Caregiver Cgtk: Tapering Opioid Plus Duloxetine

[CGTK]

Hello,

 

I am a caregiver. My patient is dealing with signs of a very serious neurological condition. He has no interest in doing any online research about his condition, which I think is wise, because we believe a positive attitude is a key to his recovery. It is not easy to maintain a positive attitude in the face of general information about his condition. So the online research is up to me. I notice that virtually all of the members here are the individuals tapering from meds themselves, rather than caregivers. However, I hope that I can be accepted as a participant here, under the circumstances.

 

I'll leave off the medical details except what seems relevant to this website.

 

He was given opioids last January (2019), for pain, and they didn't do much to help. So the opioids were increased gradually over some months, up to 120 mg. Embeda (time-release morphine) by (I think) last May/June.

 

In (I think) May, he was also given 60 mg. duloxetine by our PCP, intended to help pain. He didn't notice any effects on the pain, but continued taking them. At the time, we were desperate for anything that might help with pain. I regret not doing more research at the time.

 

Since then, he has also been given 50 mg. pregabalin/lyrica 2x/day, and we brought that down to 1x/day a few months ago.

 

He has tapered his opioids from 120 down to 80 mg. over a couple of months.

 

He is also taking many, many supplements. I know that some people don't advise doing supplements at the same time as a taper. However, we credit the supplements (among other things) for a very unexpected partial recovery with the neurological condition, so they are non-negotiable.

 

Anyway, now, having reduced opioids while keeping duloxetin steady, instead of dealing with constipation (a common side effect of opioids), he's dealing with diarrhea (apparently a common side effect of duloxetin??). This makes me wonder if the two had been somewhat balancing each other out, and now that opioids are decreasing, the duloxetin is able to exert its influence on the gut, causing diarrhea.

 

So we have pretty much decided to alternate reducing the Embeda (morphine, opioid) and reducing the duloxetin, in hopes that this will help with a certain sort of homeostasis.

 

I have read on some website (sorry, I don't remember where) that while most people taper one drug at a time, sometimes reducing one drug can amplify the effects of another drug, so some people choose to alternate tapering one drug and then the other, back and forth, and have done this successfully.

 

Anyway, we are also influenced by the information that apparently, tapering duloxetin has a better prognosis if started earlier rather than later, so we hate to put that off.

 

I'm wondering if anyone else here has experience with tapering from both duloxetin and from opioids, and also if anyone here has experience with alternating a taper of two drugs.

 

It seems that opioids act quite differently than SNRIs, although they both act on serotonin.

 

My patient has no history with depression, but from what I've read, that doesn't mean he won't experience depression as a side effect of withdrawal.

 

Anyway, I really appreciate this forum. I've already gotten a lot of great information. Thank you for your efforts. And my heart goes out to the many patients who are dealing with effects of withdrawing from these nasty drugs.

 

FYI I've never been all that impressed with the pharmaceutical industry, but after doing online research, plus reading Anatomy of an Epidemic, I've concluded that the pharma industry is nearly identical to the mafia, except that they don't go around with machine guns. That's about the only difference I see. Things are much worse than I previously thought.

 

Best wishes.

[Gridley]

Welcome to SA, CGTK.

 

Under the circumstances, I don't see any reason why we can't work with you if your patient is okay with our doing so.  

 

Regarding the supplements, it's true we don't recommend them (except for omegas and magnesium) because of the sensitized nervous systems of those in withdrawal, but that remains your decision.

 

It's also true that we recommend tapering only one drug at a time down to zero.  That said, we have had some members who have had success with alternating tapers. If I understand you correctly, you want to alternate tapering the opioid and the duloxetine while living the lyrica in place. We have no expertise in tapering opioids, but we can help you with the duloxetine.  

(Yes, diarrhea is listed as a side effect of duloxetine.)

 

Here are the basics: We recommend tapering no more than 10% of current dose every four weeks.  Some have to go more slowly.  

 

Why taper by 10% of my dosage?

 

An alternative tapering method that we also recommend is four weekly cuts of 2 1/2% per week followed by a two-week hold.  This is gentler than the 10% method as the reduction doesn't come all at once but rather is spread out over four weeks with a  hold for the system to acclimate itself to the lower dose.  This is how I've tapered my Lexapro.

 

The Brassmonkey Slide Method of Micro-tapering

 

The following link is specifically about tapering duloxetine, including information on how to obtain the non-standard doses you'll need for the 10% taper.

 

Tips for tapering off Cymbalta (duloxetine)

 

After each taper there will possibly be some withdrawal symptoms but returning to baseline before the next taper.  If symptoms seem to be harsh, that is a sign that you're tapering too fast and a hold is in order.  Here is some basic information about withdrawal:

 

What is withdrawal syndrome.

 

Daily Checklist of Antidepressant Withdrawal Symptoms (PDF)

 

When we take psychiatric medications, the CNS (central nervous system) responds by making changes over the months and years we take the drug(s). When the medication is discontinued, the CNS has to undo all the changes it made. Rebuilding the neurotransmitter production and reactivating the receptor and transporter cells takes time -- during that rebuilding process symptoms occur.  

 

Yes, Anatomy of an Epidemic was a real game-changer in how I think about these drugs.

 

This is your Introduction topic, where you can ask questions and connect with other members.  Only one Introduction topic per member.  We're glad you found your way here.

 

 

 

 

 

 

 

 

 

Edited January 13, 2020 by Gridley

[CGTK]

Quote

If I understand you correctly, you want to alternate tapering the opioid and the duloxetine while living the lyrica in place.

 

Yes, that's correct.

 

If the duloxetin is responsible for the current experience of diarrhea, we won't have much choice about stopping the opioid taper and commencing a duloxetin taper, at least once. Then after that, we'll have choices. Thanks.

[Altostrata]

Welcome, Cgtk.

 

Why do you think the duloxetine is causing diarrhea? Has this reduced since you've reduced duloxetine?

 

What has been your timetable for duloxetine reduction? Why are you reducing both drugs at once?

 

Have you looked closely at the supplements as a cause for diarrhea? Taking too much magnesium can cause diarrhea.

 

What is the daily drug schedule, with dosages?

[CGTK]

Hi,

 

We haven't started reducing duloxetine. We'll probably start today. The reasons I think Dulox may be causing diarrhea are:

 

1. Diarrhea is a side effect of Dulox. Constipation is a side effect of opioids. It's possible that the opioids have kept the diarrhea-inducing tendencies of Dulox at bay, and now that the opioids are less, the Dulox. has a chance to cause diarrhea.

 

2. He did a GI pathogen panel, and it was negative. Apparently this panel is quite sensitive and sometimes picks up on things that aren't even causing problems.

 

We haven't been reducing both drugs at once. We've been only reducing opioids so far. Opioids have been stable for several weeks now (except a couple times of forgetting), and we're planning to reduce Dulox starting today.

 

His supplements have been stable for months, and the diarrhea is recent, so I don't think the supplements are causing the diarrhea. Also, if he doesn't take his supplements because his stomach doesn't feel strong, it doesn't seem to make a difference in the diarrhea. We are aware of the magnesium effects--that has been our main strategy for keeping the constipation symptoms of the opioids under control, back when he was tending towards constipation. He was taking a lot of magnesium, until recently. With the diarrhea, we've taken out all of the magnesium citrate, and some of the magnesium glycinate as well. We could take out all of the glycinate, but that does not have a very strong action on the gut, so I don't think it would do much.

 

Anyway, we'll find out what happens.

 

His med schedule is:

 

Around noon:

40 mg. time-release morphing (Embeda)

30 mg. duloxetine (Cymbalta)

100 mg. doxycycline

 

Around 9:30 pm:

40 mg. time-release morphing (Embeda)

30 mg. duloxetine (Cymbalta)

100 mg. doxycycline

50 mg. pregabalin (Lyrica)

 

Best wishes.

[CGTK]

I have found a place on this website where an alternating taper of 2 drugs is suggested, although with a different pair of drugs:

 

"One might systematically lower the antidepressant part way, then lower the antipsychotic part way, then back to the antidepressant, managing the tapers in a way that preserves sleep. The lower dose of antipsychotic will have a lower risk of adverse effects."

https://www.survivingantidepressants.org/topic/2207-taking-multiple-psych-drugs-which-drug-to-taper-first/

 

I'm thinking this alternating taper could be good for us, with duloxetine and opioids, for a couple of reasons.

 

According to this website, it's generally best to start with an "accelerator", and ADs are accelerators, if I understood correctly.

 

However, according to other websites, ADs can make opioid tapering easier, e.g.:

https://mhc.cpnp.org/doi/full/10.9740/mhc.2015.05.102

 

In addition, checking with his body, my patient said it feels better to him when he "tries on" the alternating approach, vs. going all the way down with one first.

 

So the alternating approach might be best for him.

 

BTW I'm not asking you to recommend an approach that seems risky to you. We are under the care of a doctor who is the ultimately responsible party, so long as we follow his recommendations or go slower than his recommendations. We met with him yesterday, and I'm pretty sure this alternating taper approach is fine with him, but I'll double-check with him.

 

(Also, I am not recommending an alternating taper for anyone else.)

 

I just thought it was possible that someone here already had experience with the alternating method and/or with the 2-drug combination we're dealing with, but it looks like that isn't the case.

 

No problem, I wish you all the best, and I think you are providing a valuable service.