Buprenorphine in its sublingual forms, tablet or film, is only indicated and approved for the treatment of opioid addiction. So what do doctors do when their Suboxone patients have pain? This is an area of medicine that’s still evolving.
The treatment of pain depends on the type of pain and the expected duration of pain. We can organize pain into mild, moderate, or severe categories, and into acute or chronic. Most doctors define acute pain as pain expected to last less than three months, and chronic pain as expected to last more than three months.
Mild pain doesn’t always need an opioid medication. For example, many dental procedures cause pain that can be easily managed with anti-inflammatory medications like ibuprofen or Tylenol.
Mild to moderate pain can sometimes be treated with Suboxone, either by increasing the patient’s total dose, or by dividing their same dose into multiple smaller doses, spread out over the day. Because the analgesic effect of a dose of buprenorphine wears off after about six hours, patients on Suboxone who also have pain can try this last method. For example, I have a patient who was taking 16mg of Suboxone per day when she began having back pain from overwork. She called me, and I suggested to her that instead of switching to another opioid, first try taking half of a Suboxone 8mg film four times per day. Her total dose stayed the same, but we spread it into multiple doses. She had enough pain relief with this maneuver and didn’t need to switch to any other opioids.
Moderate to severe pain usually isn’t treatable with only Suboxone. Examples of moderate to severe acute pain would be a broken bone, or having surgery. Doctors use either of two methods. The first is to leave the Suboxone patient on his usual dose, and add another opioid for the treatment of pain. Doctors who chose this method say that Suboxone doesn’t completely block the analgesic effect of strong opioids, so patients will still get some pain relief. The second method, and the one I prefer, is to stop the Suboxone and switch to a stronger opioid for a short time, until the condition is resolved.
When a patient with a history of opioid addiction needs opioids for pain, it does increase the risk of a relapse, of course. But leaving moderate to severe pain untreated isn’t an acceptable option. Plus, there are safeguards we can use to reduce the risk of relapse. For example, the doctor treating the painful condition should be aware of the patient’s higher risk of medication misuse. That doctor may wish to prescribe smaller amounts and see the patient more often. Small amounts of opioids may be less likely to trigger a patient than a big bottle with many pills.
In some cases, the patient can identify a dependable non-addict who’s willing to hold the pill bottle and dispense to the patient as prescribed. The patient should contact people in her recovery network more often than usual, and if unable to get to regular recovery meetings, ask members to bring a meeting to her home.
Besides the risk of relapse, it can be tricky to transition from full opioids back to Suboxone. For short-acting opioids like oxycodone or hydrocodone, the patient should stop these for a minimum of 24 hours before re-starting the Suboxone, or else risk the precipitation of withdrawal if taken too early. If the patient is taking an extended-release or long-acting medication, like methadone or MS Contin, she’ll have to wait up to 72 hours to be in enough opioid withdrawal to re-start Suboxone safely.
Chronic pain is a different issue. If someone has opioid addiction and chronic pain, it’s obviously best if the pain can be treated by a non-opioid. If not, Suboxone may provide enough pain relief to make the patient reasonably comfortable. Suboxone can at least keep the patient out of withdrawal.
Chronic pain and addiction is a difficult combination of medical problems to have, and sometimes there’s no good answer. Unfortunately, this blend of problems is all too common. Many people with chronic pain developed addiction as a complication of their treatment.