My friend and MMT

[Franklin]

A girl I know has been under my wing for nine months now,while we have been sorting out her physical/medical health, only one aspect of which is now outstanding.  She started on Endorphin Replacement in January 2009 at 25ml, and is now up to 105ml.  The problem she has is that she pukes, very often after only five minutes, which seems to me to be a bad thing.

She has dosed on an empty stomach, on a moderately full one, varied the time of her visit to the pharmacy and recently started to split her dose, as well as using prescribed anti-emetics, but all to no avail.  It is possible that the outstanding and very belated abdo/pelvic scan she is now booked for will result in an explanatory diagnosis leading to treatment which will stop the puking , but what if it does not?  CSMT has decided that our friendship is unhealthy for her (she is young enough to be my daughter), and will not speak to me even in general terms, and her GP, Pharmacist and Consultants, while they are happy to comply with her confidentiality waivers, are without illicit substance expertise.

Since she gains little, if any, benefit from the Methadone; she still craves.  Has anyone any ideas, please, in case the scan shows nothing?  I wonder if it might  be possible to try another treatment, say subutex.  She has spoken of trying to reduce her meth, but she cannot be remotely stabilised yet, I believe.  She was rattling like a box of nails when I dropped her back home last night.

Any suggestions gratefully received.

Many thanks,

Franklin

[znagemq]

What is she like when consuming other liquids, tablets, food etc?
Has she said why she thinks she is throwing up? Is it the taste, consistency etc? Is she generally rattling when she goes to the chemist? Could she be pregnant?
From what you have said and based only on this I think there are a few options;
1) Mixing the dose with a more palatable drink
2) Lemon flavoured Methadone could be worth a try? Or Physeptone tablets (Basically Methadone in tablet form)
3) Subutex but this has to be dissolved under the tongue and can take 5 minutes or so.

There are other options but these suggestions need to be tried first really

[Franklin]

She can cope with food, but not too much at a time. She also drinks tea, the occasional coffee and alcohol, the last sometimes to excess.  She says she pukes because she's rattling, and I have seen such things before.  Pregnant I can assure you she is not, for although she was amenorrhoeic for 10 months, with menstruation recently re-established by HRT her piy=tuitary produces no LH, in the absence of which a fertilised ovum will not implant.

I include below what I wrote to my my OR family member 'joe', which may indicate where I am coming from:-

"I looked up Bucca-Stem, which was prescribed by the GP she saw last Friday when she asked for an anti-emetic.  I don't suppose you will believe me when I tell you that several sites, including those of manufacturers, informed me that this drug is an anti-PSYCHOTIC, in the same family as Chlorpromazine  My friend isn't simple, when she's well she has a wonderfully analytical mind, and questions everything, but where the hell does she go from here?

I am, very probably, entirely simple, allowances should be made for my idiocy etc., but I cannot see why somebody who asks for an anti-emetic should be prescribed a drug with no recorded anti-emetic effect whatever, unless the quack has jumped a stage and concluded that her vomiting is psycho-genetic in origin.  Just because she has somebody who cares for her does not mean that she is incapable of making up her own mind, surely?  If professionals are not going to speak truthfully to her, what chance does she, or any of the rest of us, stand?

I not sure whether to stand hear with my teeth bared, saying "GRRrrr!", or whether I should just cry "Help?""

If she throws , it seems to me that she throws, and chucking up after a methadone dose is not a good thing, particullarly when you can scarcely get up to the bathroom in your flat from the pharmacy that is just over the road (20 yards max.).  When she, two months ago, was admitted to hospital with a systemic infection thought to have resulted from an earlier UTI, which I had first mooted to her then GP last November, she threw her meth until such time as her deslignated nurse gave her anti-emetics.  To a degree, I can understand the doctor's reluctance to tell her what he was doing, but I feel he could have spoken with me.

I think mixture won't work, because unless it is the 'right' time, she will throw up water, tea, dry toast, anything.

Physeptone, there's a thought!  Hadn't thought of them since my childhood chum Max was pulled out of a canal in Amsterdam 35 years ago!

As for Buprenorphine, she says it's a no-no but there is no way I can check this.

Why is it that nobody is totally caring for the health of addicts, or is it just so that each and every one can wave away the rancour when things go badly wrong, waving away responsibility? 

Luv, f.

[znagemq]

Some drugs workers are good and some seem to lack any empathy what so ever and are quick to shrug off the more complicated situations either because they don't really care or because they don't know how to deal with things.
What area are you from?
Subutex - I can understand why it is a no no because it does not suit everyone. I think your friend may have to try Physeptone and see how things go with that.

[Franklin]

I live in West Midlands. UK.

I accept that not every drug worker, GP, Clinic Doctor or Nurse will be at the top of his or her game all the time, but it grieves me that there is no over-arching coordination.  It should not be down to me to chase up why samples have been incorrectly labelled, scan appointments have not been made, an anti-psychotic prescribed when an anti-emetic was requested, a query UTI has been allowed to develop into septicaemia over 7 months requiring hospitalisation by ambulance on a Bank Holiday ... I could go on, but you get the picture.

I have my own life to get on with. and cannot be there for my friend all the time.

f.

[znagemq]

It all sound a complete nightmare. Have you thought about making an official complaint? It may mean these things stop happening.
If you would like assistance or information you could ring our helpline on 0845 122 8608. We have an advocate who covers your area. It can be difficult for the carer though due to confidentiality even though your friend has said it is OK to share information with you, the professionals involved sound like they are making judgements and assumptions about this.
I wonder what anyone else on the forum thinks?

[Ursula]

To be honest, the Alliance couldn't get involved in an advocacy capacity unless your friend rang us herself.  However, if you want support and advice around possible steps forward, we can obviously give that to carers/friends.

[Flip]

Hi Franklin

I think you may be over reacting a little  to the doctors  prescription of "Buccastem". In small doses it is  very effective for cutting down and preventing nausea. It's only in high doses that it has anti psychotic effects. Its a very common anti nausea treatment, I've had it myself on numerous occassions and had no problems  with  it.

 In this instance I dont think the doctor is trying to administer anti psychotics by a "backdoor" method it's pretty much what I would expect to be prescribed if presenting with nausea. The dosage of the "Buccastem" tablets is quite small, if a doctor was wanting to administer "Prochlorperazine" for an anti psychotic effect I doubt that "Buccastem" would be the choice of delivery method.

Ive had a few problems with nausea in the past and been prescribed "Domperidone" (brand name Motilium) it appears to be quite effective, it may be worth asking your doctor about them if you are really worried about "Buccastem".  I just checked and you can get Domperidone over the counter in the UK apparently its available in liquid too which might be more suitable. Given your friends apparent gastric problems it may be best to ask your doctor rather than resorting to self treatment.

I do understand your viewpoint and guarded reaction to doctors though ; I went through something similar to what you describe  a few years back . It's bad enough trying to navigate through the various services for your own use let alone someone elses!

Good luck and I hope it works out for you.


Flip

[Lelee]

I've copied and pasted this from the internet for you.

'Buccastem M tablets contain the active ingredient prochlorperazine, which is a type of medicine called a phenothiazine. Prochlorperazine has two quite different uses. In higher doses it is used in the treatment of psychiatric illnesses. In lower doses it is used in the management of nausea and vomiting.
The Buccastem M brand of prochlorperazine can be bought from pharmacies. It contains a low dose of prochlorperazine to treat nausea and vomiting associated with migraine. The prochlorperazine works by blocking dopamine receptors in an area of the brain that controls nausea and vomiting.

Vomiting is controlled by an area of the brain called the vomiting centre. The vomiting centre is responsible for causing feelings of sickness (nausea) and for the vomiting reflex. It is activated when it receives nerve messages from another area of the brain called the chemoreceptor trigger zone (CTZ) and when it receives nerve messages from the gut.

Prochlorperazine controls nausea and vomiting by blocking dopamine receptors found in the CTZ. This stops the CTZ from sending the messages to the vomiting centre that would otherwise cause nausea and vomiting.

Buccastem M tablets should not be swallowed like normal tablets. Instead they should be be placed high up along the top gum, under the upper lip on either side of your mouth. If you wear dentures, the tablet may be placed in any comfortable position between your lip and gum. The tablet will soften and stick to your gum, taking between one and two hours to dissolve completely. The medicine is absorbed into your bloodstream through the rich supply of blood vessels in this area. You shouldn't move the tablet about the mouth with your tongue as this will cause it to dissolve more quickly.

What is it used for?

- Nausea and vomiting associated with migraine in adults over 18 years of age.'

I hope that helps put your mind at rest. It's important that your friend stabilises on her medication and as suggested it might be more benficial for her to be transferred to physeptone tablets or a more concentrated form of methadone so she doesn't have to imbibe so much liquid, instead of taking more medication to counteract her vomiting. These options are only ever used in exceptional circumstances and from what you're saying I think this meets that criteria. It's reassuring to note that medical causes are being explored but that doesn't help with her immediate need.

Let us know how it goes.

Linda

[mcdermott]

A girl I know has been under my wing for nine months now,while we have been sorting out her physical/medical health, only one aspect of which is now outstanding.  She started on Endorphin Replacement in January 2009 at 25ml, and is now up to 105ml.  The problem she has is that she pukes, very often after only five minutes, which seems to me to be a bad thing.

She has dosed on an empty stomach, on a moderately full one, varied the time of her visit to the pharmacy and recently started to split her dose, as well as using prescribed anti-emetics, but all to no avail.  It is possible that the outstanding and very belated abdo/pelvic scan she is now booked for will result in an explanatory diagnosis leading to treatment which will stop the puking , but what if it does not?  CSMT has decided that our friendship is unhealthy for her (she is young enough to be my daughter), and will not speak to me even in general terms, and her GP, Pharmacist and Consultants, while they are happy to comply with her confidentiality waivers, are without illicit substance expertise.

Since she gains little, if any, benefit from the Methadone; she still craves.  Has anyone any ideas, please, in case the scan shows nothing?  I wonder if it might  be possible to try another treatment, say subutex.  She has spoken of trying to reduce her meth, but she cannot be remotely stabilised yet, I believe.  She was rattling like a box of nails when I dropped her back home last night.

I can understand the concerns of your local substance misuse team even though your relationship may be perfectly innocent/appropriate. Vulnerable young women coming under the sway of older, seemingly more worldly, men are always going to be a source of anxiety. Rightly so, in my book.

You say your friend derives no benefit from the methadone, re. cravings. Does this mean she's continuing to use illicit heroin? If so, the nausea/vomiting isn't that surprising. It's a well documented side effect of high doses of opiates. Indeed, even if she isn't using on top, her relatively rapid titration to 105mg might well be causing the same effect.

For a very long time, I also had nausea/vomiting as a consequence of my methadone use. And by long time, I mean it persisted for maybe 10 - 15 years, on a much lower dose than your friend. And I was taking methadone by injection, so it had nothing to do with the oral route. I'd inject 40mg and throw up -- and then after a while, I'd throw up after picking up my dose but before I'd used it, in a classic pavlovian conditioned response.

I didn't regard it as a significant problem because the dose was holding me and I wasn't experiencing cravings. Given that this isn't the case with your friend, I'd go along with others and suggest she might want to try subutex for a while.

If subutex doesn't work, her choices are pretty limited. No more so than in the rest of the world, but more limited than they used to be.

For some people though, anything less than diamorphine just doesn't satisfy that desire that they have. They might not be physically withdrawing, but they still have a desire for the drug that they aren't willing or able to defer. The extent to which people have any choice in this issue is an interesting one, and is largely unexplored. I'm not even sure that it matters that much. Some people are prepared to tolerate enormous negative consequences before changing their behaviour, while others perceive fairly moderate discomfort as being 'rock bottom' and spend the rest of their lives pursuing abstinence in twelve step fellowships.

I don't think anyone knows what the answer to this particular problem is.

In some European countries, this is a new option on the menu, and we've been trialling it here in the UK in special clinics for non-responders, but the idea that there's going to be money for an expansion of this option in the current political climate seems very unlikely. Her best bet is probably to give subutex or suboxone a try.

There's also good evidence (RCT's, IIRC) that naltrexone has a fairly powerful anti-craving effect in alcoholics and opiate users, but there's no point in exploring that while she's still getting agonist therapy. But if she decided to explore abstinence based treatment, that might be worth looking at.

[Franklin]

Dear McDermott and all oters who have replied,

There is the possibility of Detox 5, followed by naltrexone implant, supported by subsequent 6 months rehab., but whilst her physical health is still unsorted, this remains a counsel of perfection.

I saw her GP this a.m., and he had not realised that the active ingredient in Bucca-Stem was an anti=psychotic until I showed him the print of the manufacturer's web-site.  He gave me a script for her for Cyclizine, an anti-histamine (3 daily), then I rang her to tell her that I had an alternative medication which I then called at her flat to give her.  She took one straight away, which did not stop her throwing last night's dinner, though when I had brought her over here from where she lives for access with her son, she took a second, and when I later dropped her off in her home town she had her meth, but had not puked by the time I rang her at 20:10 when I got home.

I have my fingers crossed, but we may be getting somewhere.  She is now waiting on her abdo/pelvic scan appointment, after which all physical/medical problems will have been investigated.

We all differ in our responses to different drugs, it seems to me.  I suffer with chronic pain, and take from 0-300 mgs of dihydrocodeine per day, depending on the level of pain and my tolerance, and also what I need to do on any particular day.  I would sooner do without altogether, but I cannot drive if I am going to be afflicted with spasms.  Alcohol I can take or leave, but as for nicotine, I am married to it.  Oh, and I did use in my youth, some 30 odd years ago.

As I understand it from my State-side friends, she will have to be down to 30 mgs per day before she can consider abstinence.  I think that a major problem is her aversion to the physical consequences of rattling, suffering with OCD as she does, given also that she needs to mother her children, and her mother, and her flat-mate, when she had her first child whilst still a child herself. (Counselling is being considered, by her, I hasten to add).  Anyway, there is perhaps a new possibility, in that if she stops heaving her dose, she might just stabilise.

If we can't hope, we might as well give up!

f.

[Franklin]

Dear Linda,

If the manufacturer says it is an anti-psychotic, and nothing more than that, I do believe that useful in the treatment of 'nausea and vomiting associated with migraine in adults over 18 years of age.', without citation, can be considered little more than anecdotal.  I am fascinated that the directions for consumption that you reproduced vary from her GP's sub-lingual advice.  Bucca-stem.it's there in the name really, isn't it?  I could get angry, but it would seve no purpose.  Grrrr!  Luv, f.

[Lelee]

Dear Franklin

Your earlier post said

'but I cannot see why somebody who asks for an anti-emetic should be prescribed a drug with no recorded anti-emetic effect whatever, unless the quack has jumped a stage and concluded that her vomiting is psycho-genetic in origin.'

I was seeking to reassure you that the 'quack hadn't jumped a stage and concluded her vomiting was psycho-genetic in origin', and that this drug did have a common 'recorded anti- emetic effect'.

From my earlier post copied and pasted from the internet:

 'Buccastem M tablets contain the active ingredient prochlorperazine, which is a type of medicine called a phenothiazine. Prochlorperazine has two quite different uses. In higher doses it is used in the treatment of psychiatric illnesses. In lower doses it is used in the management of nausea and vomiting.
The Buccastem M brand of prochlorperazine can be bought from pharmacies. It contains a low dose of prochlorperazine to treat nausea and vomiting associated with migraine. The prochlorperazine works by blocking dopamine receptors in an area of the brain that controls nausea and vomiting.'

Both oral administration routes, bucal and sublingual, are effective and pass through the mucus membrane into the system and will not pass through the liver before entering systemic circulation

You have said your friend has responded well to the anti histamine so that's good news. We're doing our best to help. 

Linda   
 

[Franklin]

I know, and you are helping, for which many thanks!

Luv, f.

[Franklin]

I share with you my laughter and tears, firstly because my Telford friend is puking less, beginning to to show signs of stabilisation, has a new (female) drug worker with whom she can relate, and is showing greater engagement with reality than I have seen in her for ages. 

Secondly, my hairdresser has resolved to go on Endorphin Replacement Therapy, and is making a fair go of rebuilding her life. 

I got a 'phone call from a number I didn't recognise yesterday, assumed it was from a dealer, because I lend my 'phone to people on occasion, cautiously answered 'Yes?', and was surprised when it turned out to be my daughter's mum, accepting, on behalf of both, my invitation to her and daughter to lunch on Friday.  There has been no face to face contact for 23 years. 

What have I done to deserve all this happiness?  I wish that I could truly share it out! 

Franklin.