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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.
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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:

Last updated on: January 3, 2019