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9 Articles in Volume 6, Issue #2
Assessment and Treatment of Chronic Pain
Clinical Drug Testing for Pain Medicine
Epidural Indomethacin Alternative in Adult Onset Diabetics
Focus on Urine Drug Monitoring
Office-based Treatment of Opioid Physical Dependence
Oxycodone to Morphine Rotation
Pain Care at the End of Life
Tennant Blood Study—Summary Report
The Psychiatric Model of Treating Chronic Pain

Office-based Treatment of Opioid Physical Dependence

New hope for patients with concomitant pain and opioid physical dependence.

Opioid physical dependence may prove inevitable when dealing with those in chronic pain. Practitioners’ concerns include adequately addressing pain using opioid therapy while avoiding the potential for abuse, misuse, and addiction.1 Pharmacological measures such as Methadone Maintenance Therapy (MMT) are sometimes used to combat this problem. Recently, a new drug in the arsenal of treating opioid dependence was released. On October 8, 2002, the U.S. Food and Drug Administration approved two drugs containing buprenorphine—Subutex (buprenorphine hydrochloride) and Suboxone (buprenorphine hydrochloride and naloxone hydrochloride)—for the treatment of opiate dependence.2 While the main impetus for the release of this drug stems from the lack of accommodation for patients desiring therapy for opiate addiction,2 what is critical to the pain treatment specialist is that buprenorphine is also a potent opioid analgesic as well. Buprenorphine is used both to alleviate withdrawal symptoms associated with opiate dependence and for maintenance therapy. While Suboxone is generally used for maintenance therapy, Subutex is reserved for detoxification purposes because of its increased potential for abuse. While much progress has been made, a number of obstacles result in the underutilization of Suboxone for maintenance therapy.

There are an estimated 810,000 heroin addicts in the United States.3 Current estimates suggest that there are nearly a million Americans dependent on opiates, but that only about 20% are getting treatment in licensed methadone clinics.4 This figure does not account for those 31.2 million persons that abuse opioid pain medications non-medically and are, or will potentially become, addicted.5 Given the magnitude of the problem of opioid addiction, an effective treatment is crucial in addressing the problem.

Pharmacological Considerations

Suboxone exhibits unique clinical properties that are beneficial in the treatment of opioid dependence and particularly for those who are having concomitant pain problems. Its active ingredient, buprenorphine, is a long-acting partial opioid agonist which binds strongly to the receptors, reduces cravings, alleviates symptoms of withdrawal (when administered after the person is in withdrawal), and prevents the efficacy of other opioid agonists when taken in combination with naloxone.6 While naloxone is purely an opioid antagonist, the Suboxone formulation is taken sublingually and very little of the naloxone is metabolized by this route (see Figure 1, adapted from Jones, 2004). The naloxone is specifically added to the formulation in order to prevent the intravenous abuse of buprenorphine. If Suboxone is crushed and injected intravenously, it would precipitate severe withdrawal symptoms in the opioid-dependent person.6

The efficacy of buprenorphine maintenance therapy has been shown to be greater than that of placebo and equal to that of moderate doses of methadone.7 However, buprenorphine offers many advantages over MMT. Because buprenorphine only partially stimulates the µ receptor, respiratory depression, pain reduction, and feelings of well-being or pleasure are less intense than with morphine, heroin, methadone, or any full opioid agonist. The safety profile of buprenorphine, especially when administered in the form of Suboxone, is better than that of methadone. Suboxone is less likely result in physical dependence or respiratory depression and its long duration of action allows for patient-tailored flexible dosing, which can be taken at home (daily trips to a clinic are not necessary). After the daily dosage has been stabilized, there is rarely a need to alter the dosage. As mentioned previously, Suboxone is less likely to be abused due to the naloxone formulation. At long last, physicians can treat opiate-dependent persons in an office practice setting.8

Figure 1. Zones of affinity and action of opioid agonist and opioid antagonist.

Considerations for Prescribing Suboxone

There are many issues to consider when initiating Suboxone therapy—not the least of which is candidate selection. Patient selection is an important indicator for efficacy of Suboxone maintenance therapy. Appropriate candidates should:

  • have a diagnosis of opioid dependence
  • exhibit current signs of opioid withdrawal
  • be interested in buprenorphine treatment
  • understand the risks and benefits of buprenorphine treatment
  • be expected to adhere to the treatment plan
  • be willing and able to follow safety procedures
  • agree to treatment after the review of options
  • be provided needed resources
  • be psychiatrically stable
  • not be pregnant (on initiating or during the course of treatment)
  • not be dependent on or abusing alcohol
  • not be currently dependent on benzodiazepines, barbiturates, or other sedative-hypnotics
  • not be at high risk for using during the course of treatment
  • not have had prior adverse reactions to buprenorphine
  • not be on medications that may react with buprenorphine
  • have no medical problems that are contraindications to buprenorphine treatment
  • have an adequate support system
  • have an appropriate level of motivation9

When initiating therapy, it is important for the patient to be in a state of opioid withdrawal. Because buprenorphine binds strongly to the opioid receptor, it generally displaces other opioids that may still occupy receptors. If a sufficient number of opioid receptors are occupied by other opiates upon induction of buprenorphine therapy, the patient may experience precipitated withdrawal.9 Induction is usually accomplished with an initial dose of 4 to 8mg. Maintenance doses of between 4 and 24mg per day are likely to be efficacious for most patients.8

A comprehensive program is warranted for continued success of Suboxone maintenance therapy. Adjuncts to therapy include monitoring via urinalysis, involvement in a 12-step program, and individual counseling. For those looking for a magic pill to cure addiction, it must be stressed that motivation, support, and beliefs play a crucial role for the success of recovery.10

Another important aspect to consider while administering buprenorphine therapy is the handling of acute pain states. Recommendations for treating acute pain (such as surgery or traumatic injury) for patients on Suboxone maintenance include:

  • Continue buprenorphine therapy and titrate a short-acting opioid to effect. (Higher doses of full opioid agonists may be required to compete with buprenorphine at the µ receptor, thus caution should be taken if buprenorphine is discontinued abruptly).
  • Divide the daily dose of buprenorphine and administer every 6-8 hours to maximize its analgesic properties.
  • An alternative to the above recommendations is to discontinue buprenorphine therapy and titrate a full opioid agonist to prevent symptoms of withdrawal and achieve analgesia. When the acute pain state is resolved, discontinue the full opioid agonist and resume buprenorphine therapy.
  • A final option is to convert to Methadone Maintenance Therapy until the acute pain is resolved.11

There are misconceptions that lead to the under-treatment of acute pain for those on opioid maintenance therapy, and this should be avoided.11

Becoming a Waived Physician

Despite the dramatic increase in the number of patients that are being treated for opiate addiction via the maintenance therapy that Suboxone has provided, there remain a large proportion of opiate-dependent persons left untreated. The administration of buprenorphine is limited in several ways.

First, buprenorphine can only be prescribed by physicians that obtain a waiver to do so. In order to obtain this waiver, the physician must meet one of the following six conditions:

  1. hold a subspecialty board certification in psychiatry from the American Board of Medical Specialties
  2. hold certification from the American Society of Addiction Medicine
  3. hold a subspecialty board certification in addiction medicine from the American Osteopathic Association
  4. with respect to the treatment and management of opioid-addicted patients: completed not less than eight hours of training provided by the American Society of Addiction Medicine, the American Academy of Addiction Psychiatry, the American Medical Association, the American Osteopathic Association, the American Psychiatric Association, or any other organization that the Secretary determines is appropriate
  5. has participated as an investigator in one or more clinical trials leading to the approval of a narcotic drug in schedule III, IV, or V for maintenance or detoxification treatment, as demonstrated by a statement submitted to the Secretary by the sponsor of such approved drug
  6. other training or experience that the Secretary considers to demonstrate the ability of the physician to treat and manage opioid-addicted patient12

Many propose that these restrictions are overreaching and prohibitive to many that would benefit from Suboxone treatment. While some steps have been taken to make Suboxone more readily available, there are those that feel more needs to be done. Many physicians are turning patients away that are seeking treatment for opiate addiction because of the 30 patients per physician limit.13 In July of 2005, Congress passed legislation that would allow each physician that has obtained a waiver in a group practice to prescribe buprenorphine for up to 30 patients. Prior to this legislation, a group practice was limited to 30 patients being prescribed buprenorphine at one time, regardless of the number of physicians in the group that were qualified to do so.14

Another obstacle that leaves many seeking treatment is the lack of physicians that obtain certification to prescribe buprenorphine. While it is hoped that a sufficient number of physicians will seek certification to utilize the drug to its fullest potential, it appears that this is not the case due to the difficulty of motivating primary care physicians to take on addicts as patients.8 Hopefully, as Suboxone proves efficacious and more physicians become educated regarding the drug, there will be more physicians that are willing to fill the void that is currently present in addictions treatment.

Summary

Buprenorphine is an opioid and a very effective pain reliever. It has now been approved for treatment of opioid dependence in a physician's office—or even in a take-home setting, if the formulation contains naloxone. To treat opioid dependence, a physician can obtain a special waiver to prescribe to addicts.

A great attribute of the formulations of buprenorphine, now available, is that they may effectively treat patients with concomitant pain and addiction.

Last updated on: January 3, 2019
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