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.
- Opioids are synthetic chemicals similar to opium. Traditional examples include codeine, fentanyl, hydrocodone, oxycodone, morphine, methadone, and others.
- 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.
68 thoughts on “The REAL story of buprenorphine access for pain and addiction to mitigate death risk”
Buprenorphine was approved in the USA in 1981 by the FDA as Buprenex injectable for acute and postop pain. Not 2002. Recognized as 30X more potent than IV morphine, it was marketed with the partial agonism being a ‘safety feature’. It never took off. Branded and expensive, it was no better than other generic IV opioids and had a similar side effect profile (in opioid-naive postop patients). Sooooooo, you may want to edit your opening paragraphs.
As for safety of buprenorphine vs other opioids….. I’ve not seen data to support or refute this, mostly because of the low numbers of buprenorphine prescriptions relative to other agonists. If there’s something, I’d like to see it. Plenty of deaths were documented in France from Subutex when it hit 8mg doses.
Dr. Fudin, just curious…. what is the value of that putzy little dose of naloxone in the buprenorphine formulations? If it takes so much more narcan to reverse buprenorphine, what do they think that tiny dose will do if an abuse chooses to inject the medication IV?
However, thank you guys for the website. Overall, tremendous information and insight.
Thank you for the note Jeffrey. I agree, the naloxone is more of as gimmick in my mind compared to any potential benefit it might add. Afterall, buprenorphine at doses that would be used to overdose will occupy about 90% of receptors and has a lower ki compared to naloxone.
If I do nothing, just exist- being ruled over by these elite who repress, and control me, never mind how they have allowed other peoples wrongs I have nothing to do with- they ruin my somewhat of a life I had to fight through Hell for 2 decades to finally get after first my life ruined by a strangers drunken driving in another vehicle- truck- which killed two frineds. I get my working dosage of AVINZA Medicine taken away from me- that I DID NOT HAVE TO KEEP UPPING THE DOSAGE- would have worked the entire 41.5+ years of daily constant Pain due to c1-c2 fusion and other severe injuries to my head and face- minus the time to find the working dosage.
Oh the lies told about Opiate/Opioid Medicine.
So called U.S. government awards money to drug addicts, while punishing us people with a Severe Chronic Pain Illness for these other people’s illegal wrongs we have nothing to do with- we get NO guaranteed trial- just freely punished/tortured- again, and the law suit most likely that the drug addicts will by more street drugs- with the money kick backs going right back to the people in so called U.S. government- and their wealthy Luciferian friends.
Yes if I just exist doing nothing, sitting and laying down, even not all days- Belbuca works well, but if I do anything my Pain just rides over it like I’ve taken nothing.
Which is why I now know, that the so called united states country is the biggest con- fraud- lie I have ever known about!
Proof we are run by evil- what is the one Medicine they throw in the trash?
It is the Medicine which worked the best and longest for me- AVINZA
That I went through Hell to finally receive. But as I said- there is NO real united states country- it is the biggest fraud/con ever pulled on this earth.
It is run/ruled, by Luciferians, and their Luciferian workers who work for them. NOT at all referring to most everyday people not in the fraud/con government.
My pain Mgmt dr, of 3 yrs, wants to dump me because of a urine tox screen that came up pos for something he didn’t say what…..I’m in chronic severe pain disc disease and osteoarthritis. I’m in love dose oxycodone and 15 mg morphine sulfate release. I know my tox screen had to be good as it always is. I had a big prob finding a pain dr to accept my insurance and I can’t afford cash pay. Any suggestions?……janet
Janet, Oftentimes providers misinterpret urine screens, most often of the immunoassay type. Go to my app at http://www.remitigate.com/urintel and run a report. That may clarify what your doctor is misinterpreting, and you can print and share the results with him/her.
I was also accused of abusing my pain meds after a particularly bad night of DDD pain. My doc switched me to suboxone and I’m one of the lucky ones- it works better than the other opioids for my chronic pain, and I’ve been a chronic pain patient for over 20 years. The docs are afraid of losing their licenses and lots of chronic pain patients are really suffering. I have been experimenting with Kratom as well, since it’s legal and easy to buy. It seems to potentiate the pain relieving quality of the suboxone, so it helps for breakthrough pain. But I’d never tell my doc about the Kratom since the FDA doesn’t acknowledge Kratom as having any medicinal uses. Personally I think they’re dead wrong about that.
I made the transition to Suboxone about six months ago and couldn’t be happier despite an issue or two. The deep back and rib pain went from severe to very mild. Life is worth moving about again. Based on what I have read, I am one of the lucky ones who had a great response to the chronic pain issues. In addition, my depression lifted significantly. Still need to find a stronger laxative and I’m not sure if this opioid is contributing to my heart arrhythmia and much higher blood pressure. I’m dropping a few pounds to confirm the issue (I gained 50 lbs after graduating Hospice). I’m averaging 4 mg a day and is still very effective. Prior to this drug, the opioids I was prescribed was so low it was pointless. Still scratching my head on how cruel medicine has become. Hospice was the only time I ever got out of pain. Fortunately, I am getting stronger and lucked out once again.
Jett, Glad to hear. If it is in fact opioid induced constipation, there are specific drugs for that. Examples are Relistor, Movantic, and Symproic.
Bupe saved my life after 20 years of severe pain . I spent 7 YEARS bed bound almost 24-7..
4.5 years later I’m living my best life and have my life back! Fentanyl, oxy etc did ZERO for my excruciating pain as where bupe takes away 95% of my pain in 30 minutes . This medicine should be more available to chronic pain patients and lives would be saved !
Marlena your post gives me hope. My husband has been on opioids for 20 years and was suddenly dropped from his pain management doctor because of this new law they are doing steroid injections only. Due to the pain my husband attempted suicide. If some of the people on here were in my shoes they would try ANYTHING to get there loved one relief. He has his whole lumbar spine fused. Anyway Thank You
Food for thought! Great article. Please keep the comments coming so we all learn more on the real story of buprenorphine.
The real question is…does analgesic effect increase in the low dose range, or does analgesia increase with increased dose? Low dose being like a couple mg daily or less, and high dose being like 16-32 mg or whatever.
The jury is still out on this. There is conflicting data.
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.
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.
Megan, Whether or not buprenorphine has a ceiling effect on analgesia has not been determined. It does have a ceiling effect on CO2 accumulation.
That is SIMPLY not true. I mean, c’mon, man. If you’re gonna have a site like this, don’t lie. It very clearly DOES have a ceiling effect on analgesia, other sources clearly site. Not only that, wow, Jeff. The compassion man. It’s freaking overwhelming! This person makes an incredibly cogent point, and you don’t even acknowledge it. You do what so many pain clinicians are doing right now, in order to save your license, you punt to a product that doesn’t always work. Not only doesn’t it always work, but it makes a LOT of people incredibly SICK (as in unliveably unwell). The headaches, the nausea, the rest of it. The lack of quality pain control that leads people to want to exit stage left, man. I mean… what kind of doctor are you when you misdirect with this slight of hand and don’t even comment on the more salient and pressing problem?! What happened to do no harm? This person is saying what a lot of us are… if it wasn’t for their kids, man, they’d K-I-L-L T-H-E-M-S-E-L-V-E-S because some douche decided to order Chinese fentanyl off the Dark Web and now _we’re_ the ones paying for it! It’s not the person out here grabbing a Milan patch and slapping it on every 48! It’s the drug user, and let me just tell you, it’s a sad story, sure, BUT IT’S THEIR CHOICE! THEY ARE CONSCIOUSLY MAKING THE CHOICE TO SHOOT UP OR SNORT OR WHATEVER THEY’RE DOING, it’s not your pain patients some Senator is railing about! It’s his kid who wants to cure his weekend boredom! Well, trust me, pal… that has NOTHING to do with US!
And because you’re all scared of getting your licenses revoked, you’re all running! NO ONE has the gumption or the brains to make the right call. To call BS on the whole thing and stand behind your patients! YOUR PATIENTS YOU PRESCRIBED OTHERS THINGS BESIDES BUPRENORPHINE (OR BELBUCA OR BUTRANS OR WHATEVER FLAVOR YOU WANNA HAWK NOW!) BECAUSE YOU KNEW IT WOULD W-O-R-K! God, duh.
Seriously, Jeff or Jeffs or whoever you are! Have some pride in your profession! Sure, buprenorphine works for some folks, and that’s great! Wouldn’t life be wonderful if it was this easy cure-all for everyone! BUT IT’S NOT! And to either profess or pretend that it does is just irresponsible and weak. And disappointing! There’s a tool for every job and morphine and fentanyl and Oxy, I suppose, though I have no direct knowledge of it as I have never used it, have their direct usages!
DO NOT LEAVE YOUR PATIENTS BEHIND! DO NO ABANDON THE PEOPLE WHO NEED YOU! To do so is harming the folks you’re here to defend!
Megan I’m on month 2 of being on the Butrans patch and I can tell you my quality of life sucks my dog has not had any walks for 2 months my rescue medicine (oxycodone 10 mg 3x a day) was doing all the work on 10 mcg ( they told me 10 mcg is a pretty heavy dose BULL SH1T ) I’m on the 15 mcg and it helped a bit on the first few days but to go to 15 mcg I had to loose 1 dose of my rescue medicine so now I got 2 doses of my rescue medicine and I’m still stuck in bed I feel crappy and don’t got the energy or desire to do a thing … I begged to go up to the 20 mcg but I’m so sick of dealing with feeling like my life is now useless and stressing 24/7 about patches falling off and not sticking I’m gonna say forget it his crap give me my old medicines back it may have under treated my pain but some relief and a life is better then no life ( before this dammed lockdown on opiates I was on a dose 3 x of what I was getting )
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.
Thank you Gina and best of luck!
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,
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.
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
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.
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.)
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.
This does not answer his question.
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 .
I CERTAINLY HOPE YOU SEARCHED FOR A ATTORNEY TO ASSIST WITH THAT TERRIBLE STORY.
Sad to say J that’s the VA for you.
I too am a vet and I was conned by the VA to join the new pain management team they are making like a FOOL I broke the most sacred rule in the USMC… NEVER VOLUNTEER now I think the only pill that will help now is a lead pill
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!
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.
Thank you so VERY MUCH!
Truly crappy advice, Jeff. Don’t tell your doctor you took something you had sitting around for years in your SAFE. You don’t want to burn that bridge and I don’t blame you!
Tell him you’ve been reading about the new CDC guidelines. Tell him you’ve been reading Dr. Jeff’s forum here. =P Or some dude on the web’s site who really likes Buprenorphine that way your admission stays here. =P God. Then tell him you’re wondering if you could qualify. Tell him you realize that Oxy is a harder hitting medicine (in that it acts on several receptors), but that if he’s on board, you’d really like to try Belbuca and just see how it goes. Tell your doc that you didn’t do incredibly well on it in the past, but that you think it’s because you didn’t titrate down correctly, and that you’re hoping this time to wean off the Oxy (as recommended) and titrate up on the Belbuca. This will have the SAME results, I guarantee you, without risking your relationship with a good doctor. =P
Dumb advice. This will work, Craig. And I am sure glad that it’s working out for you! I hope it continues to. From one person living with massive chronic pain to another. From one person who LOATHES being on these drugs, would choose to get high on pretty much anything else =P (like a nice joint!) Best of everything, Craig.
Do you use Belbuca? Can you take vicodin with Belbucca for breakthroughs?
You can if prescribed. Vicodin works better for breakthrough pain with low dose Belbuca. If you require Vicodin regularly, your doctor should consider raising the Belbuca dose so that you don’t need to chase the pain with Vicodin.
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
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.
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.
Jesus H. Arrogance is so infuriating, I swear to God. 300mcgs of Belbuca is like… a NORMAL adult dose. Whoever told you it wasn’t was an idiot. I’m sorry. (I have to stop and laugh… I’m almost sure since this forum is moderated that none of my posts are going to go through — despite my clear understanding of not just this drug, but several others, PLUS my full knowledge of the situation in this “Opioid Epidemic” we’re currently NOT facing. Yes, I said NOT. I could explain more, but I’m not sure it’s important to bother at this time). Anyway, if this gets through, I suggest you bring a metric crapton of documentation along with you on your next pain visit (print EVERY SINGLE COMMENT FROM THE MANUFACTURER’S’ WEBSITE TO SIMILAR SITUATIONS OFFERED BY OTHER PATIENT’S/DOCTORS (EVIDENTIARY, ET AL) TO BRING WITH YOU) to show that 150mcgs is just irresponsible in truly MANAGING your pain, and that to NOT investigate it as an option is TRULY HARMING YOU as a person! Tell your doctor what you can’t do (I’m sure there’s more than just get a good night’s sleep!) and how it’s impairing your QUALITY OF LIFE! This is BEYOND important! And if they don’t care? Find a new doctor.
If you’re one of the lucky ones who can use this product, they should thank their lucky stars. Seriously, you don’t have to be a jerk about it, but be HUMAN. You are worth more than just glossing over, especially when the glossing is bogus. I’m there in fighting spirit! And I’m wishing you LOTS of luck!
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
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?
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.
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!
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.
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?
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.
Thank you! Exactly! It’s so infuriating how many pain clinicians don’t understand the Naloxone component of Suboxone and still prescribe when it’s not necessary (or is sometimes an even bigger irritant =P). Still, I think you could have offered some commentary on what a clinician might add for break-through that’s commonly prescribed.
I agree that Belbuca doesn’t work for 12 hours. Just like Fent patches don’t work for 72. I mean, it’s a reach, and for some they do, but for MOST they do not. Why your doctor couldn’t break your dosage, instead of continually INCREASING so you could use it 3xs a day is just… boggling! It seems like that would be the smarter play here. Aggravating and ignorant! =P Maybe the smarter play here is to print out all the documentation you can find on efficacies and people experiencing similar situations where the outcome is breaking that dosage into something more manageable (in this case the 3xs a day). I’m sure there’s evidence of this happening and explaining that educating yourselves _TOGETHER_ on this drug just felt like the responsible thing to do in this age of the “epidemic”. ;P This way it seems like you’re being _ACCOUNTABLE_ and not patronizing. ;P
Wishing you the best Sick of! I’m sick of it, too!
Well l need to ask why u “wonderful” Dr didn’t just put u back on the opiates along with the dose that works! Drs are putting pts on these bup formulations not necessarily for the pts Benefit, it’s usually for Drs benefit as these drugs are schelue 111 along with not having an MME! Pretty slick as the DEA was doesn’t go after them! Think about this if u will!
Eileen, There’s no reason to be sarcastic, as I’m just trying to educate the patient and medical community here.
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!
Yes Jacqueline, you are exactly correct!
Hehehe. Uh. Yeah. That’s the thing. This “epidemic” isn’t from pain patients who are adequately using their medications. This is from bored twenty-somethings and thirty-somethings and forty-somethings who are dropping by their local dealers or shopping off the Dark Web. It’s from the squeaky wheel senator’s whose kids are killing themselves by their own choice. By their own hand.
Is it a sad situation? To be sure. But is it OUR problem? Not even close. It’s just a really convenient scapegoat. And it friggin’ sucks. When the suicide rate starts overclocking this BS epidemic, maybe people will consider putting some real numbers together, but I can guarantee, until then? We’re gonna be the ones to pay.
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!
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.
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…
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.
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.
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.
You know, you say that.. that _we’re_ the ones misrepresenting your msg. And yet… it’s really only here in a few comments that your real msg comes through. And trust me, I APPRECIATE IT. I would LOVE to see this msg BETTER represented up above! Because YOU DO sound like you’re saying bupe is for everyone. You do sound like you think it’s a one-for-all! And it is represented as being some panacea! A simple switch! So… if anyone is guilty of a misrepresentation, doc… maybe it’s not us? =D
Honestly, some of your candor here in these comments is really appreciated about this drug. And your intellect on how it interacts with the body is just invaluable! I am sure you’re shocked, it’s not like I have a lot of really positive things to say, but it’s not that. I am just honestly EXHAUSTED with the medicine profession and its HAUGHTY HUBRIS. Clinicians who either don’t understand their medications or misrepresent what a patient is in need of or GRATINGLY accuses their patients of things like pill seeking behavior when they are just TRYING TO LIVE. We get that — for whatever reason (for you guys) — this is a field of cynics… but seriously. You have to be able to approach the medicine you do with trust. If you can’t, you’re in the wrong field, and I can guarantee you that every single person here has experienced that insane bias. How many times some moronic pharmacist has wanted to question what your doctor has prescribed you. Or how your clinician has said, “Hey, sorry. I can’t treat that. You need to go to an entirely different doctor.” Or worse. The side eye. The terrible questions. The skepticism. You go through that a hundred times and I promise you, you start answering forums like these just like me. =P
I’m sure my brusque attitude hasn’t been best received, but I would like to not only say this (honestly), but to thank you. I’m sure it hasn’t seemed like it up to this point, but I _do_ appreciate what you’re trying to do here, and I do appreciate the time you take to answer folks. I might not always agree with what you say, and usually it’s from a best-scenario situation, but I really do appreciate what you’re doing. And your understanding of medications and how they work systemically is just unmatched.
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
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.
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
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?
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.
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?
You continue to amaze with your keen knowledge and insight
😉 Thank you!
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.