Using Buprenorphine for Chronic Pain Management

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The opioid crisis and the treatment of chronic pain are complex problems. The Centers for Disease Control and Prevention (CDC) says there is insufficient evidence that long-term opioid use outside of end-of-life care has benefits for patients with chronic pain. Still, opioids remain widely used for this purpose.

Older woman having shoulder pain.

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Primary care providers can prescribe opioids for chronic pain. Many, however, are reluctant to do so because these drugs can cause dependence or lead to overdose. This is why primary care providers may refer chronic pain patients to pain specialists.

Chronic pain is a common problem. Most people who experience it will visit a primary care provider first. This is why researchers are interested in developing an effective alternative to opioids that primary care health providers would feel comfortable prescribing.

This article looks at the medication Subutex (buprenorphine), how it is administered, and what some of the side effects can be. It also discusses buprenorphine as a possible opioid alternative.

What Is Buprenorphine?

Buprenorphine is in a class of drugs called opioid partial agonist-antagonists. It is used to treat opioid dependence, which may include dependence on prescription narcotics or heroin. As an opioid substitute, it works by preventing withdrawal symptoms when a person stops taking opioids.

How It Works

Buprenorphine works in a way that may also make it helpful for treating chronic pain. It binds to the same receptors in the brain that opioids bind to. These receptors are responsible for pain relief. It also stays attached to those receptors for longer, which means it has a prolonged effect.

Because buprenorphine only partially activates the receptors it attaches to, it is less potent than opioids. Finally, it doesn't create strong feelings of euphoria, as opioids do.

Administration

Buprenorphine is one of two ingredients in Suboxone, a drug used to treat opioid dependence. The other ingredient is naloxone, a short-acting drug that blocks the effects of opioids, including dangerous side effects like:

  • Respiratory depression (slow, ineffective breathing)
  • Sedation (sleepiness)
  • Hypotension (low blood pressure)

Suboxone can help deter substance abuse.

Buprenorphine is usually administered as a sublingual tablet or film, which means it is dissolved under the tongue. When combined with naloxone it is given as a sublingual tablet or film or as a buccal film, which is dissolved between the gum and cheek. Other forms of buprenorphine include:

  • Patch
  • Injectable
  • Sublingual spray

The FDA is currently reviewing the sublingual spray as a potential treatment for acute pain.

Side Effects

Buprenorphine and Suboxone are not as dangerous as traditional opioids. Still, they can have negative side effects including the following:

  • Back pain
  • Blurred vision
  • Constipation
  • Difficulty with sleep
  • Mouth numbness
  • Headache
  • Stomach pain
  • Tongue pain

More serious side effects can occur, including:

  • Difficulty breathing
  • Swelling of the mouth or tongue

These side effects require immediate medical attention.

Dental problems have been reported with buprenorphine formulations that are dissolved in the mouth. These include:

  • Tooth decay
  • Cavities
  • Oral infections
  • Tooth loss

These problems can be serious and have been reported even in people with no history of dental issues.

Mixing buprenorphine with other drugs like benzodiazepines can be lethal.

It is important to remember that although buprenorphine is generally safer and less potent than traditional opioids, misuse can lead to dependency.

What the Research Says

Research shows that buprenorphine can reduce chronic pain without precipitating opioid withdrawal or serious adverse effects.

A 2017 review found that buprenorphine in any formulation was effective for the treatment of chronic pain. Importantly, no serious adverse effects were reported in any of the studies.

A 2014 review also found that sublingual buprenorphine is effective for the treatment of chronic pain, though most of the studies included in the review were low-quality. Additionally, the authors noted that buprenorphine could be more effective at treating certain kinds of pain and have fewer dangerous side effects. Those taking buprenorphine could also be less likely to develop tolerance.

Some researchers also hypothesize that buprenorphine may be able to help people with opioid-induced hyperalgesia. People with this condition have extreme pain sensitivity caused by opioid use. The pain may be similar to the pain the opioids are intended to treat, or different. Some researchers think this condition could explain why opioids stop working for some people.

Prescribing Buprenorphine

To a limited extent, buprenorphine is already being used to treat chronic pain in the United States. Suboxone, for example, is sometimes prescribed off-label for the treatment of chronic pain. The transdermal buprenorphine patch is also available in the United States for the treatment of severe chronic pain. Still, there is no general agreement on whether buprenorphine should be used for this purpose.

Currently, the few studies examining the effect of buprenorphine on chronic pain are too dissimilar in their approaches. This makes them difficult to compare.

Before buprenorphine can become a standard treatment for chronic pain, a few issues need to be resolved. For example, past studies have rated patient pain in different ways. This makes it difficult to analyze the data. Pain rating scales in buprenorphine studies need to be standardized. Dose and the way the drug is administered would also need to be tailored to different types of chronic pain.

Primary care health providers can become eligible to prescribe buprenorphine after completing eight hours of training. Still, this isn't something many primary care providers have done.

The CDC has guidelines in place for the treatment of chronic pain in the primary care setting. The guidelines recommend opioids only when non-opioid treatments haven't worked. They also recommend prescribing opioids at the lowest possible dose. In this context, buprenorphine could essentially be considered an opioid alternative.

Summary

Opioids are often used to treat chronic pain, but there is a risk of overdose and dependency. Some studies have found that buprenorphine may be an effective opioid alternative.

Buprenorphine is not as dangerous as the opioids that are often prescribed for chronic pain. It is currently used to treat opioid addiction. Although it is not yet an FDA-approved treatment for chronic pain, some healthcare providers prescribe it off-label.

Buprenorphine can have side effects, including sleep problems, headache, and stomach pain. Serious side effects can also occur.

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