Suboxone and pain

[ziggyziggy]

What are your views on use of suboxone for chronic pain with and without opiate addiction issues? What do you think of switching patient to suboxone, currently on chronic opiate therapy for legit chronic pain but abusing the pain pills (overuse)?
Or does Butrans has any role?

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[Aether2000]

Suboxone is approved in the US only for the treatment of addiction, not for chronic pain treatment. Given the special DEA license that is required to prescribe it for its approved purpose, the lack of such a license in the face of off label prescribing of the drug may appear to regulators (DEA and Medical Licensing Boards) as an attempt to skirt the law.
Using it to treat a patient that has overdosed on oral opioids when questions of addiction are in play would be hazardous legally unless you have the special DEA license. Butrans typically achieves 1/20-1/10 the blood levels of Suboxone, and may not be a useful analgesic when high dose oral opioids have previously been administered, and certainly is not useful as an addiction treatment.

 

[ziggyziggy]

I am particularly interested in this to use in pain with co-morbid opiate abuse. I do have X number and understand that use of suboxone for mild-moderate chronic pain is off-label. But does it offer any type of pain relief in clinical scenario and at what dose ?

What are my other options besides referral to buprenorphine or methadone maintenance program?

 

[PinchandBurn]

i've only seen bad things. stay clear!

 

[drf]

I've detoxes pts using suboxone. Low stable dose with plan to finish taper as outpt. To be clear, it was never used for addiction.

Sometimes I write suboxone 2 mg QD for pain and it gets filled. Sometimes the pharmacy refuses.

 

[NEPain]

I've found that it is pretty good for pain in patients that truly want pain relief and not a high. The problem is that it makes treating acute pain difficult because the buprenorphine essentially occupies the mu receptors so that high doses of pain meds are needed to be effective. So if the pt is going to have surgery, or is in a car wreck, it can be hard to treat the pain.

It is nice for tapering patients off of opiates (legal without x number since it is not treating addiction). 8/2 suboxone strip bid starting during withdrawal (or else the pt will get precipitated withdrawal) for a couple of weeks, followed by taper over a week or two works well with minimal symptoms. If they stay on the suboxone long term, then weaning is difficult.

 

[lobelsteve]

I've found that it is pretty good for pain in patients that truly want pain relief and not a high. The problem is that it makes treating acute pain difficult because the buprenorphine essentially occupies the mu receptors so that high doses of pain meds are needed to be effective. So if the pt is going to have surgery, or is in a car wreck, it can be hard to treat the pain.

It is nice for tapering patients off of opiates (legal without x number since it is not treating addiction). 8/2 suboxone strip bid starting during withdrawal (or else the pt will get precipitated withdrawal) for a couple of weeks, followed by taper over a week or two works well with minimal symptoms. If they stay on the suboxone long term, then weaning is difficult.

If you want to use suboxone, you better be real comfortable with the COWS/MCOWS scoring and grading system. Precipitated withdrawal can result in hospital admission (damages).

 

[NEPain]

The COWS score is good, but nobody does in office induction anymore that I know of. Just tell the patient they'd better be good and f'ing sick before they start or they will feel much worse.

Opiate withdrawal isn't deadly and you can give them some clonidine to help wait until they're "dopesick".

If you have that discussion with the patient I can't see any liability.

 

[lobelsteve]

The COWS score is good, but nobody does in office induction anymore that I know of. Just tell the patient they'd better be good and f'ing sick before they start or they will feel much worse.

Opiate withdrawal isn't deadly and you can give them some clonidine to help wait until they're "dopesick".

If you have that discussion with the patient I can't see any liability.

I've reviewed files where there was and COWS was documented as 8.

 

[specepic]

I use my psych/addiction collegues for this. I stop or wean opioids first, send to them.

Have seen other pain docs combine butrans patch with perc's which seems strange