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In their 3/26/2019 commentary “Want to Reduce Opioid Deaths? Get People the Medications They Need”, a New York Times Editorial recently suggested that opioid deaths could be avoided if we are able to get patients critical medications at a critical time. Their original article postulates the various reasons why there is a glaring lack of access to treatment for patients with Opioid Use Disorder (OUD). While their assessment was spot-on regarding buprenorphine access and life preservation, we feel that they overlooked an equally critical issue regarding buprenorphine access for patients suffering from chronic pain.

Buprenorphine was first approved in February 2002 as an injectable formulation indicated for treatment of moderate to severe pain; not OUD. It was not until October of 2002 that buprenorphine was FDA approved as a sublingual tablet for treatment of OUD. Many clinicians are unaware that currently two other buprenorphine products are FDA approved and available for the treatment of chronic pain in the outpatient setting, Belbuca and Butrans.

We feel it is important to understand that, while buprenorphine is an atypical, nontraditional and unique opioid1 that could help mitigate the nation’s current opioid crisis and treat OUD, it may play an equally important role moving forward in the treatment of chronic pain. This point was recognized by the recent HHS Pain Management Best Practices Inter-Agency Task Force, which was established to propose updates to best practices and issue recommendations that address gaps or inconsistencies for managing chronic and acute pain. Policymakers, third party insurance payers, clinicians, and journalists lack an understanding of buprenorphine’s pharmacology as well as its importance for treating chronic pain in persons requiring long-term opioid therapy. Proactive treatment with buprenorphine for chronic pain may prove more beneficial in mitigating death risk than reactive buprenorphine access for OUD after the fact. Notwithstanding, access for both populations would no doubt save more lives than either alone.

Buprenorphine has shown to elicit similar and even superior analgesic effects compared to equivalent doses of traditional opioids such as morphine in a multitude of published studies. Moreover, because most of buprenorphine’s activity is at the spinal level rather than the brain (unlike traditional opioids), there is a plateau of dose-related carbon dioxide accumulation and commensurate reduced risk of respiratory depression. But traditional opioids, unlike buprenorphine cause increased respiratory depression with escalating doses; this lowers the risk of opioid overdose from buprenorphine compared to other opioids irrespective of whether it is prescribed for analgesia or OUD.

Buprenorphine is not a less potent analgesic compared to traditional opioids. For example, an injectable buprenorphine dose of 0.3mg has similar analgesic activity to injectable morphine of about 10mg. Buprenorphine is therefore approximately 33x more potent than morphine for analgesia. This exemplifies how potency is simply the amount of drug required to elicit a response; potency does not mean that one drug is stronger or weaker than another.

Furthermore, as the initial article inaccurately suggests, methadone is not “weaker” than other opioids such as OxyContin2, fentanyl, and heroin, as methadone accounts for similar analgesic efficacy, respiratory depression, and exhibits stronger binding at the site of activity within the CNS compared to many traditional opioids. For these and many other reasons, methadone should not be compared to or grouped with buprenorphine in terms of efficacy or safety whether used for OUD or as an analgesic.

Buprenorphine is a safer opioid option compared to traditional opioids.  Commercially available products should surely be considered first-line therapy for treating chronic pain or OUD prior to consideration of traditional opioids like oxycodone for chronic pain or methadone for OUD; not vice versa.

  1. Opioids are synthetic chemicals similar to opium. Traditional examples include codeine, fentanyl, hydrocodone, oxycodone, morphine, methadone, and others.
  2. OxyContin is an extended release dosage form of oxycodone.

As usual, comments are enthusiastically welcomed!

The Authors (aka “The Jeffs”):

Jeffrey Fudin, PharmD, FCCP, FASHP, FFSMB
Dr. Jeff Fudin is Adjunct Associate Professor, Albany College of Pharmacy and Health Sciences and Western New England University College of Pharmacy, and Chief Executive Officer, Remitigate, LLC

Jeffrey Bettinger, PharmD
Dr. Jeffrey J. Bettinger, PharmD, is currently a PGY-2 Pain and Palliative Care Pharmacy Resident in Upstate NY with a planned completion date of June, 2019. He has accepted a position as a Clinical Pharmacist Specialist in ambulatory pain management at Saratoga Hospital in Saratoga NY following his residency.

Jeffrey Gudin, MD
Dr. Jeff Gudin is board-certified in pain management, addiction medicine, anesthesiology and hospice and palliative care. He has been practicing pain management and addiction medicine for more than 20 years.

42 thoughts on “The REAL story of buprenorphine access for pain and addiction to mitigate death risk

  1. How are you now? Is there an update? I too was suddenly cut off from high dose oxycodone for a brain injury/relentless nerve damage pain and put on the hateful suboxone. I relate to you very much.

  2. Doesn’t buprenorphine have a ceiling effect, as in after so much it doesn’t offer pain relief? I was put on Suboxone briefly. It did nothing for my pain & actually made me sick. Switched to Subutex. Although I was no longer sick, it still did nothing for my pain. My concern is that for ppl like me, ALL other opioid analgesics will be unavailable. Only buprenorphine. What if it doesn’t help the patient? We need access to all modes of relief, and unfortunately we’re not getting that anymore. We’re considered high risk patients, drug seekers or unworthy of help. No wonder so many are committing suicide. I know I’m over it. If it weren’t for my kids, I don’t think I’d be here much longer. I’m very tired of myself & millions of others losing their life to save those with an addiction problem.

  3. Thank you , Dr Fudin for your knowledge and your blog. After 20 yrs being a responsible opiate user, I was cut off due to pain and primary drs leaving at same time., April 2016. lots of fun there. In June of 2019, I’m beginning to get my life back w Suboxone 8mg/2mg, 3 films a day. Drs don’t seem to understand or want to, honestly, help those w chronic pain. My new primary of 2 yrs says he can’t even help me anymore (due to suboxone). Wow. I don’t know how he was helping me anyway on 5mg oxycodone, when I had bottles of 30mg morphine er and 15mg oxycodone. It’s a crying shame REALLY, there aren’t more doctors like you. I only have oodles of mri’s inoperable neck surgery, c5 to c7 are fused and c4 is so deterioated I’m wondering how much longer I’ll be able to live on my own. Crazy.

    1. I understand where you are coming from Gina after being put on a gambit of Pain Med I was told by a Pain Doctor that I am suffering from an opioid use disorder and placed me on suboxone, they did help me control the cravings but when my chronic pain flared up my Dr. actually went to help me with my pain trying to use I guess a little known Medical treatment plan by cutting my dose of suboxone down and putting me hydromorphone 4mg 3 times a day, here is a link to the treatment plan,
      https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1892816/
      my Pharmacy filled both prescriptions the first month and refused to fill them the second month, so my Doctors called me to tell me what was going on and told me to change pharmacies I did so and that Pharmacist wanted to talk to my Doctor before filling both scripts but before my Doctor had a chance to call the new place called my old Pharmacy to transferred my scripts and was told that I was changing Pharmacies due to their refusal to fill both meds the second month so they refused to fill them also and even accused me of Pharmacy Shopping. So I know how you feel when it comes to needing help and not finding it out here due to the Label we are carrying by being on Pain meds. If it wasn’t for the love of a wonderful woman I would have blown my brains out by now. My Doctors treatment plan the first month was working great because the Pain meds were helping with the pain I am suffering from and the suboxone was helping to control cravings that I would have had without said med.

  4. I am on 8mg suboxone and have side
    Effects ….I cut down to 6mg.
    Pudendal neuralgia and arthritis
    Would like to go on belbica
    Buph of 2 mg daily to try lower dose
    I just have pain and do not need
    Naloxone. So what strength patch
    You recommend?

    1. Stefan, I cannot give medical advice on this forum. In general, Butrans is 15% adsorbed, so a 20mcg/hour patch, the highest strength absorption is about (20)(24 hours) = 480mcg(.15 absorbed) = 72mcg.
      Suboxone 6mg=6000mcg of which about 30% is absorbed sublingually, or 6000mcg(0.3) = 1800mcg.

  5. Dr. Fundin,

    I’m wondering about comparing the pain killing power of methadone to buprenorphine.
    For effective pain relief (no need for breakthrough pain medication) I need a dose of 60 mg methadone per day. If I’m prescribed less then I start needing other meds on top of the methadone.
    What I’m wondering is should I be able to achieve similar results using Belbuca? So far I’m titrated up to 450 mcg 2x day, and I’m still achieving only slight relief. Do you expect that once I’ll hit the prescription ceiling of 900 mcg 2x day before I can expect the same kind of relief?
    I’m terrified that I’m going to be stuck on this regimen with no where to go now that the new CDC guidelines make it so difficult to be prescribed methadone at anywhere near an effective dose for me. Can I even take other meds for breakthrough pain on Belbuca?
    Anyways, any enlightening you can shed on this would be greatly appreciated.
    (The nature of my pain is from a 5 vertebrae fusion arround my L1 due to a compression fracture which resulted in 85% occlusion. Regarding my previous methadone dose, once I’ve been titrated to 60 mg per day I’ve achieved very good pain management and I’ve never had to exceed that dose. When the dose has been reduced I haven’t been able to achieve adequate relief without supplementing the dose with Dilaudid or something else strong.)

    Thank you

    1. Joseph, These two drugs are very different, each with various attributes in relieving pain. Between the two, methadone is clearly far more dangerous, but if carefully monitored by an experienced clinician, could be a good option.

  6. Dr.Jeff,I’m65+ retired military,female orthopedics,1st asst surg. and field support for airborne division( jump status) through the yrs we treated each other as needed no off time,just couldn’t call in sick.Now that my body is feeling reality .I’d been on fentanyl patch,ir morphine breakthrough.I didn’t/don’t drink/smoke job too intense(3 Drs ortho,rehab,internal med decided best treatment,too many allergies). After 20+ yrs I’m sent to pain management who for almost 3.5 yrs continues my pain regime. Found I had chf, couldn’t have the replacement for knees;however my good Dr suddenly terminated my meds saying this new med was super .I’d never heard of it…suboxone…1st night I thought I’d die,2nd night I prayed to. I begged for reassessment I was cursed out. Kept telling the doc in September something was wrong,ignored me. Oct 6 I had emer dvt in calf pulmonary embolism(saddle) the Dr at civilian hospital asked why I waited,VA Dr in ER profiled me as drug seeking. He said sudden termination when I was complaining about leg pain without exam could have cost my life. Pain Dr has never examined me just says pain doesn’t exist .

  7. Hi Doc. Thanks for what you do! There is a shortage of people like yourself in these trying times for patients. I’ve had terrible back problems for years and I will spare you all of them details. I don’t take pain pills to get high as I hate them. I take them for legitimate pain. That said I was taking oxycododone back in 2013 and got to feeling better and wanted off of them so my doc prescribed me 8mg tablets of Buprenorphine. That didn’t work out for me at the time b/c I was not told to stop the oxycodone first. So I just went cold turkey. Fast forward to 2015 and my back went out again so I’ve been in pain management every since. My new doc (as I moved out of state) is a very good doc. He give me injections and voila back all good. Well I had to go through a series of them and severe sciatica set in on me and I’ve had it for 3.5 years. That being said at one point he put me on 7.5 butrans patch and 10/325 oxycodone 2 times daily for breakthrough pain. Couldn’t take the patch as it made me sick. So I had to go to the dentist last week and I had to take more pain pills than I normally do so I ran short for the first and only time. So, I look through my safe and noticed I had them 8mg Buprenorphine tablets back from 2103 since I was short I took one just to see if it would help. And OMG I feel better than I have since 2015. I’m scared to tell my doc about it b/c I’m afraid he will get upset and I don’t want to burn that bridge. So here is my question after all that lol! I’ve been taking the 8mg Buprenorphine for a week now and I have figured out the hard way that you need to be in withdrawal to take the Buprenorphine before it will work. I can’t figure out the equivalent dose of Butrans patch b/c I know he don’t have a problem giving me that. So could I go from 8mg Buprenorphine tablet to 7.5 mcg butrans patch without any withdrawal? What is the difference in the dosage? Should I just be upfront with my doc about what I did? Thanks for what you do and I APPRECIATE you soooo much and have a GREAT Easter w/e!

    1. Craig, The Butrans patch is a far lower dose than what you took in tablet form. I suggest you be honest with your doctor, because I’m sure he/she would rather prescribe buprenorphine than oxycodone. I would suggest Belbuca instead because that is far better absorbed than Butrans and it comes in higher strengths. See A Brief Review of Buprenorphine Products and share it with your doctor.

  8. Can you explain more about potency vs efficacy for opioids and how one measures how efficacious and how strong an opioid is vs another opioid… thank you

    1. Potency is a measure of how much drug is needed to elicit a response. For example, 30mg of oral morphine may elicit the same response as 20mg of oxycodone. Therefore oxycodone is more potent because less of it is needed to have the same outcome in terms of analgesia. The ability to cause analgesia is the efficacy. Naloxone is a string antagonist, but has no analgesic efficacy, but it has great efficacy as an opioid reversal agent. Because both morphine and oxycodone have the same outcome in terms of analgesia and side effects, both are similarly strong opioids.

  9. Dr. Jeffs: Many thanks for a very informative article. I am an otherwise very fit 60 yr old engineering professional with chronic pain. After an L5-S1 fusion left me with severe postoperative pain, I was placed under physician-supervised opiate therapy for eight years, which did an adequate job of mitigating my pain. I was a good patient, and never experienced any additive thoughts or behavior. However, the constant treatment had a pronounced impact on my state of mind, and I eventually became severely depressed. I tapered off the hydrocodone / Oxycontin in about six weeks, and spent the next year visiting seven different neurologists & pain specialists, all of which has frankly left me cynical of chronic pain patient (CPP) care.

    During that time I learned how distanced too many medical professionals are from their patients’ suffering, and how their lack of empathy feeds patient mistrust. I’ve had pain management doctors ask, re-ask, and ask again basic questions that were clearly addressed in earlier sessions (“So, where exactly is your pain located?”). I’ve had far too many suggest better sleep hygiene (good mattress, no laptops or alcohol before bed, etc.) when the obviously real problem was I couldn’t sleep due to god-awful pain! And I’ve heard countless suggestions to try acupuncture, yoga and even medical cannabis, the latter of which my job clearly disallows.

    But most frustrating is their ignorance of the very medicines they’re supposed to understand. I had previously asked (practically begged) for Belbuca, and was told that Buprenorphine therapy simply wasn’t well understood when applied to pain management. Instead, I was given a Fentanyl patch, which made me terribly sick over not one, but two trial dosing cycles. When I finally did get Belbuca, I was told I couldn’t go above 150 mcg / 12 hrs because of “tolerance considerations.” That’s especially maddening because I’m fairly sure that 300 mcg would be just about right. (I don’t expect miracles; I simply need the pain volume turned down enough to function as a normal human being.)

    Thing is, the Belbuca actually lowered my pain without the cognitive problems that Vicodin and Oxycontin brought. (My mood even improved.) Which makes my treatment plan absurd. Because if you can’t adequately address the pain, when what’s the point?

    This has to get better. The medical community clearly needs an updated set of medicinal options that offer improved efficacy in a safer format. But the practice of Pain Management also needs doctors who truly empathize with their patients’ and who are dedicated to improving their patients’ quality of lives without overly-compromising the care they provide.

    Thanks again for helping to light the way.

  10. 1249 fifth ave.
    c/o terence cardinal cooke rm.679 I was wondering if u could help me in a related matter. I am ready to be released from nursing care facility. But they refuse to give my medication for only a day. I am curtly taking methadone, fentanyl patch. I was previously on a methadone program six yrs ago when my accident happened I now am in a wheelchair and can’t even begin to figure out how even if I could get to a program. Is there a Dr here in NYC or ulster or duchess cos where l am hoping to be released to. Thanks very much

  11. Another drug worth further investigation is the alkaloid of the Kratom plant from Southeast Asia. Kratom appears to bind the kappa opioid receptor but not the mu opioid receptor, resulting in less sleep-induction (narcosis) and possibly less respiratory depression, while having useful effects for relieving pain that are self-reported by users who’ve used it for the purpose. It would be sensible for scientific research to be done, on supplementing full-agonist opioids with kratom alkaloids for pain control, because this might offer patients who need their full mental alertness an option to limit pain without getting sleepy. There have been false claims made for Kratom by nonmedical personnel that have resulted in injury and death: A police officer in upstate New York died a few years ago from a pulmonary embolism and lung hemorrhage while lifting weights in his basement gym. The deceased officer was apparently self-medicating for chest pain from the pulmonary embolism, with very large doses of Kratom and never asked a doctor about his worsening chest pain. This has been erroneously reported in the media as a PE “caused by Kratom”. The reality was that this senseless death shouldn’t have happened, because people who influenced how the deceased thought about pain, should have warned him to think of a chest pain as a symptom of a potentially life-threatening ailment like heart disease or a blood clot in the lung. A doctor would have put the man on bed rest, blood thinners, probably some supplemental oxygen to help him breathe, and probably a full-agonist opioid for pain for the first couple of days, which would have helped him rest while the clot stabilized. Rehab would have started with sitting up in bed, then taking short walks, and finally, longer walks. Once he was managing a hundred-yard walk with a walker, he’d be sent home from the hospital. No doctor would have told the guy to keep on lifting weights. The weights would have to wait until he was quite well. But when uneducated bodybuilders start trying to give medical advice and other bodybuilders start believing them, these are the kinds of errors that can happen.

    In summary, Kratom may be another alternative to full-agonist opioids and it may be cheaper to make than Suboxone. I’d like to see it taken seriously as a medical choice. It’s present limbo as a nutraceutical is causing misinformation to spread about it. What do you think?

    1. Bob, I think a lot of things from your post. First, “a pulmonary embolism and lung hemorrhage while lifting weights in his basement gym” was more likely to be from illicit use of anabolic steroids, as this is commonly seen. Moving past that, although much of what you said is correct, kratom is in fact a partial mu agonist at mu receptors.
      1. There are over 25 chemically similar alkaloids with variable / mixed properties
      2. Pharmacologically active components include 7-hydroxymitragynine and Mitragynine
      3. Both are Opioid (R- enantiomer) agonists; Kappa > mu > delta

      Other mixed mechanisms of action and various pharmacodynamic pathways include but are not limited to monoamine oxidase, plus reuptake inhibition of serotonin, noradrenaline and dopamine, all of which can cause tachycardia. In short, without a medical examiner very savvy in clinical therapeutics, it’s hard to know the real cause of death. You may be interested in an earlier post here, Kratom, Save ‘em, Bait ‘em, or Crate ‘em.

  12. Jeff’s please elaborate on this sentence from this article:

    Moreover, because most of buprenorphine’s activity is at the spinal level rather than the brain….

    I realize the point is a lower risk of respiratory depression, but my question is specifically about activity at the spinal level??? Can you explain that? Does the activity at the spine level have any affect on this being a better med for spine pain?

    Also, please comment on the lack of access to Palliative Care for cpp. Myself and most other cpp are told we don’t qualify for it. We are told that this area of service is for chronic conditions like diabeties, heart disiease ect., but not diseases that cause life long chronic pain? I am shocked at how many medical professionals don’t know the difference between PC and Hospice! My Geneticist at The Harvey Institute Baltimore was appalled when I told her I was denied by two providers that provide PC.

    I have Elher’s Danlos, Arachnoiditis, symptomatic Tarlov Cysts, Thoracic Scoliosis, severe, multi-level spinal DDD, Osteoarthritis. EDS comes with a long list of symptoms in and of itself!!! I can’t get any Dr. to provide additional non opioid, “out of the box” medication specifically for my conditions. They state it’s “outside the scope of their practice” then can’t direct me to anyone who will!

    Many thanks!

    1. Jacqueline,

      There are mu opiate receptors throughout the central nervous system (brain and spine) an also in other tissues throughout the body. Respiration is controlled by higher brain centers above the spinal cord, but the spinal cord does have activity with regard to analgesia. No, just because bupe works mostly at the spinal level, that does not mean it is better for spinal pain. The affect from bupe in the spinal cord and brain are systemic, not local. “Also, please comment on the lack of access to Palliative Care for cpp. Myself and most other cpp are told we don’t qualify for it.” Buprenorphine in the form of Butras and Belbuca are specifically FDA approved for chronic pain and/or palliative care. If you are unable to obtain it, it’s because the prescriber is unfamiliar wither these products and is/are coupling it with Suboxone and other bupe products that are specifically indicated for opioid use disorder (not pain), and/or the insurance company is refusing payment in favor of less expensive, more toxic option.

      1. I’m on Belbuca 750mcg 2 times a day for chronic pain. It works okay for the most part. I have a problem with a lot of breakthrough pain. For myself in particular ( because In my lifetime I have had horrible or weird reactions to medications including antibiotics) I don’t believe belbuca is staying in my system for 12 hrs. My pain doctor wants to move me to 900 mcg two times a day. Then if that doesn’t work she wants to switch me to Suboxone for pain relief as an off-label. She wants to try this because she says I’ll be able to take a higher dose of the buprenorphine. I am not going to take something that is not FDA approved for pain(Suboxone). I had a genetics test done for narcotics and nobody can explain it to me. I have asked my pain doctor to research lowering my Belbuca dose and seeing if it’s possible to take 3 times a day. Which has still not been researched. She admitted not knowing much about Belbuca and this is a pain clinic. Are there any other pain meds out there that can safely be added to belbuca for breakthrough pain that I can bring up to my pain doctor for discussion?

        1. Julie, It’s hard for me to answer this question without knowing your entire history. Your doctor’s plan does seem reasonable though, although if using bupe off-label, I would not use Suboxone. Plain bupe is available as Subutex and other formulations without the naloxone as present in Suboxone.

  13. By the way, is there anyway to get an accurate count of how many chronic pain patients have really overdosed and died from only taking their opioid medication as it was prescribed? Not od’s where alcohol or other non prescribed medications were taken.

    Wouldn’t that be interesting to know??? I think that would be very telling!

  14. I think pharmacogentic testing should be more affordable and accessible for patients. I just had it done through Genelex. I bypassed my insurance company because I’m sick of all the damn hoops they make patients and Drs. jump through. I paid $379 out of pocket. I realize many patients cannot afford this, but I will be a chronic pain patient until death. I have found this to be a most useful tool for myself, my providers and pharmacist.

    Out of all the 26 (it may be 28) P450 genes for metabolizing meds, I have nine with a significant clitch. This explains why I had such severe side effects from oxycodone when my RX benefit provider forced me off Nucynta ER because it is expensive and they didn’t want to pay for it. I appealed on my own behalf because it got done quicker than if I had waited for my Dr. to have the time.

    I agree it would be very, very challenging to transition to buprenorphine from traditional opioids. The insuance companies make weaning almost impossible due to needing prior auth for every single opioid med even for a lower dose than a patient already takes. It’s all a nightmare! This is the worst time in the history of this country to be a chronic pain patient. There are no words that can describe the injustices we have to endure!

    Thanks Drs. Jeff!

    1. Well said Jacqueline. And I agree that pharmacogenetic testing could be extremely helpful. The price you quoted thankfully isn’t too bad. But, you are correct, as long as we have a profit driven healthcare system where insurance companies dictate care, only those that can afford to pay will receive the best care. I suppose to some extent that would also be true for a government system, but at least everyone would have access.

  15. Thank you for this discussion. I have heard lots of talk regarding this subject lately. I have heard it can work for many patients, just not all of them as you agree. Most pain patients are concerned they will be force to change to buprenorphine and tapered off their traditional opioid medication. There are medical policy groups discussing forcing patients onto bupe by diagnosing them with OUD or Persistent Opioid Dependence, a diagnosis made up by PROP. Practitioners could justify switching their patients to bupe by these diagnoses. I would like to know more about the money involved with Indivior and others set to make a boat load off bupe if patients are switched. I would also like to know if there are gov. grants or incentives for clinics to switch to using bupe for pain. Could be interesting…

    1. Cyndi,
      As many other comments here, there seems to be an assumption that I’m suggesting most r all pain patients that are stable, be switched to buprenorphine. I’m not suggesting that at all. I’m merely saying that BEFORE traditional opioids are prescribed for long-term use, a buprenorphine product SPECIFICALLY FDA APPROVED TO TREAT PAIN (that does not include Suboxone or any other high dose buprenorphine product specifially FDA approved for opioid addiction) be considered first before drugs like hydrocodone, oxycodone, morphine, etc. To answer your questions…

      Nobody dislikes the rhetoric and false statements by PROP more than me. But, “opioid use disorder” has been around a long time, just like alcoholism – it was not invented by PROP.
      Practitioners could justify switching their patients to bupe by these diagnoses. If switching for managing pain, absolutely. I agree!
      “I would like to know more about the money involved with Indivior and others set to make a boat load off bupe if patients are switched If companies were to market their products that are FDA approved for OUD, to treat pain, they would be fined millions by the government. They are not allowed to market these off label. Lower doses of bupRenorphine are FDA approved specifically for pain for outpatient use. They include Belbuca and Butrans ONLY. Likewise, these cannot be marketed for OUD.
      “I would also like to know if there are gov. grants or incentives for clinics to switch to using bupe for pain.” NO. Just the opposite; they have not gone far enough to suggest or require that bupe be tried PRIOR to traditional opioids to treat pain.

  16. It doesn’t work for everyone! Patients need to know.
    Nor do most want to go through the hell just to switch to it. Because it’s not a fun task. People with comorbities are dying from withdrawal and tapers. So we still have got to have a variety of choices. Patients MUST know THIS;
    If you have been taking Long Term, Strong Full agonist opiates for Chronic Pain? That Patient has got to go into pretty Deep withdraw called a ( COWS scale) of 20, it’s Best to even be worse off 30.. This might work for Abrupt cut off of meds. It’s a Torture treatment.
    Patients, Look this up for yourselves).
    Or you have to be tapered down So low that your back in Full Agnoy before switching to Buprenorphine, Period. It will cause Precipitated Withdraw. And That causes A lot of Suffering pain before being able to convert just to try it. That’s NOT something everyone can do. This is the TRUTH. Sorry, Bupe is not for everyone.

    1. Donna, Many on here have misrepresented our message. We are not suggesting that buprenorphine is for everybody, nor are we suggesting that most if any should be transitioned from their current opioid therapy to buprenorphine. The intent of our response was to clarify scientific facts and to suggest that when the INITIAL decision is made to start an opioid for long-term use, buprenorphine should be considered prior to diving in to full agonist opioid; that would avoid discomfort and the COWS you mention, and also provide a safer option up front which could later be transitioned to a full agonist opioid is necessary, not the other way around.

  17. Our specialty is certainly challenging- with no objective pain measurement tools (yet) and a multitude of treatment options with only partial efficacy. In addition, let’s remember that “pharmacogenetically” we are all different, and therefore some patients will respond more favorably to an intervention than others. As clinicians, our challenge is to find a regimen of effective, tolerable and safe medications. I believe there is a differential effect on respiratory depression for this molecule, and my clinical experience supports the published data on the analgesic utility of buprenorphine at both low (microgram) and higher (milligram) doses- individualized to each patient. JG

  18. Jeff’s, great job of nailing the issues. Buprenorphine is an excellent choice for an opioid medication for the treatment of chronic noncancer pain (CNCP) . If possible, I would transition as many patients as possible from traditional full mu agonist chronic opioid therapy (COT) to buprenorphine for COT of CNCP. Unfortunately many of my therapeutic decisions are guided by insurance company policies that may be more mercenary than therapeutic.

    1. There is no difference between cancer or non cancer pain sir , suboxone does not work for all Cpp either. I was tricked into giving up my full agonist pain meds for suboxone, even the smallest amount of suboxone made me feel “high” , dizzy, confused , dehydrated, no libido to name a few nor did it control my pain the way full agonist opioids did. It is time to stop this opioid hysteria & realize “OUD” Is a BS term also. My dr said might have 1. Symptom of OUD because I took ONE MORE PILL than the bottle said. Are you kidding me? I’m an addict all the sudden because I took one extra pill for a gout flare up? Cmon

  19. I have been talking to a lot of chronic pain patients about buprenorphine for chronic pain, since my pain management doctor started pushing buprenorphine for any patient she couldn’t get to agree to a taper, about a year or so ago. Now granted this is far from scientific, but it seems a small percentage of folks, perhaps 5-10%, say it works better than their previous opioid. Another 10-20% say they got similar relief, and the vast majority say it doesn’t work as well for pain as the opioid they were on previously. About 75% said it also had worse side effects, with numerous people citing side effects as the reason they are no longer taking it. Another significant portion stopped taking it because their insurance would not cover it and it was prohibitively expensive. I still have a lot of concerns. Are there any long-term studies for the effectiveness in treating chronic pain? Do we know if people experience tolerance at the same rate with buprenorphine as with other opioids? (Dr. Schatman brings up a valid question here). A lot of patients also mentioned that withdrawal was worse coming off of buprenorphine than their previous opioid. And you have already done an entire article on issues with acute analgesia while on buprenorphine. Can you comment on these concerns? And I suppose what I really want to know in the end is… Do you think buprenorphine’s reduced risk of respiratory depression warrants intractable pain patients who have been stable for years on another opioid being switched to buprenorphine? Or is the big buprenorphine push really more to do with the fact that it isn’t tracked on PDMPs and therefore feels “safer” to prescribers?

  20. A couple of points need clarification, dear friends. First, while buprenorphine was first FDA approved for pain, it had been used for years in Europe for MAT in the last century. Second, buprenorphine received FDA approval for pain following a 12 week trial. I’ve worked with myriad patients who were put on buprenorphine for pain, and they did well…..for 12 weeks. My clinical experience, as well as the research, tells me that this is NOT a “pain medication”. Just my thoughts, Big Jeff, Little Jeff, and Jeff Jeff.

    1. Michael, Don’t you think it can me both? Afterall, anticonvulsants work for seizures and neuropathic pain; SNRIs work for depression and pain; benzodiazepines work for anxiety and are skeletal muscle relaxants; probenecid works for gout and to enhance penicillin longevity; aspirin works for pain and thromoboembolism prevention; birth control pills work for pregnancy prevention and endometriosis pain… I can go on and on. And for the record, pretty much all drugs that are FDA approved for anything had approvals based on 12-week pivotal trials, including antidepressants and anticonvulsants. Why in the world do you feel that buprenorphine, which has opioid agonist properties, doesn’t have analgesic benefit? Did I misunderstand you?

  21. My husband switched from his prescribed pain medication to Suboxone almost a year ago and has had remarkable results. He has unoperable cervical degenerative disk disease. He has his mind and life back.

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