Buprenorphine for Chronic Pain– a good choice?

A question about the use of Suboxone and buprenorphine for chronic pain:

I would appreciate your comments about long term use of Suboxone for pain. I am a post-polio patient for the last 12 years and have been +10 pain in my buttock. Every exam has come up negative and it is assumed that the pain in my buttock has been caused by a crush injury. I have been on every opiate available and have had to quit all because of severe pruritis. The physician I was seeing was treating me with Suboxone. He unfortunately just passed away. Suboxone has given me some relief. I would appreciate your input if this is the appropriate path to continue. I have been considering SCS, but no patient data base is available for polio. I thank you in advance if you might make some comment about Suboxone and pain.

Sincerely,

XXXXXXXXX

My Response:

I’ll address the pruritis first– which is ‘itching’ for the non-medical types.  Opiates cause the release of histamine, with morphine by far the worst in this regard.  The histamine causes intense pain along the vein during IV injection and will also cause a drop–sometimes significant drop– in blood pressure.  It will also cause hives to appear, and to itch– usually only for an hour or less.  With oral morphine the histamine release is much less dramatic.  But then there is another itch– usually on or in the nose.  This itch will drive people nuts, as it will sometimes feel like it is an itch that is not ‘scratchable’.  People also start to think that the itching person is doing cocaine, as he/she tends to rub the nose frequently.  I don’t know if buprenorphine is less likely to cause either of these ‘itches’, but as I think about it I have never had that complaint from a patient, and I have many patients taking Suboxone or Subutex.

For readers who aren’t familiar with the term, post-polio syndrome is a condition that develops decades after a polio infection that may or may not have been severe or debilitating. The mechanism that is thought to be behind the condition is that the polio virus attacks and kills motor neurons in the spinal cord—the neurons that send projections to our voluntary muscles, and that send signals to make the muscles contract. The remaining motor neurons then carry a heavier work load, as they carry signals to muscles that used to be served by other neurons. As time passes this extra load leads to loss of more neurons, which then places additional load on the remainder of the neurons, and so on.

At the same time this is going on, the muscle develops problems that lead to painful spasms. A normal biceps muscle, for example, will have thousands of muscle fibers that contract in an organized fashion in response to the nerve signal. But if every third nerve is destroyed by the polio virus, you end up with a biceps muscle that has a mixture of overworked muscle fibers and other fibers that are not contracting at all. There is no longer an efficient, coordinated contraction of the muscle, but rather a spastic contraction that has much less strength, since there are fewer fibers contracting. The overworked fibers become sore, and some may become ‘hypertrophied’ (the response one gets with weight training), but because of the uneven distribution of muscle growth there may be areas that get ‘ischemic’ (starved of oxygen) during activity.

Usually with muscle conditions the treatment is physical therapy, but since this condition can be made worse with activity, PT is not generally the answer (by my understanding– I haven’t worked with post-polio patients since my days as an anesthesiologist and so my information may be dated). I don’t know the effectiveness of the other typical muscle medications, e.g. flexeril, skelaxin, or diazepam.

I don’t know of specific issues related to post-polio syndrome in regard to treatment with buprenorphine, so I will be speaking in general terms about the use of buprenorphine for chronic pain. This is something that will certainly grow in the future; I notice a number of clinical trials looking at buprenorphine and chronic pain (go to clinicaltrials.gov), and the other options are not good, so buprenorphine will likely become a ‘go-to’ substance for patients with chronic pain.

As you know, the problem with using narcotics for chronic pain is that tolerance develops and takes away the effect of the medication. This tolerance occurs with all opiate agonists, and opiate agonists exhibit ‘cross tolerance’, meaning that a person tolerant to one agonist is tolerant to all of them. I do have a few patients who take opiate agonists for chronic pain, but I always wonder if they are getting any benefit from the medication after taking it for so long. Some docs make the horrible mistake of increasing the dose of pain medication in response to patient requests– I certainly know where they are coming from, as it is hard to say ‘no’ to a patient who is in pain and who has paid money to see me. But I have too often seen the result of doctors who cannot say ‘no’—we had such a prescriber in my area last year (he cannot prescribe opiates anymore, thank heavens) and when he lost his license my office was flooded with calls from patients in severe withdrawal, looking for another source for narcotics. Most of these people were not seeking narcotics when they first saw him; some even claimed to have no idea that pain pills are addictive. The rumor is that the doc’s trouble began when a young person died from an overdose on pills that were tracked back to his prescriptions. I also know of at least one suicide in a patient who was getting scripts from the same doc, who was trying to get off the pills. Patients that came to me from his practice were on ridiculous doses of pain medications; 400 mg of methadone per day for ‘thumb pain’; 300 mg of oxycodone PLUS dilaudid for ‘breakthrough pain’; hundreds of mg of oral morphine several times per day—for headaches! Crazy! And all of those people STILL complained of being in pain!

There are many cases of patients in similar situations who get off all narcotics and find that they have less pain than they did ON the narcotics. In some cases this is because they do other healthy things at the same time they stop narcotics, such as lose weight, which makes a big difference with back pain. But other times it is more complicated. People who take opiates become very ‘somatic’, i.e. they become hyper-aware of physical sensations to the point of noticing every little ache or pain, including pains that other people might totally disregard as simply the ‘normal’ pains that come with life. One goal with the treatment of chronic pain is to increase the patient’s activity level and increase the involvement in hobbies and social activities—primarily to serve as distraction and get the person’s focus on things that are outside of the body. There is nothing worse for chronic pain than being alone and thinking about the pain all day.

Back to this specific situation… buprenorphine is a potent opiate, with analgesic effects similar to about 30-40 mg of methadone or 50-60 mg of oxycodone. But tolerance quickly develops, reducing the impact of the drug on pain. But… tolerance ALWAYS develops—with ALL narcotics. I have not seen any evidence that tolerance is any more of an issue with buprenorphine than with any other pain medication.

There are at least two big advantages to using buprenorphine for pain over using other opiates. The first is that because of the ‘ceiling effect’, the maximal effect of buprenorphine is capped. This prevents the situation I referred to above, where patients end up on huge doses of pain medication—there is no reason to increase to those levels, as there is no increase in analgesic effect from doing so. Second, and even more beneficial, is that buprenorphine has partial-agonist properties that somehow result in much less (if any) cravings for opiates. The loss of cravings with buprenorphine is quite dramatic—I have seen many addicts shake their heads in amazement at the change in how they feel. Chronic pain patients taking agonists usually become ‘psychically attached’ to the drug; they develop a ‘relationship’ with the pain pills so that they are ‘always on their mind’ (to quote a country singer). Something about being in a relationship with narcotics seems to always cause misery in one form or another—depressed mood, bad relationships, loss of interest in other things in life… it is unusual to find a patient taking chronic narcotics who is happy, in my experience anyway. On the other hand I have many patients taking daily buprenorphine who are quite happy. They don’t get the ‘relationship’ with the drug; in fact, over time they eventually start forgetting to take it—which I always see as a GOOD thing.

So to come to some kind of conclusion (finally!)… I think buprenorphine is a great choice for use for chronic pain, IF a person truly needs to take a narcotic… with the understanding that in general, narcotics are NOT good choices for chronic pain.

SD