From the Guidelines
Opioids should not be used as a first-line treatment for pain management in patients on Suboxone (buprenorphine/naloxone) due to their potential ineffectiveness and risks. Instead, non-opioid medications such as NSAIDs, acetaminophen, and adjuvant medications like gabapentin or muscle relaxants should be considered first for mild to moderate pain management 1. For severe acute pain, several approaches can be taken, including:
- Temporarily increasing the Suboxone dose (up to 24-32mg daily, split into 3-4 doses) 1
- Discontinuing Suboxone and switching to full opioid agonists (requiring higher doses and close monitoring)
- Using high-potency opioids like fentanyl or hydromorphone that may partially overcome buprenorphine's blockade 1 Any approach involving opioids requires consultation with both pain management and addiction specialists to ensure safe and effective pain management. Key considerations include:
- Buprenorphine's high binding affinity for opioid receptors and its potential to block other opioids from working properly 1
- The risk of precipitating acute opioid withdrawal when using mixed agonist and antagonist opioid analgesics 1
- The importance of avoiding combination products containing fixed doses of acetaminophen and an opioid to prevent hepatic toxicity 1 By prioritizing non-opioid medications and carefully considering the pharmacological properties of opioids, healthcare providers can develop effective pain management strategies for patients on Suboxone while minimizing risks and ensuring the best possible outcomes in terms of morbidity, mortality, and quality of life.
From the Research
Opioid Use for Pain Management in Patients on Suboxone
- The use of opioids for pain management in patients on Suboxone (buprenorphine/naloxone) is a complex issue, with various studies providing insights into its efficacy and safety 2, 3, 4, 5, 6.
- According to a study published in 2002, opioids can be effective in managing chronic noncancerous pain, but patients may develop tolerance and physical dependence, requiring additional intervention 2.
- A 2008 consensus statement suggests that opioids, including buprenorphine, can be used for pain management in elderly patients, but careful consideration of comorbidities, patient functional status, and potential adverse effects is necessary 3.
- A scoping review published in 2025 found that pain management strategies for patients on extended-release buprenorphine for opioid use disorder are diverse and controversial, with a need for clear guidelines and high-quality evidence 4.
- A case report published in 2019 demonstrated the additive analgesic effect of tramadol and buprenorphine in a patient with opioid use disorder, highlighting the potential for tramadol as an effective treatment option for pain in patients on buprenorphine treatment 5.
- Another study published in 2008 discussed the role of opioid antagonists, partial agonists, and agonists/antagonists in office-based detoxification, including the use of buprenorphine and naloxone in Suboxone 6.
Key Considerations
- When using opioids for pain management in patients on Suboxone, it is essential to consider the potential for addiction, tolerance, and physical dependence 2, 3.
- The choice of opioid and dosing regimen should be individualized based on the patient's specific needs and medical history 3, 4.
- Non-opioid adjuncts, such as nonsteroidal anti-inflammatory drugs, may be used in combination with opioids to improve pain management and reduce adverse effects 2, 4.
- Further research is needed to determine the optimal pain management strategies for patients on Suboxone, including the use of opioids and non-opioid adjuncts 4, 5.