OK, so this isn’t the most exciting title one will see about Suboxone… but urinary complaints are some of the more frequent side effects that I hear about from Suboxone. The complaints fall into two or three different categories. Realize that these are NOT complaints that I have read about in the literature or heard about from the manufacturer; these are things that I hear in the course of my practice from patients on Suboxone.
Frequent Waking to Urinate
During normal sleep the body does several things to turn off the production of urine by the kidneys. The pituitary gland releases a drug called vasopressin or ‘antidiuretic hormone’, causing the kidneys to reabsorb more of the water in the distal tubules of the kidney, making the urine more concentrated and lower volume. Other hormones like renin and angiotensin are released by the kidneys and adrenal glands, causing the pressure in the filtration area to decrease and sodium to be absorbed in another part of the kidneys. All of these things are intricately connected and balanced; they are thrown off when you go to a late movie and order a large bag of salty popcorn and wash it down with a big coke, which adds fluid to your system and also caffeine, which stimulates water to flow from the bloodstream to the urine at an increased rate.
But in the absence of the popcorn and coke at the movies, the kidneys generally shut down so that you can sleep without the interruption of a full bladder. Opiates throw all of this off a bit by affecting the secretion of these hormones. The major effect is on antidiuretic hormone, but opiates have effects that are more subtle on a number of hormone systems. The result is that patients on Suboxone make urine at night while they are trying to sleep, and their bladders fill up and wake them up, sometimes several times per night. I suggest that people limit fluid intake toward the end of the day; that will reduce the formation of urine and perhaps improve sleep. There are other options for extreme situations; a drug called ‘desmopressin’ is sold as a nasal spray, and it will shut down the kidneys for the night if necessary. It is also used in children to reduce bedwetting.
I Gotta Go… Right Now!!
I have heard several patients complain that they will not have to ‘go’, but then suddenly… they WILL. In fact, they suddenly have to go SO BAD that they will have an ‘accident’ if they aren’t near a tree to run behind. I assume that this is the result of bladder spasms– sudden tightening of the muscles that squeeze the bladder and force urine to come out. I don’t know the mechanism for this one, except that urination is a function of the ‘parasympathetic nervous system’– a part of the nervous system that controls all of our organ systems, including the bowel and the heart. As I said before, opiates have effects throughout the brain, spinal cord, and peripheral organ systems; some subtle, others more dramatic. I have not heard about bladder spasms and Suboxone from the literature, although given the complaints by several patients I do watch for reports along those lines.
The act of ‘going’, or ‘micturition’, requires the parasympathetic nervous system to open things up… this system shuts down for some guys when they are standing at the urinal at Lambeau Field, a long line of impatient guys behind them anxious to get back to watching the game. This is also called a ‘shy bladder’, and it occasionally leads to drunk men yelling ‘c’mon, just go and be done with it’ from the back of the line, usually as they dance around to avoid peeing their pants. Opiates interfere with this system as well. In fact, patients who receive spinal or epidural narcotics sometimes need to be catheterized in order to urinate for up to 24 hours. When I was an anesthesiologist we had a rule against using spinal narcotics for day surgery, and one reason was to prevent pateints from needing to return to the ER to have their bladders emptied. High doses of oral or parenteral opiates will often prevent a person from peeing as well.
I… Can’t… Go…
Those darn prostate glands! Older guys get a bit blocked off by the prostrate gland; this is aggravated by any drug that has ‘anticholinergic’ side effects. This can be a problem with some opiates, but I have not seen it as a problem from buprenorphine.
There it is… all you wanted to know about urination and more. Most people are also well aware of the effects of Suboxone on the ‘other’ part of bathroom business… but that is for another story. Until then… eat prunes and drink lots of liquids… but drink them early in the day so you don’t have to get out of bed to pee! All of this is just more evidence for the obvious… that the body works best when it is in its native state, and that any medication is going to throw things out of whack a little bit. With a potentially fatal illness like opiate dependence, the effects of buprenorphine on number one and number two are just trade-offs that must be made. Remember that we are in the very early stages of a new way of treating opiate dependence; in the future we will certainly have medications that avoid many or all of these side effects. Your job for now is to make sure you live that long!