May 30th, 2016

Opioid Pain Medication: A Neglected Option

You have heard a lot about how the overuse of potent opioid medications for the treatment of pain can lead to opioid addiction. Finding alternatives to opioid medications is important, but sometimes opioids are the best option. When this is the case, using ones that are least likely to cause addiction makes sense.

Buprenorphine, best known for treating opioid addiction, is an option that is frequently neglected for the treatment of pain. The parenteral formulation (Buprenex) was released in 1985 and has been widely used in veterinary medicine. More recently a transdermal patch (Butrans) has been approved for the treatment of pain. The sublingual form (Suboxone and others) is FDA approved for the treatment of addiction but can be legitimately used “off label” for the treatment of pain. Oddly enough, when used in this form, the prescriber does not have to take special training to get a “waiver” and is not limited to 100 patients.

The advantages of sublingual buprenorphine over other opioid pain medications include not causing tolerance or dangerous levels of respiratory depression. Because it only partially activates the opioid receptor sites, it has the additional advantage that it is not as “reinforcing” as other opioids and may, therefore, be less likely to trigger an addictive process.

Despite this history, when sublingual buprenorphine became available in this country in 2003 for the treatment of addictions, I was told that it was not useful for pain management. I was fortunate to meet Dr. Howard Heit, a prominent expert in the overlapping fields of pain and addiction. He taught me that buprenorphine would help reduce pain if the daily dose was increased above the standard addiction ceiling of 24 mg to 32 mg and the medication was taken three or four times daily instead of once or twice. To my surprise and the relief of my pain patients, it worked.

My own experience has now led me to the conclusion that for patients suffering from both pain and addiction, buprenorphine may perhaps be the most preferable option when opioid level analgesia is needed. However, using the medication in this way is sometimes not possible because of the refusal of insurance companies to approve the “off label” use of this medication in higher than standard doses.

There are already indications that physicians are prescribing fewer opioid medications. At the same time, there is concern that physicians may “overcorrect” and return to the pre-1990’s pattern of under-treating pain. Perhaps remembering buprenorphine as a viable option will help us find a middle ground.


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