Chronic Pain Management — The Role of Buprenorphine

Posted on Sunday, May the 17th at 6:02pm

By: Dr. Stephen F. Grinstead, LMFT, ACRPS, CADC-II

There’s an effective medication for both opiate addiction treatment and/or maintenance that is FDA (Food and Drug Administration) approved. The medication is buprenorphine, an opiate agonist/antagonist, which is very effective pain medication for appropriate patients. It has been used in chronic pain management for many years—mostly in its injectable form. Buprenorphine is available in the United States as sublingual (dissolved under the tongue) medication and is many times more potent than injected morphine. Buprenorphine is different from other opiates in that the patient usually feels more “clear headed” when taking it.

According to research posted in the American Journal of Therapy in 2005, patients who failed to achieve lasting analgesia with long-term opioid therapy have achieved benefit using sublingual buprenorphine, a partial mu agonist. The drug was investigated in an open-label study with 95 consecutive patients who were referred by local pain clinics for detoxification from long-term opiate analgesic therapy (mean 8.8 years) due to increasing pain levels, worsening function and in 8 percent of the patient’s, opiate addiction.

This study showed that after abstaining from all opiate analgesics for a minimum of 12 hours, patients received low doses of sublingual buprenorphine or Suboxone (buprenorphine/naloxone). The daily sublingual buprenorphine dose ranged from 4 to 16 mg (mean, 8 mg) for an average duration of 8.8 months. Eighty-six percent of patients experienced moderate-to-substantial pain relief, improved mood and functioning.

Being the first oral medication that has been approved in the U.S., physicians can now prescribe buprenorphine in their offices for people who are dependent or addicted to opiates such as opiate pain medication, heroin, or methadone.  Buprenorphine is an effective medication for opiate addiction which does not require daily or weekly visits to a clinic. Buprenorphine blocks the effects of other opiates; it eliminates cravings and prevents withdrawal symptoms such as pain and nausea. Patients can be maintained on buprenorphine or go through detoxification.

Subutex and Suboxone are the brand names that buprenorphine is being marketed as for the treatment of opiate dependence. Both medications contain the active ingredient Buprenorphine Hydrochloride, which works to reduce the symptoms of opiate dependence. Subutex contains only Buprenorphine Hydrochloride which was developed as the initial product.

The second medication, Suboxone contains an additional ingredient called Naloxone to guard against misuse or abuse. Subutex is usually given during the first few days of treatment, while Suboxone is used during the maintenance phase of treatment. Both medications come in 2 mg and 8 mg strengths as sublingual (placed under the tongue to dissolve) tablets.

One significant drawback with this medication for opiate addiction treatment is that only qualified doctors with the necessary DEA (Drug Enforcement Agency) identification number are allowed to offer in-office treatment and provide prescriptions for ongoing maintenance. Up until very recently, prescribers were limited to a 30 patient ceiling. 
Fortunately, the Office of National Drug Control Policy Reauthorization Act of 2006 (ONDCPRA) modified the restriction on the number of patients a physician authorized under the Drug Addiction Treatment Act of 2000 (DATA 2000) may treat subject to the following conditions:

• Physicians must currently be authorized under DATA 2000.
  
• Physicians must have submitted the notification for initial authorization at least one year ago.
  
• Physicians must submit a second notification that conveys the need and intent to treat up to 100 patients and certifies their necessary qualifying criteria and their capacity to refer patients for appropriate counseling and other appropriate ancillary services.

However, this medication is also being used very effectively by some pain management physicians for people living with chronic pain. It is important to remember that medication is only one method of treatment for effective chronic pain management. It is crucial to develop non-medication based treatment interventions, as well as learning to treat the psychological/emotional components of chronic pain. A multidisciplinary team approach always gives the best treatment outcomes.

For someone with chronic pain who has developed an addictive disorder, this medication may be the best intervention possible along with concurrent addiction treatment protocols. It is also important to help people differentiate between the physiological and psychological/emotional components of their pain. Once that is done, then cognitive behavioral approaches can help people manage the psychological components more effectively.