Are there any opiates on the market or coming to market for pain that don't get you high

Factual Questions
81

Interesting observation, I couldn’t help but notice you’ve had a similar experience to me, where I noticed a generic med performed different than the brand name. I asked my doctor about this and he said there’s a regulatory component to this where for a drug to be called an ‘equivalent’ generic, it only needs to have 90% molecular match to the active ingredient in the pill, so there’s some wiggle room for pharma companies.

I also read that the other thing with opiates is that sometimes there’s cross tolerance (complete or incomplete) between opiates with different molecular structures so if you switch from one to another for a short period of time, it may give your body enough of a break to help make the initial drug more affective again

82

I’ve heard people on other forums also claim that the generic opiate pain meds from India are crap. Maybe they got a bad supply.

83

No, they’re right. They are crap. I read the reviews on medical sites and they all say the same, it’s junk and also that the fillers they use caused problems.

Ah, here it is.

84

Hydrocodone was always sort of a crap opioid in the first place, IMHO. Its effectiveness often depends on its conversion to hydromorphone yet some people don’t metabolize it into hydromorphone very well. Hydrocodone itself does not activate the opioid receptors nearly as well as hydromorphone.

The same is true for codeine, which must be metabolized into morphine to be effective. Yet up to 10% of the population lacks the enzymes to do this job.

85

No kidding? My mother and I both don’t react to it much; I always wondered the mechanism why.

86

I respond well to Hydrocodone but the India crap don’t have the amount they claim to have. If I took two together then I got some relief.

87

So to clarify, theres at least 3 opiates that can kill pain but do not cause euphoria, or cause a very mild form of euphoria compared to recreational opiates.

Methadone
Tramadol
Kratom

However QtM says he has seen bad experiences with both methadone and tramadol.

It sucks. This is an area of medicine that needs a lot of R&D.

88

Tramadol and methadone both give some euphoria to at least some patients, generally patients with a history of opioid abuse.

I can’t speak for kratom personally like I can for the other two, but opioid addicts in general report euphoria from kratom also.

I don’t know where the idea came from that there are opioid agonists that relieve pain but don’t cause euphoria. Even mixed agonist/antagonists like buprenorphine and pentazocine result in some euphoria in some individuals, once again more likely in opioid addicts.

89

Well then that makes two of us that are exceptions. I’ve been taking opiods for 15 years and while the dosage had certainly increased, they still work and are in fact the only thing that works.

If my doctors can come up with something, anything to deal with the pain I’ll never take another opiod the rest of my life. The problem is they haven’t. Cortisone shots - nope, gabapentin- nope, RF Coagulation - nope.

So, what now? Doctor tells me were out of options with only one left. A morphine pump. See, unfortunately for some of us opiods are the ONLY answer. As with the person above, without the opiods to control the pain I truly think a bullet would be the only option as the pain is just too intense. I truly couldn’t imagine years of this without relief.

Thru last year has been terrifying and depressing. Doctors not wanting to write prescriptions, pharmacies not wanting to fill them and with each passing day some idiot screaming for tighter restrictions. I worry each and everyday that tomorrow they’ll pass laws and take away or access to these drugs. Then what? What are people like me supposed to do? Take a few Tylenol and tough it out? For those that think that, may I suggest you try it yourself? I assure you that life without opiods would be unacceptable.

Oh and this supposed euphoria from these opiods? Mine must be broken as I don’t get that feeling. In fact other than stopping my rear end up like someone hammered a cork in my butt I get zero effects other then pain relief.

90

There are different kinds of opiates that affect different people and different subreceptors differently.

It was my understanding it was the mu opioid receptor that causes euphoria. So perhaps some opiates are able to kill pain w/o causing the euphoria by balancing out how each subreceptor is activated. If the Mu receptor causes euphoria, and the kappa receptor causes dysphoria then you’d assume a mu antagonist and kappa agonist would kill pain w/o euphoria.

Looking online, the drug nubain does that and it doesn’t cause euphoria. But the side effect profile isn’t nice.

Kratom has properties that make it unpleasant at higher doses. Tramadol is Schedule IV supposedly because it isn’t as habit forming. However that info may have been incorrect originally.

91

So I’m guessing thats kind of the answer to my question. Drugs that are antagonists to the mu receptor but agonists to the kappa receptor would kill pain but have a lower abuse potential.

92

The first time I was prescribed opiates (2006 or so) I was in acute physical pain (my infected ear didn’t cause my eardrum to burst, apparently because it was scarred, and the scar tissue was strong and fibrous. Rather, my eardrum just wept fluid and hurt intensely for hours).

I got quick pain relief from the prescribed opiates, which was great. But I had heard so much about opiate euphoria that I was surprised when I didn’t feel it at all.

Seven years later, I threw out my back and got another prescription. This time, it was like all of the bad things in the world just evaporated along with my back pain. I felt a deep and unfamiliar sense of well-being.

The difference, I believe, is that the second prescription arrived when I happened to be in profound emotional pain (my marriage was crumbling and in an extraordinarily ugly way. But I’m doing lots better now!). Someone way upthread suggested that while opiates relieve pain, they also relieve suffering.

That was totally my experience. When I was happy, I felt no euphoria. When I was miserable, the euphoria I felt may have been like the joke about banging one’s head on the wall—it feels sooo good when you stop. The opiates stopped the involuntary headbanging, and the relief was, well, euphoric.

I imagine some happy people also feel euphoria on opiates. But I think sometimes people ignore the emotional pain relief aspect of opiates when discussing their potential for abuse. Addiction is terrible, but I can totally see why someone who is truly suffering would seek whatever relief they could find.

93

Nubain is abused, too. I’ve even done so. Nubain is most likely to be abused by an opioid-naive population, as it will precipitate withdrawal in those who are opioid dependent. So it does limit its abuse potential, but doesn’t make it zero. Opioid-naive users of nubain report euphoria. And the DEA admits they don’t have a good handle on just how much nubain is being abused because as a non-schedule drug they don’t track it. DEA and nubain

So nubain could be a good drug for some pain patients, but they’d need to be off all opioids first, to benefit. AND it’s injectable only, so that complicates it. I’d think buprenorphine would work better, since it comes in an oral form. They both have the mixed agonist/antagonist ‘ceiling effect’ in that higher doses don’t cause more euphoria nor more respiratory depression, so it’s harder to kill oneself with that type of drug than it is with heroin or fentanyl.

Binding affinity to the various opioid receptors and mixed agonist/antagonist actions are at best rough guidelines for how the drug will actually work in an individual, especially one prone to opioid abuse.

94

I’m glad that you at least admit that such patient exist and that their needs do need to be kept in mind. There seems to be a notion that no opioids should be be given to anyone who doesn’t have cancer, which frankly scares the hell out of me and my wife. She has been on Methadone treatment for chronic neuropathic pain for around 15 years. She gets no high, but it allows her to function if not at a normal level of activity at least enough to get out of bed to do the dishes or the laundry. Without this prescription she is in tortuous pain that she describes as her legs being on fire. We do understand the overdose risk of the Methadone and so she is careful to only take as prescribed. But in her case you have to weigh the potential danger of overdose against the certainty of her death, should she commit suicide to escape the constant torture of her unmedicated pain.

I fully support reducing/eliminating opioids as the first line of defense against pain, and increased education of physicians. But for those people for whom these are the only drugs that allow them to function, they need to be left available.

Sorry about the soap box but this is an emotional subject for me.

95

15 years ago I ranted on this message board that the medical establishment was being far too free with opioids due to the delusion that pain was the 5th vital sign and that we were seeing an alarming spike in the inadvertent opioid OD death rate as a result.

3 years ago I ranted on this message board that we’d gone too far the other way, and were undertreating pain in a small but still significant number of pain sufferers who merited more opioids.

I seem to stay in the middle, but the world shifts around me. :confused:

96

That’s disappointing. However maybe those other drugs could be an alternative to schedule II opiates as an option for patients. Even if they are still prone to abuse, the abuse potential and od risk is less than some other opiates.

My dad is a chronic pain patient and uses opiates (among other things) to deal with the pain. It’s sad to see his medicine cabinet, it’s full of prescription meds, topical creams, tens units, otc pain relievers, etc he uses to deal with his daily pain issues, like he is searching for a solution and can’t find it. I hope research into finding safer and better ways to treat pain disorders comes out of this war on opiates.

97

I hope this isn’t too much of a hijack, but why are these pendulum swings so huge? I mean, opiate addiction is a very complicated problem, so I’d expect the dispensing pendulum to swing to some degree.

I’m aware of the policy changes and resulting whiplash, but in my experience as a patient (for what that’s worth) there’s enormous variability between individual clinicians even as those clinicians are trying to follow the same prescribing guidelines/policy.

Frankly, I’m shocked by how often[sup]1[/sup] I encounter grossly misinformed and/or overtly judgmental clinicians when the subject comes up. I get that not every physician is a specialist in pain management or substance abuse, but that doesn’t explain the strangely pointed sanctimony I’ve observed.

I’ve always chalked up that reaction to America’s Puritan heritage and/or a twisted understanding of the precautionary principle, but is there more to it than that?

Why do a significant minority of generalists react to patients taking controlled substances the same way Carrie Nation reacted to people sipping whiskey? Why do some clinicians feel free to express moral disapproval when they’d almost certainly not express it to a patient asking for birth control or an STI screen?

Is it possible that some prescribers just have rigid “drugs are bad, mmmkay?” views on the subject? If so, why aren’t those views dismantled during their training the same way a rigid attachment to phrenology would be?

I know it’s often hard to distinguish between people who really need scheduled meds and and drug-seeking addicts, but there’s a lot of legitimate frustration on the patient side of this. When the pendulum swings too far, it causes genuine suffering—regardless of the direction of the swing.

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[sup]1[/sup] I’m not a chronic pain patient, so it doesn’t come up that often. But it pops up unexpectedly. For example, I take naltrexone to control my drinking. I wasn’t a full-blown alcoholic by any means, but I developed a problem and got help. My drinking is well controlled without naltrexone, but it’s even better controlled with it.

When I moved for a new job, I saw an on-call doctor to get a “bridge” prescription to tide me over until I could find a PCP. She was a board-certified internist, but she wouldn’t write me a script because “naltrexone is schedule II and has a high potential for abuse. Furthermore, I’m troubled that you claim to be seeking treatment for excessive drinking but you’re not sober.”

Um…naltrexone isn’t a scheduled drug at all, let alone schedule II. Also, anyone who takes naltrexone to get high is going to be intensely disappointed. It’s an opiate antagonist; it makes drinking less fun and it makes opiates zero fun. The way I’m using it is both on-label and a well-established treatment modality.

This internist obviously had no idea what she was talking about, but I’m asking about the general case. I’ve had several other similar interactions, which is both frustrating and a little humiliating. I can’t imagine how awful it must be for people in real, opiate-appropriate pain.

98

US culture, is often one of all or nothing. And doctors are often stupid, and unwilling to admit it. If you need naltrexone (which I well know is NOT an abusable drug, nor is it scheduled) consult a board certified addiction medicine specialist. One who supports medication assisted recovery/harm reduction.

I’m purposely staying off my soapbox on this.

But the bottom line is that pain, like death, are pretty much inevitable in human life, and while progress has been made, good deaths and well managed pain issues are still more the exception than the rule. Sometimes that’s due to improper management, but other times effective treatment can’t be found, or can’t be brought to bear in time.

99

Were you prescribed the same drug both times, or do you know for sure?

100

First, thanks for answering my questions!

Thanks also for your input on who to consult…I appreciate it. For what it’s worth, while my PCP wrote my prescription, that was with the full knowledge and support of my psychiatrist at the time; her practice involves lots of work with addiction and recovery. We were explicitly pursuing pharmacological extinction…and frankly, it worked (for me) much better than I expected.

I’m pretty sure that soapbox involves the general subject at hand, but on the off chance that you have strong feelings about naltrexone or how it was prescribed to me, I’d be interested in hearing more. If you have more to say on those subjects and want to say it to me, please feel free to send me a message through the board.