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.