Today I received a call from a patient who has been taking Suboxone for about six months, asking for help with a pain issue.  Before getting into the specific details I’ll mention something that I have mentioned many times before; some people do very well on Suboxone maintenance for opiate dependence, and others do less well.  Some people take their daily morning dose of Suboxone and then live life almost as non-addicts, rarely even thinking about opiates as they go about the business of life. 

Even former addicts deserve pain relief!!

Others can remain in an addictive relationship with opiates.  Suboxone bails them out of jams or prevents jams from happening in the first place.  They don’t spend all of their money on oxycodone or heroin, and in most cases they will manage to avoid taking opiate agonists most of the time.  But they clearly think about opiates much more than would be ideal.   They dose Suboxone more than once per day, even while admitting that they are probably only getting a ‘placebo effect’ when they take that second dose late in the day.  Some are even worse off, taking little chunks of Suboxone at times because they think it gives them a ‘lift’ of energy or mood. 

This type of behavior doesn’t necessarily end in disaster (although it sometimes does), but people stuck in this pattern don’t seem to benefit as much as those who dose once and forget opiates for the rest of the day.

The patient who called today wanted something ‘i.e. something narcotic’ for ‘severe throat pain that felt like a hole in his throat’—or as my kids would call it, a sore throat.  He didn’t have a diagnosis, but playing the odds he probably has a virus, or perhaps strep throat.  I’ve had strep throat many times, as have most people, including all of my kids.  I’m a pretty compassionate guy as far as my kids go, and I can’t think of a single time I considered treating their sore throats with a narcotic.  I did not provide narcotic for this patient either; doing so would have been unprofessional for multiple reasons, including the fact that he first needed to know what was using the sore throat, before simply masking the pain with narcotics.  But even after a diagnosis has been made, it is not appropriate to treat a sore throat with narcotics even in a person without addiction, let alone in a person with an addiction to opiates.

I have had similar cases; people on Suboxone requesting narcotics for back pain, hand pain, carpal tunnel pain, fibromyalgia, a sore tooth, a sebaceous cyst… things that ‘normal’ people would never seek narcotics for!  I usually get into a discussion, and sometimes an argument, where I try to make the point that most people go through their entire life without taking a schedule II narcotic.  If they did have a schedule II narcotic prescribed it was almost always for severe pain from kidney stones, major surgery, or perhaps from an acute spinal disc herniation; NOT for a sore throat.

There are several issues at stake here and I’ll try to avoid getting them confused with each other.  First, people with opiate dependence who take or don’t take Suboxone must remember that they cannot control their use of opiates.  In the days before Suboxone, opiate addicts were scared to death about needing to take narcotics for surgery.  I remember cases I had as an anesthesiologist where addicts made me promise to withhold narcotics even if they begged for them during the post-op period.  I tried to convince those people that they simply HAD to take narcotics in some cases, as there are risks associated with untreated severe pain such as pneumonia from failure to expand the lungs after gallbladder surgery or heart attack from hypertension after abdominal aneurysm surgery. 

To summarize, addicts could take their fear too far and avoid narcotics that were necessary to their surgical recovery, but the bottom line was that the smart addict avoided narcotics whenever possible, and was quick to recognize and admit the thought all addicts have after stumbling on a sidewalk crack:  ‘good- maybe I’ll break my leg and need some Percocet!’

Suboxone allows some degree of carelessness because taking Suboxone prevents a free fall into compulsive opiate use.  But I see too much complacency, and it is important for addicts to realize that not everybody on Suboxone does well.  I have seen cases where an addict on Suboxone believes he/she is safe lightening the dose of Suboxone now and then and taking a couple ‘80s’ for a weekend of pain relief, only to end up back on oxycodone ‘full-time’, no longer able to benefit from buprenorphine. Opiate addiction is a ‘crafty MF’ to borrow a phrase.  We are lucky to have a tool to help some escape the misery of addiction.  But those who take sobriety for granted and abuse the opportunity provided by Suboxone are asking for a heap of misery, and there may be no respite the next time around.

A separate issue is whether opiate addicts DESERVE pain treatment, and I don’t want to be misunderstood on this issue because of my comments above.  There are times in life when a person may need potent schedule II narcotics to treat pain, and in these situations, an opiate addict is as deserving of pain relief as any other patient.  I have seen MANY times over the years where a doctor will take note of an addict’s high opiate tolerance, and instead of prescribing a higher dose of a narcotic will prescribe a lower-than-normal dose or none at all!  I have heard doctors say ‘out loud’ things like ‘I’m sick of these people, and I’m not giving him anything!’ 

When a person with high opiate tolerance (often because of a carelessly- prescribing physician) goes to the local pain clinic for relief of genuine pain, the pain docs will look for a lucrative injection that can be performed, and in the absence of an injection they will look at the patient with a blank expression and say ‘I’m sorry but I can’t help you—I’m not giving you anything.’  They don’t want to do the hard work and don’t want to take on the trouble of a person who has been damaged by other narcotic prescribers.  Why bother trying to help that person when the next guy has insurance that pays $700 for the 20 minutes of time it takes to do an epidural steroid injection? 

If you have a high opiate tolerance and you are refused adequate pain treatment, you have rights.  If you are in that position, send me an e-mail and I will hook you up with a group that advocates for such patients– a group with many lawyers!

I hope that you can differentiate between the two situations described above.  There will always be a gray area between the two types of situations, but the ideas behind each of the two extremes are clearly different.  Opiate addicts learn to see every pain as deserving of treatment with narcotics regardless of whether the pain is coming from a viral cold, a migraine headache, or major surgery.  Addicts who do well are those who recognize that narcotics are rarely necessary and rarely if ever taken by non-addicts. 

On the other hand, in the rare cases where narcotics are clearly indicated, addicts have as much right to pain treatment as anyone else.


jsp4th · September 14, 2009 at 8:59 pm

I was sober and on suboxone for almost a full year when I got yet another kidney stone. I was taken to the local ER by a member of my family, and when questions like “are you currently on any medications?” were answered by “yes I’m taking Buprenorphine” I got “the look”. That day I was really in “severe” pain and before Bupe I was in the same place, and within ten minutes had IV Demerol. This time, I.B. 800, and one Flexeril before leaving. 12 hours later I was back in the ER, and this time after about 2 hours of throwing up on myself from the pain of a 9mm stone, I was given a “fifty” of IV Demerol and got sent home with (6) 5/500 Vicodin to be taken 6-8 hr PRN pain. “You got to be kidding me”, I said. Well come Monday I go to my M.D. (I’ll call him Doc. V.), and tell the girls behind the desk what I went through, and was told the Doc. was not in all week, and about a minute later here comes the Doc. from an exam room. I told him what was happening and guess what, he told me he couldn’t help me this time, and I was asked to leave. Now last stone I had was smaller, and Doc. V gave me all the Schedule II drugs I needed. Well I somehow get to a local Urologist and upon entering the office collapse in pain, right in the waiting room. I’m taken to the back, had a talk with one of the Urologists and tell him,the best I can about my weekend, and day so far. I was given Oxycodone APAP 10mg and instructed to take up to 2 every 6hrs PRN pain. I discussed this with my sub doc. and was told that I should call his cell phone if this should happen again, he then approved of my short discontinuation from sub, and after a week of feeling like crap went back on Bupe, toughing out the pain for another 5 weeks, and the very “fun” passing of a 9mm x 5mm kidney stone. I feel like a second rate citizen, sometimes less than that when people find out I’m a recovering addict, and when people find out I’m on Bupe. It is very depressing and sometimes all I want to do is stay in the house, and sometimes that’s exactly what I do. All I’ve ever known is addiction, (I’m 26 now, my 1st Oxycontin and the last time I was sober was at age 15) and I try to be tough, never forgetting how far I’ve come over the last 434 days (or 37,497,600 seconds)that I’ve been in treatment, but one can’t help to be offended by people whom hate you, yet don’t know you. Stay strong, and hang in there everybody, and you too Doc.! Giving up isn’t an option, not for anybody recovering, because more times than not, giving up is a suicide mission, and haven’t there been enough deaths from opioid addiction?
-JayJay Sober date: July 9th, 2008

happywags · September 26, 2009 at 6:27 pm

Dear Sir,
I just found your article doing a google search and am most interested in what you had to say in the last two paragraphs. I have been in a situation for 2+ years where I have legitimate chronic pain an no Dr. will prescribe me pain medication and have told me to my face that I will just have to suffer. At the end of your article you said that anyone that has been wrongly treated for their pain should email you, so I am. After reading your words I now feel as though there is finally a light at the end of the tunnel and would really appreciate the opportunity to explain to you what has happened to me and hopefully have you point me in the right direction to proceed. Thank you in advance.

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