What's the best strategy to manage pain in a patient on Suboxone (buprenorphine/naloxone)?

Managing Pain in Patients on Suboxone

For patients on buprenorphine/naloxone (Suboxone), the best pain management strategy is to continue the maintenance buprenorphine therapy while adding multimodal non-opioid analgesics and, when necessary, higher doses of short-acting opioid analgesics for moderate to severe pain. 1

Understanding Buprenorphine's Pharmacology

Buprenorphine has unique properties that affect pain management:

• High affinity for μ-opioid receptors
• Partial agonist activity (ceiling effect for respiratory depression)
• Long half-life (24-60 hours)
• Displaces other opioids from receptors

These properties create challenges when managing acute or chronic pain, as buprenorphine can block the effects of traditional opioid analgesics.

Pain Management Algorithm for Patients on Suboxone

Step 1: Continue Buprenorphine Maintenance

• Maintain the patient's regular Suboxone dose to prevent withdrawal and increased pain sensitivity 1
• Verify the dose with the patient's opioid treatment provider
• For chronic pain, consider dividing the daily buprenorphine into 8-hour doses (e.g., 4-16 mg divided three times daily) 1

Step 2: Maximize Non-Opioid Analgesics

• Implement aggressive multimodal non-opioid analgesia:
  • Acetaminophen (scheduled, not PRN)
  • NSAIDs (if not contraindicated)
  • Adjuvant analgesics based on pain type:
    • Neuropathic pain: gabapentin, pregabalin, tricyclic antidepressants
    • Musculoskeletal pain: muscle relaxants, topical agents
  • Regional anesthesia or nerve blocks when appropriate

Step 3: For Moderate to Severe Pain

• Add short-acting opioid analgesics at higher than usual doses 1
• Avoid mixed agonist-antagonist opioids (pentazocine, nalbuphine, butorphanol) as they may precipitate withdrawal 1
• Use full μ-agonists like morphine, hydromorphone, or fentanyl
• Administer on a scheduled basis rather than PRN to prevent pain reemergence
• Monitor closely for respiratory depression, especially with higher doses

Step 4: For Refractory Pain

• Consider increasing buprenorphine dose in divided doses 1
• If maximal buprenorphine dose is reached, add long-acting potent opioids like fentanyl, morphine, or hydromorphone 1
• For severe refractory pain, consider transitioning from buprenorphine to methadone maintenance 1

Important Considerations and Pitfalls

1. Avoid Undertreatment: Inadequate pain control can lead to decreased responsiveness to opioid analgesics, making subsequent pain control more difficult 1

2. Patient Anxiety: Reassure patients that their addiction treatment will continue and their pain will be aggressively treated 1

3. Medication Interactions: Be vigilant about potential interactions between buprenorphine and other medications that may prolong QT intervals 1

4. Respiratory Monitoring: Closely monitor respiratory status when adding opioids to buprenorphine therapy 2

5. Avoid Combination Products: Limit use of fixed-dose combination products containing acetaminophen and opioids to prevent acetaminophen toxicity when higher doses are needed 1

6. Patient-Controlled Analgesia: Consider PCA for hospitalized patients to minimize anxiety about pain management 1

7. Mental Health Assessment: Screen for depression and other mental health issues that may complicate pain management 1

By following this structured approach, clinicians can effectively manage pain in patients on Suboxone while maintaining their addiction treatment and minimizing risks of respiratory depression, withdrawal, and inadequate analgesia.