Suboxone for pain?

[DocHoliday84]

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Hello. I am a pall med fellow, trying to learn more about buprenorphine for pain. I understand that Buccal buprenorphine is the formulation approved for chronic pain and use of suboxone is considered off label, but I am curious if anybody has much experience with suboxone for chronic pain. I am especially wondering if you find that higher doses continue to have more analgesic effect, or if this trails off as your doses get higher? Seems like it could be a great choice due to its favorable side effect profile, but I am curious how well it actually works in your guys experience. So far I have an N of 1 on this, switched a cancer patient onto suboxone from fentanly patch by the microdosing method, and he did quite well, reported much better pain control.

 

[BobBarker]

No, the higher dosages don’t increase the efficacy for pain. 2mg #30 1/2 bid is a typical dosage.

 

[lobelsteve]

2MG bid for me

 

[bedrock]

“Life is pain, Anyone who says otherwise is selling something…”

 

[kstarm]

First, kudos to you for exploring this. We are having to help our palliative service navigate a number of issues at the crossroads of palliative care and addiction. These cases have been the most challenging ones I have had to be a part of. Lots of times well meaning providers got in over their heads.

Buprenorphine doesn't know if it is being used for addiction or pain. I usually try it as first line if possible and I am trying to find what ever preparation is affordable. I will go up to 16mg of bupe either subutex or suboxone. These are always cases were patients were on full agonist before seeing me. Is it OUD or pain? it is hard to know sometimes but if the patient is stable and getting benefit without concerning behaviors I tend to not worry as much.

This is a free CME course for buprenorphine in terminal illness: Buprenorphine for Pain in the Setting of Terminal Disease – Michigan OPEN

Finally, ECHO is a program across the nation to share different learnings and resources. The Hennipen County Echo in minneapolis MN does an online meeting once a week that is free and provides CME. The last month or so, and going on through July is all about pain and addiction management in palliative care/cancer pain. The ECHOs are recorded if you wanted to go back and watch. A lot of very well done talks: Project ECHO

 

[DocHoliday84]

First, kudos to you for exploring this. We are having to help our palliative service navigate a number of issues at the crossroads of palliative care and addiction. These cases have been the most challenging ones I have had to be a part of. Lots of times well meaning providers got in over their heads.

Buprenorphine doesn't know if it is being used for addiction or pain. I usually try it as first line if possible and I am trying to find what ever preparation is affordable. I will go up to 16mg of bupe either subutex or suboxone. These are always cases were patients were on full agonist before seeing me. Is it OUD or pain? it is hard to know sometimes but if the patient is stable and getting benefit without concerning behaviors I tend to not worry as much.

This is a free CME course for buprenorphine in terminal illness: Buprenorphine for Pain in the Setting of Terminal Disease – Michigan OPEN

Finally, ECHO is a program across the nation to share different learnings and resources. The Hennipen County Echo in minneapolis MN does an online meeting once a week that is free and provides CME. The last month or so, and going on through July is all about pain and addiction management in palliative care/cancer pain. The ECHOs are recorded if you wanted to go back and watch. A lot of very well done talks: Project ECHO

Thank you so much for this response! I will definitely check out these resources.

 

[melancholy]

Hello. I am a pall med fellow, trying to learn more about buprenorphine for pain. I understand that Buccal buprenorphine is the formulation approved for chronic pain and use of suboxone is considered off label, but I am curious if anybody has much experience with suboxone for chronic pain. I am especially wondering if you find that higher doses continue to have more analgesic effect, or if this trails off as your doses get higher? Seems like it could be a great choice due to its favorable side effect profile, but I am curious how well it actually works in your guys experience. So far I have an N of 1 on this, switched a cancer patient onto suboxone from fentanly patch by the microdosing method, and he did quite well, reported much better pain control.

I also applaud you for exploring these avenues to improve pain management in your line of work. In some healthcare systems, palliative care sometimes limit their involvement with regards to pain management while they handle other aspects of palliative care (which is unfortunate for patients when they could have better integration of care and more options available).

Obviously just anecdotal, but having about a year and a half of experience converting multiple patients to different Buprenorphine formulations (most prev on full opioid agonist regimens), dosing is all over the map and unpredictable. I do think you can rationalize titrating higher than a "lower" dose like 1-2mg bid up to at least 12mg total daily (i.e. 4mg TID) to see if you can achieve some level of analgesia (assuming absence or minimal side effects). Usual analgesic dosing is usually TID to be honest although a few patients experience end-of-dose failure and do better with QID dosing. I have some patients on up to 24mg daily (8mg TID). I don't have enough experience to say whether the incremental improvement in pain relief levels off as you get to higher doses, but it does not feel like trying to titrate patients above Gabapentin 600mg TID and getting diminishing benefits at higher doses.

Everything is risk vs benefit of course and in palliative care, your considerations are often different from the standard non-malignant chronic pain patient. That being said, for patients who are on moderate/high doses of chronic opioid therapy, the potential advantages short and long term of being able to successfully transition to Buprenorphine long-term are worthwhile.