I recently gave a lecture to medical students about opioid dependence and medication assisted treatment using buprenorphine, methadone, or naltrexone. I was happy to see their interest in the topic, in contrast to the utter lack of interest in learning about buprenorphine shown by practicing physicians. In case someone from the latter group comes across this page, I’ll list a few things to do or to avoid when caring for someone on buprenorphine (e.g. Suboxone).
1. Buprenorphine does NOT treat acute pain, so don’t assume that it will. Patients are fully tolerant to the mu-opioid effects of buprenorphine, so they do not walk around in a state of constant analgesia. Acute pain that you would typically treat with opioids should be treated with opioids in buprenorphine patients. Patients on buprenorphine need higher doses of agonist, usually 2-3 times greater than other patients. Reduce risk of overuse/overdose by providing multiple scripts with ‘fill after’ dates. For example if someone needs opioid analgesia for 6 days, use three prescriptions that each cover two days, each with the notation ‘fill on or after’ the date each will be needed.
2. Don’t say ‘since you’re an opioid addict I can’t give you anything’. There are ways to provide analgesia safely. If you do not provide analgesia when indicated, your patient will only crave opioids more, and may seek out illicit opioids for relief. Unfortunately nobody will criticize you for leaving your patient in pain, but they should!
3. Don’t blame the lack of pain control on laws that don’t exist, for example “I’d like to help you but the law won’t let me.” Patients deserve honesty, even when the truth makes us uncomfortable. We get paid ‘the big bucks’ for tolerating the discomfort that sometimes comes from frank discussions with our patients.
4. Don’t assume your patient can or cannot control pain medications. If a patient has been stable on buprenorphine for years, he/she may have a partner or family member who you can trust to control pain medications. Some patients stable on buprenorphine can control agonists used for acute pain, but I wouldn’t stake my life, or theirs, on that ability. A useful compromise is to prescribe enough pain medication to cover 1-2 days of analgesia on each of several prescriptions, each with a ‘fill after’ date, to reduce the amount of agonist controlled by the patient at one time.
5. Don’t tell your patients that ‘opioids don’t work for chronic pain.’ I see stories on such great medical sources as the ‘Huffington Post’ explaining that ‘opioids never help chronic pain’. In reality, your patients know that opioids DO treat chronic pain, so they will consider you a liar or an idiot if you clam they don’t. The challenge is explaining the risk/reward equation to your patients, and explaining why treating chronic pain with opioids often leads to greater problems, as the risk/benefit equation is changed by tolerance.
6. I know this will cause heads to explode, but don’t assume that chronic pain is always less severe than acute pain. What if your patient’s chronic pain is worse than the typical pain after cholecystectomy or ACL repair? Most doctors would gasp at the idea of recovering from major surgery without opioids. What if the pain from failed back syndrome is worse?! I have had a few patients who, I’m certain, experience a great deal of suffering, and have gone so far as to have brain or spinal cord implants to get relief. I’m not arguing that we treat chronic pain in the same way as acute pain. But we shouldn’t jump to the conclusion that chronic pain isn’t severe enough to warrant opioids in order to dismiss those complaints more easily.
7. Don’t tell your patient to stop taking buprenorphine unless you’ve talked with the doctor who is prescribing that medication, and realize that the doctor you are calling knows more about buprenorphine and addiction than you do.
8. Don’t ask patients ‘how long are you going to take that stuff’ or criticize patients’ use of buprenorphine medications. Likewise psychiatrists shouldn’t tell patients scheduled for knee arthroscopy that the procedure is controversial, or talk patients out of hernia surgery.
9. Don’t assume that the doctor prescribing buprenorphine knows what YOU are doing. Too often patients will tell me about surgery that they failed to discuss in advance, even calling about pain hours after getting home from a procedure they failed to mention. Some people seem to believe that doctors regularly collaborate on their care, even though the opposite is closer to the truth.
10. Don’t assume that unusual or atypical symptoms come fromo buprenorphine. One truism of medicine is that doctors tend to blame unexplained symptoms on whatever medication they know the least about. Fevers of unknown origin, mental status changes, or double vision are not ‘from the buprenorphine!’
Those are the gripes at the top of my list. Did I miss one of yours? Or for patients, have you suffered from breakdowns in the system?
Addendum: 11. When treating post-surgical pain in buprenorphine patients, choose one opioid and stick with it. What often happens is that doctors will use one opioid, say morphine… and when nurses call a few hours later to say the patient is still screaming, they change to a different opioid, then another after that. As a result, the patient is placed on insufficient doses of several opioids, rather than an adequate dose of one medication.
There are two critical issues in treating such patients effectively. First, providing pain relief comes down to competition at the mu receptor. A certain concentration of agonist in the brain and spinal fluid will out-compete buprenorphine and provide analgesia. You cannot get there by adding other opioids together. If you use oxycodone for an hour and then change to dilaudid, you are starting over. Instead, choose one drug, preferably something that can be given intravenously, and stick with it. Morphine is not a good option btw, because of the low potency and histamine releasing properties of that drug.
Second, remember that analgesia and respiratory depression travel together, both mediated by the mu receptor. Anesthesiologists know this principle well… opioid medication can be titrated to respiratory rate, providing that the medication is given IM or IV. If a patient is breathing 28 times per minute, he/she is in pain. If the patient is breathing 6 times per minute, pain is not a problem, and the patient should be monitored for respiratory depression and possible overdose. When treating pain, doctors should aim for a respiratory rate of 14-18 breaths per minute, making sure that the medication is actually getting into the bloodstream (the risk comes when patients are given SQ injections or oral doses of narcotic that enter the bloodstream later, causing toxic blood levels).
John R Nienow MD · March 25, 2017 at 3:44 pm
Unfortunately, most of these gripes come from the general non-recognition of Buprenorphine, and Methadone, as treatments. In the county jail in which I attend, other docs would like to give arrested inmates the “chance to get off” their Buprenorphine or Methadone, which in turn justifies the forced withdrawal from these treatments, without a discussion with the prescribing physician or a real understanding of what those treatments are doing. There is no recognition of the opiate problem within jails, propagated by forced withdrawal, nor the increased risk of overdose and death upon release. Moralism reigns supreme.
Jeffrey Junig MD PhD · March 26, 2017 at 9:00 am
marine1968 · March 25, 2017 at 9:21 pm
Yes….i am about to suffer the consequences of physcian fear and ignorance. In two days i will be undergoing a hip replacement. Because i am a self confessed chronic pain opiate patient ( on a low dose 0f 60ME) my surgeon told me that he will rely on my continued use of chronic pain meds for post op pain. I tried to explain that over ten years i have developed an eggective tolerance on the 60 ME but he was not interested.
Looking forward to a miserable next two or three weeks.
Jeffrey Junig MD PhD · March 26, 2017 at 8:59 am
I’m sorry. All I can suggest is that you make your suffering known, by calling the clinic and on call services when the pain is unbearable. Don’t display anger, because anger is easier to dismiss as ‘addict behavior’. Make sure you document what is said during that time, and when you’re beyond the 3 weeks, give some thought to how things were handled. If you are confident that the standard of care was not met–i.e. that your pain was not addressed in a professional manner– contact the medical board in your state and file a complaint. Every state has a process for that, and that is the one thing that gets the attention of doctors very quickly. I’m not a big fan of medical boards, in part because of my own experiences over the years; the investigators are attorneys, not doctors, so they don’t always understand clinical issues very well, but that is the system that we have. I don’t think doctors will care about this issue until they see other doctors being punished for ignorance.
Susan Cary · March 26, 2017 at 11:07 am
My understanding is that the transdermal patches are not for acute pain, but I know buprenorphine has been used for post-op pain in Britain for a long time. Also, increased doses of a person’s regular Suboxone dose have been used in divided doses have been used for post-op, acute, pain with good results.
Jeffrey Junig MD PhD · March 26, 2017 at 12:39 pm
Butrans contains buprenorphine, the same active drug as in Suboxone, but in far lower doses. The top dose of Butrans– 0.5 mg per day– is about 10% of a typical 16 mg dose of buprenorphine used for addiction treatment (the bioavailability of sublingual buprenorphine is about 30%).
Butrans could be used to treat any type of pain, but any transdermal delivery system is a lousy way to treat acute pain because of the slow onset time– at least a few hours to reach significant blood levels. I suspect part of the reason Butrans is not recommended for acute or postoperative pain relates to the experience with transdermal fentanyl, which was initially used in that way but got a ‘black box warning’ after a couple deaths in young people, who used it for that indication.
Buprenorphine prescribers sometimes tell patients to divide their dose when taking the medication for mild pain, but there is no good evidence that doing so acheives ‘good results’ for post-op pain (and frankly no evidence that supports doing it for mild pain either, other than a practice trend that is unsupported by research, and that has no logical basis scientifically). Dividing the dose provides a placebo effect; nothing more. Expecting divided doses of buprenorphine to treat post-op pain, in someone tolerant to a dose of buprenorphine above the ceiling threshold of about 4 mg, is like expecting a person who falls from the Sears Tower (1450 ft) to do better than someone falling from the Freedom Tower (1776 ft). If you want to do what you’re suggesting, go ahead. But I hope that any physician who does as you suggest, i.e. tells a patient to ‘divide your regular dose’ and expect that to treat surgical pain, has an opportunity to see what that feels like someday!
Jeffrey Junig MD PhD · March 27, 2017 at 7:42 pm
I agree with many of your comments. I don’t think that there have been many criminal prosecutions of doctors for buprenorphine diversion, but doctors have been charged when people overdose from ridiculous prescribing of pain meds. Florida, which as you know was ‘ground zero’ in the prescription drug epidemic, may be more aggressive than other states.
I have a link on the top of this forum to news about buprenorphine; there was a story yesterday about a law proposed in Pennsylvania that would add additional oversight to doctors who prescribe buprenorphine products, and charge doctors who prescribe buprenorphine/Suboxone a ‘fee’ of $10,000 per year. That would end buprenorphine treatment in that state.
So much ignorance out there…. it is almost impossible to die from buprenorphine or Suboxone. About 40 people die with traces of the drug in the bloodstream each year in the entire country, compared to over 30,000 overdose deaths without buprenorphine in the bloodstream. Yet you will read about ‘severe risks’ from buprenorphine diversion in a newspaper on a daily basis.
Charles Anthony Foutch · March 26, 2017 at 9:23 pm
Most healthcare people will still call you a drug seeker. I was in burn unit with scorched lungs a broken heel bone so bad i had fracture blisters. I was hurt so bad they were contemplating amputating my foot but luckily I had one of the best surgeons in TN put it back together. They gave me IV Morphine and Lortabs. I was in the worst pain of my life a 10.5 on 1-10 pain scale. One of the nurses told the other nurse. I don’t think he really was in pain. I went ballistic.
Jeffrey Junig MD PhD · March 29, 2017 at 7:28 am
Anyone with a history of addiction knows how badly they are treated. Every now and then I will get a call from a surgeon who wants to make sure his/her patient gets adequate pain relief. I am so impressed that they took the time to do that– because it is so rare. We SHOULD be having those discussions all the time. I’ve read your comments on other posts- I don’t blame you for your anger, after what you’ve been through.
Jon mankowski · March 29, 2017 at 10:31 am
Sometimes I wish there were a hundred more like you Dt Junig.
Jeffrey Junig MD PhD · March 29, 2017 at 11:42 am
That’s very nice of you. I just got called about 20 obscenities a few hours ago by ‘sam’, after I told her that ‘Subutex’ doesn’t exist anymore, and what she was talking about was ‘buprenorphine’…. she said I was a jerk who ‘always needs to be right’, followed by obscenities that I wouldn’t even use. What she doesn’t understand is that there are true things and false things said about buprenorphine, and the whole reason for my blog is to try to keep things accurate.
So anyway, your comment was timed perfectly. Thanks again!
William Taylor, MD · April 4, 2017 at 8:46 am
Your posting inspired me to write up an instruction sheet with recommendations for surgeons for managing buprenorphine patients with postop pain. Our plan is to give this to folks having elective surgery so they can give it to their surgeons. There’s a reference to an article from Kornfeld and Manfredi in the Am. Journal of Therapeutics.
Docs tend to be on their best behavior if they know another doctor is closely interested in a patient’s care.
Jeffrey Junig MD PhD · April 5, 2017 at 6:58 pm
That’s great! I have one that I give to patients as well. I’ve also asked to speak to surgery residents at the two nearby teaching hospitals… but they haven’t been interested, not yet anyway. I’ll keep trying…..
coryguy52 · April 7, 2017 at 2:52 pm
Dr. Junig, First off , thank you for the “Talkzone” I’ve learned a great deal. I’ve been on Buprenorphine for about 5 years now and it wasn’t until I started reading your texts that I learned so much about suboxone. But, pertaining to this particular subject I do have my own horror story. Last August I started having a horrible pain from my back side to my hip then down my Rt. leg. It rivaled the kidney stone pain I had some 2 years ago. I went to the ER at one of the best hospitals in the city of Pittsburgh. I wanted to be completely honest and above board so the first thing I told them was that I was on Bupe. Then, I got “The Look.” They took some X-rays and said they couldn’t find the source of my “so called” pain. (Their words) I was literally crying from this intense shooting pain. So they admitted me for pain control. But they never controlled it. I couldn’t even stand long enough to urinate, I would just collapse into bed. I even ASKED for a catheter so I wouldn’t have to try and stand, again, nope! Well, it turned out that they said they couldn’t help me and my choice was to go home or go to a nursing home. Some choice. I’m still to this day fighting pain and weakness in my right leg, but after that experience, I’m terrified to tell the Drs. about it for fear of repeating last August’s fiasco. Thanks for listening.
Jeffrey Junig MD PhD · April 7, 2017 at 4:43 pm
Ugh. I hear so many stories like that… so many that I wonder if people should keep that part of their histories to themselves. Of course these days, doctors can look at the drug database for their state, and see which medications you are taking, and if you are caught in a lie, the ‘look’ will be even worse.
Your pain and weakness SOUND like symptoms caused by nerve root compression. There are only a few things that would account for both pain and weakness. The typical workup would be to do an MRI, to see if the L4 nerve root is compressed as it leaves the spine. If you Google ‘dermatome map’ you will see the distribution of pain or numbness caused by nerve root compression at each spinal level.
If that’s the problem, treatment would include relieving the pressure on the nerve root via surgery or epidural sterioid (Which reduces inflammation and in that way reduces pressure).
Another useful test is the EMG, which would help identy the location of the interruption of nerve function.
So frustrating.. ALL patients deserves a good work-up of their symptoms. If you are not treated well, let the medical board in you state know what’s going on!
coryguy52 · April 10, 2017 at 7:02 pm
Thank you for your comment, as a matter of fact I finally worked up the nerve to tell my PCP about my struggle. He in turn put in to my insurance company a request for an MRI. And today I received the ok to get the test. I really hope that something can be worked out so that this nightmare can end. Again, sir thank you for caring for those of us who deal with ALL the issues associated with addiction. Even when it’s in check with Bupe, then a whole other set of issues occur, like the medical professionals who treat us like $#!t on their shoes. I wish they were more like you Dr. Junig!!
Simone · April 15, 2017 at 6:59 am
i believe there is a serious issues with HDB treatments in patients who require strong analgesia to treat acute pain.
Jeffrey Junig MD PhD · April 16, 2017 at 9:24 am
Simone, you posted links to abstracts, and I appreciate your efforts. I’m not sure where you get your ’40 mg morphine’ number from, but morphine is not a potent opioid, and I agree that it would not likely do much in a patient on high dose buprenorphine. The links and quotes about up-regulation and ‘endocytosis’ are interesting, of course, but they describe phenomena that are triggered by ALL molecules that activate opioid receptors. I’m not including them here, as they will confuse the issue.
About your comment– I can assure you that opioid agonists will treat pain in patients on buprenorphine. The NIH consensus article entitled ‘Acute Pain Management For Patients Receiving Maintenance Methadone or Buprenorphine Therapy’ is a good place to start.