What are the recommendations for pain management in patients on Suboxone (buprenorphine/naloxone)?

Pain Management in Patients on Suboxone (Buprenorphine/Naloxone)

For patients on Suboxone (buprenorphine/naloxone) maintenance therapy who require pain management, the first step should be to increase the dosage of buprenorphine in divided doses as an initial approach to managing chronic pain. 1 This strategy takes advantage of buprenorphine's analgesic properties while maintaining treatment for opioid use disorder.

Stepwise Approach to Pain Management in Patients on Buprenorphine/Naloxone

Step 1: Optimize Buprenorphine Dosing

• Increase the dosage of buprenorphine in divided doses (every 6-8 hours)
• Dosing ranges of 4-16 mg divided into 8-hour doses have shown benefit in patients with chronic noncancer pain 1
• Example: For a patient on 16 mg daily, consider 4 mg every 6 hours

Step 2: Add Non-Opioid Analgesics

• Use adjuvant therapy appropriate to the pain syndrome 1:
  • NSAIDs for musculoskeletal pain
  • Gabapentin for neuropathic pain
  • Acetaminophen (monitor total daily dose to avoid hepatotoxicity) 1
  • Topical agents when appropriate
  • Steroids for inflammatory conditions

Step 3: Consider Buprenorphine Formulation Change

• Consider switching from buprenorphine/naloxone to buprenorphine transdermal formulation 1
• Transdermal buprenorphine has shown efficacy in persistent noncancer-related pain 2

Step 4: Add Additional Opioid Therapy (If Needed)

• If maximal dose of buprenorphine is reached with inadequate analgesia, add a long-acting potent opioid such as fentanyl, morphine, or hydromorphone 1
• Higher doses of full opioid agonists may be required due to buprenorphine's high binding affinity for μ-opioid receptors 1
• Monitor closely for respiratory depression and sedation

Step 5: For Breakthrough Pain

• For acute exacerbations or breakthrough pain in low-risk patients, use small amounts of short-acting opioid analgesics 1
• Establish clear agreements with patients on:
  • Number of pills dispensed
  • Frequency of use
  • Expected duration of treatment

Step 6: Consider Conversion to Methadone (Last Resort)

• For patients with inadequate analgesia despite all previous strategies, consider transitioning from buprenorphine to methadone maintenance 1

Important Considerations and Precautions

Avoid These Medications

• Mixed agonist-antagonist opioids (pentazocine, nalbuphine, butorphanol) must be avoided as they can precipitate acute withdrawal 1

Special Monitoring Requirements

• When using additional opioids with buprenorphine, have naloxone available and frequently monitor level of consciousness and respiration 1
• Higher doses of full opioid agonists may be needed due to buprenorphine's high receptor affinity, but caution is needed if buprenorphine is discontinued 1

Mental Health Assessment

• Screen for depression and other mental health conditions that may impact pain management 1
• Address modifiable factors such as coping skills, recent loss/grief, unhealthy substance use, and mood disorders

Common Pitfalls to Avoid

1. Underdosing opioid analgesics: Due to cross-tolerance with buprenorphine, higher doses of opioid analgesics at shorter intervals are often required 1
2. Using as-needed dosing: Analgesic dosing should be continuous or scheduled rather than as-needed to prevent pain reemergence 1
3. Abruptly discontinuing buprenorphine: This can lead to increased sensitivity to full agonists with risk of sedation and respiratory depression 1
4. Failing to verify maintenance doses: Always verify the patient's buprenorphine maintenance dose with their prescriber or program 1
5. Neglecting to reassure patients: Patients should be reassured that their addiction treatment will continue and their pain will be aggressively treated 1

By following this structured approach to pain management in patients on Suboxone, clinicians can effectively address pain while maintaining treatment for opioid use disorder and minimizing risks.