Can We Have Opioid Analgesia Without Addiction?

I don’t have pull with the addiction-related organizations out there.  I’m never been a joiner, and I tend to notice the problems caused by medical societies over the good things that they supposedly accomplish.    For example PROP, or ‘Physicians for Responsible Opioid Prescribing’, have a specific mission.  Once a group has a mission, any considerations about individual patients go out the window.  PROP has propagated the message that opioids are NEVER beneficial for patients with chronic pain. But can we have opioid analgesia without addiction?

Legislators with no knowledge of clinical medicine hear that message, and respond by passing draconian laws that interfere with any considerations of individual patients.  I would guess that the people of PROP pat themselves on the back for encouraging laws that remove physician autonomy.  I’m sure they figure that they are smarter than all the family practice docs out there.  But in reality, they are only destroying the control of doctors over patient care, and handing that care over to politicians.  Way to go, PROP.

In the same way, the societies that hold meetings about meetings, that elect Secretaries who become Vice Presidents who become Presidents, get to publish the articles that describe clinical protocols.  The doc who spends every day talking with patients has no access to these sources, and little ability to influence those protocols.  Sometimes the societies and organizations get things right… and sometimes they get things wrong.  The latter is the case with post-op pain control in patients on buprenorphine products.

I’ve written about this before, as regular readers know.  Over the past 8 years I’ve had dozens, if not hundreds, of patients on buprenorphine undergo surgery.  The surgeries include coronary bypass, thoracotomy, rotator cuff repair, C-section, nephrectomy, total knee or hip replacement… and a host of minor surgeries with scopes and lasers.  I’ve treated these patients in a number of ways, in part because hospitals that provide emergency care have different ways of dealing with post-op analgesia.  I rarely have control over what they do acutely– but I almost-always take over pain control when patients are discharged.

In the past few months there have been several ‘articles’ stating that the best way to handle surgery, in people on buprenorphine products, is to stop the buprenorphine before surgery, and treat pain using opioid agonists.  This opinion is not supported by any data.  It is someone’s opinion– usually someone who has a title, i.e. someone who spends at least some of his/her time in society meetings.  That time is removed from the amount of time that could be spent treating and speaking with patients.  Frankly, the ‘higher’ a doctor is in society circles, the less time they spend in patient care.  That comment will anger the docs who it applies to.  I can hear them now– saying I’m only full of ‘sour grapes’. But maybe those same docs should look in the mirror, and wonder how they ended up as ‘President’ of a society.

I’ve used the approach claimed as best practice in the society journals– i.e stopping buprenorphine before surgery– and the same thing always happens.  Tolerance to opioid agonists rises very rapidly in the post-op period.  Patients are discharged on huge doses of opioid agonists.  And at some point, agonists must be discontinued for 24 hours to allow for re-induction with buprenorphine agents.  I’ve had several recent patients go through this exact process– and my frustration motivates this post.  One guy shot himself in the femur, and the bullet also passed through his lower leg.  He needed fasciotomy to avoid losing the leg. His Suboxone was discontinued at admission, and ten days later he was discharged on 30 mg of oxycodone every 2-3 hours– i.e. over 200 mg per day.  The other person was in a serious car accident, and had multiple fractures—  femur, pelvis, ribs, wrist– as well as internal injuries.  After 3 weeks he was released on over 300 mg of oxycodone per day!

On the other hand, I’ve had many patients go through the surgeries listed earlier while maintained on buprenorphine, 4-8 mg per day.  In ALL cases, they had excellent analgesia with lower doses of oxycodone than in the people who stopped buprenorphine.  Most patients did well on 15 mg of oxycodone every 3-4 hours– a max of 120 mg of oxycodone per day.  In a few cases– i.e. in the most painful operations, in the most sensitive patients– I had to use 30 mg of oxycodone every 4 hours.

The most amazing thing about the combination of buprenorphine and opioid agonists is the absence of tolerance to agonists, when buprenorphine is present.  I’ve had patients with recurrent injuries that required repeated surgeries, including a woman who tore her rotator cuff and the surgical repair THREE times over three months.  She took the same amount of opioid agonist for three months, with no noticeable decrease in efficacy.  After the final operation, after three months on significant amounts of opioid agonist, she simply stopped the agonist and resumed her full dose (16 mg) of buprenorphine.  She had no withdrawal, and not other complications.  She simply stopped the agonist and resumed buprenorphine treatment.

I’ve come to realize that buprenorphine effectively ‘anchors’ tolerance when patients take opioid agonists, as long as the buprenorphine is continued.  Patients always say the same thing:  that the pain was reduced by the agonist, but that it didn’t ‘feel’ like the agonist they used to take.  In fact, patients who could never control pain pills found that they COULD control agonists if they stayed on buprenorphine.

A couple years ago I presented these findings at an annual meeting of ASAM.  The slides can be found here.  I believe that some day, combinations of buprenorphine and opioid agonists will be the standard approach to pain treatment.  The combination allows for opioid analgesia without tolerance, without euphoria, and with little or no risk of addiction.  If THAT doesn’t piqué your interest, you have no business reading about opioid dependence!

I picture combinations of buprenorphine and fentanyl… especially since both are now FDA-approved as transdermal patches.  Or perhaps a combination of fentanyl lozenges and sublingual buprenorphine.  The possibilities are endless.  Throughout history, the miracle of opioid analgesia has been cursed by the attachment to tolerance, dependence, and addiction.

Imagine if that curse was lifted from opioid analgesia.    Can you even dare to imagine that world?  I’m telling you… it is closer than you think—- and there for the taking.