited before posting: I deleted about 4 paragraphs from the first draft, tho added a bit to it as well. My "please stay tuned" was long enough. Anyway, thanks much for your help. I look forward to any and all any insight or information that you or anyone here can offer. And, in case anyone is interested, I am much better today. But will wait a tad longer than 5 days before cutting the next 15 mgs.

    Grinolla

    [This message has been edited by Grinolla (edited 08-08-2003).]

     
    Old 08-08-2003, 08:54 PM   #13
    verylucky
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    Yowza!! I'm flattered but I want to make it real clear that I'm just sharing my experiences and my understanding of the research I've done. So please, anyone who has had different experiences than me, by all means chime in.

    ["But my question is how much dependence can there BE after just one week?"]

    You are looking at it from the wrong angle. Don't look at it from the standpoint of what is going into your system from this point forward but from the standpoint of what your system has taken in over the past 6 years.

    This may sound like a really stupid analogy but here it goes. Imagine you are an opiate receptor in your brain and for the last 6 years you have received a certain amount of stimulation every day to prevent a symptom in some other part of the body. Now, 6 years later, due to the maturation process, that other part of the body is no longer symptomatic. The fact that the other part of the body is no longer symptomatic, doesn't remove the fact that you, as an opiate receptor, have gotten used to (i.e. dependent on) receiving a certain amount of stimulation (over and above what a "normal" opiate receptor would receive). Now, just because the other part of the body no longer requires the extra stimulation, doesn't mean you can stop receiving what you, as an opiate receptor, are used to receiving without putting up a fight (i.e. withdrawals).

    Just because you no longer have symptomology that requires analgesics, and you are going from the MS Contin to the suboxone as a result, doesn't mean your opiate receptors aren't still going to want the "extra" stimulation they have been used to getting the past 6 years. So, the receptors have to be slowly weened back to where they can, once again, produce the naturally occuring opiates in your brain because your brain chemistry has been changed to a point where your body no longer can produce the opiates naturally. Hence, the need to slowly reduce the stimulation so your body's chemistry can catch up. It doesn't matter if you switch to the suboxone for only a week, the fact is your neurotransmitters are STILL being stimulated unnaturally (regardless of the substance causing the stimulation). Is that clear as mud???

    Yes, it is "trial and error" to find the right dosage of the suboxone to match the stimulation that the opiate receptors have been receiving. This is called titrating -- you start at a low dose and then move up or down depending on the effects you get from the particular dose.

    For example, I was taking mega-doses of Oxycontin and have been thru W/Ds numerous times (which get worse and harder to stop during each subsequent attempt at going cold turkey). Anyway, I was Chewing 200-300mgs per day--chewing 100mgs of Oxycontin is equal to taking 20 percocets all at one time. Therefore, I was started on a relatively high dose of the suboxone... 12 mgs. That wasn't enough to stop the W/Ds so we went to 16 mgs... still not enough, so we went to 18, then 20 and, finally, 22mgs did the trick. I stayed on 22 mgs for 2 1/2 weeks and then cut back to 20 mgs without any noticeable decrease in the positive effects (i.e. just being "normal" with no cravings or mental obsessions).

    The plan is to cut back 1-2mgs every 2-4 weeks until we get to around 8 mgs/day. At that point, we are going to stay on that dosage for a couple of months to "let the dust settle", as my addictionologist says. After that, we are going to reduce very slowly with the hope of being completely off the stuff in 6-9 months.

    You may have seen some of my posts where I talk about the most recent research which seems to indicate that some folks are simply unable to produce the naturally recurring opiates in their brains. Those are, typically, people like me who relapse time after time after time..... Therefore, I have accepted the fact that I may have to take a "maintenance dose" of the suboxone for the rest of my life. That's cool with me as long as I can continue to experience this thing called "normal" (i.e. no cravings, etc.).

    Since you are not an addict, my situation doesn't really apply to your situation other than the fact that you can use the suboxone to taper off the opiates that your body has become dependent upon. Which, according to what I've learned, is a really good idea since the W/Ds from suboxone are supposed to be much less severe than the W/Ds from the traditional opiates.

    The half-life of the opiates are how long, after taking a dose, the opiate receptors are being stimulated. For example (this is purely hypothetical), let's say the half-life of hydrocodone is 4 hours, Oxycontin is 6 hours, and MS Contin is 10 hours. Comparatively speaking, the suboxone has a half-life of 24 hours. Which means the receptors "lose" the stimulating mechanism by a much slower means when using the suboxone. (Again, this is purely hypothetical, so don't anyone freak out on me about the numbers I am using)

    Hence, if we use the earlier analogy, you, as an opiate receptor, will have a much longer period of time in which to adjust to not having the stimulation you were used to and the stimulating effect will leave you much slower thereby giving you more time to "adjust" and start producing the stuff normally again.

    I hope this helps a little. Again, if anyone else has any thoughts or experiences on the subjects addressed, I would really appreciate hearing what they are.

    MONDAY: how was the jury duty experience? I'm serious, I want to know what your impression of the process was. Does Alabama have an open voir dire process? Does the judge do most of the questioning? Or are the attorneys turned loose to ask the potential jurors questions? I would really like to know what you found distasteful or annoying about the process. Thanks.


    verylucky

     
    Old 08-08-2003, 09:41 PM   #14
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    Grinolla,
    I've got to hit the sack. I told my 6-year old son I would take him golfing tomorrow/today so I can expect an early wakeup call around sunrise. I'll check in tomorrow to get your thoughts on what I posted tonight.

    verylucky

     
    Old 08-09-2003, 06:29 PM   #15
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    verylucky wrote & I responded with only an introduction (looks can be deceiving), as I am still working on the rest.

    <<Yowza!! I'm flattered but I want to make it real clear that I'm just sharing my experiences and my understanding of the research I've done.>

    First off, while I greatly appreciate the instant gratification & substance your timely replies have afforded me, I am having trouble responding in kind. I cannot write off the top of my head unless it is about something with which I have firsthand experience, & it has taken me a while to digest the info in your post as well as to formulate a response. Your latest one was especially hard. And, secondly, experience is *exactly* what I seek; it is not only just what my doc lacks, but also what I think is ultimately what everyone has to rely on. Drs base their clinical practices on what they learn from their experience with pts. And use of this medication is a big experiment for all. You are trying to answer questions that my doc blew off, that he ultimately admitted that he just did not know, probably because he did not have the experience you do. I am also getting the distinct feeling that nobody else wants to chime in. Maybe because of the taper v. maintenance issue.

    Again, not to worry about potentially lacking balance in experience. (the "objectivity" concern) Aside from the fact that your experience is simply your experience, I can always evaluate the credibility or weight of information according to what I already know. I have devoted much time for several yrs to the cause of so-called "pain law," the goal of which lies in improving access to the treatment of intractable pain with opioid therapy through education & legal action. While not exactly an appropriate subject for this forum, the knowledge or information re: opioid therapy is quite relevant. But I am totally ignorant about buprenorphine & it's unique pharmacological properties.

    And, as indicated, your last post was a bigger challenge for me because it seemingly contradicts my understanding of the impact of opioids on receptors in several ways, but primarily by seeming to suggest that Bup or the tapering of it somehow plays a role in restoring endorphin production. It is complicated to address, & I am still working on it. Perhaps it is also not entirely relevant to my questions either, but still constitutes a particularly important subject in my opinion. But trying to reconcile what you posted about the rationale for tapering from Bup with my view of what goes on with our receptors in response to exogenous and endogenous opioids (endorphins) took some thinking time on my part. And the problem likely makes no sense in the abstract, but I did want to explain and apologize for my delay before tackling the specifics. My understanding is also derived from my research and experience, personal and (quasi)professional.

    Anyway, I hope you and your 'lil one had a nice golf outing together. I will be finished sometime tommorrow. I better be; among other things, I have to complete my medical deductions by 8/15. And I am going to any and all lengths to avoid facing, even finding, those facts. I did finally make the motel reservations for that 9/02 "induction," but my mind is still far from made up and your post raised all sorts of new questions. But that is not at all a bad thing in my view.

    And, did our minds at least meet on that "other" issue?

    Grinolla

     
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