Does increasing the dose of Suboxone (buprenorphine) help with an increase in chronic pain?

Increasing Suboxone Dose for Chronic Pain Management

Based on expert opinion, increasing the dosage of buprenorphine (Suboxone) in divided doses is recommended as an initial step in managing increased chronic pain, with dosing ranges of 4-16 mg divided into 8-hour doses showing benefit in patients with chronic pain. 1

Step-by-Step Approach to Suboxone Dose Adjustment for Pain

Initial Dose Adjustment

• When a patient on Suboxone experiences increased chronic pain, the first intervention should be to increase the buprenorphine dose and change to divided dosing 1, 2
• Divide the total daily dose into three doses given every 8 hours to maximize analgesic effect 1
• For example, if a patient is on 16 mg daily, consider changing to 8 mg every 12 hours or 5-6 mg every 8 hours

Dosing Considerations

• The effective dosing range for pain management is 4-16 mg daily in divided doses 1, 2
• Buprenorphine has a ceiling effect on respiratory depression but not necessarily on analgesia, allowing for dose increases with relative safety 1
• Malinoff et al. found that 86% of patients with chronic pain experienced moderate to substantial pain relief with improved functioning when transitioned to buprenorphine at doses ranging from 4-16 mg (mean 8 mg) in divided doses 1, 3

Alternative Formulation Options

• If divided sublingual dosing is insufficient, consider switching from buprenorphine/naloxone (Suboxone) to buprenorphine transdermal formulation 1, 2
• The transdermal patch bypasses hepatic first-pass metabolism (which affects 90% of sublingual dose) and may provide better analgesia 1
• Transdermal buprenorphine has proven efficacy and may be safer than full opioid agonists for chronic pain 1, 4

When Increased Suboxone Dosing Is Insufficient

If maximal buprenorphine dosing fails to control pain:

1. Add adjunctive non-opioid therapies appropriate to the pain syndrome (NSAIDs, gabapentinoids, topical agents) 1

2. Consider adding a potent full opioid agonist such as fentanyl, morphine, or hydromorphone 1

   • Note: Higher doses of additional opioids may be required due to buprenorphine's high binding affinity for μ-opioid receptors 1
   • Careful monitoring is essential when combining buprenorphine with other opioids 1

3. As a last resort, consider transitioning from buprenorphine to methadone maintenance if all other strategies fail 1

Important Clinical Considerations

• Pharmacology: Buprenorphine has high binding affinity for μ-opioid receptors and slow dissociation, providing long-lasting analgesia 1, 5

• Safety profile: Buprenorphine has been recommended as a first-line opioid for chronic pain, especially in elderly patients, as it may be associated with less cognitive impairment, falls, and other adverse effects compared to Schedule II opioids 6

• Potential limitations: In some cases, buprenorphine may block the effectiveness of other opioids due to its high receptor affinity, which can complicate acute pain management 7

• Mental health assessment: Always screen for depression and other mental health conditions that may impact pain perception and management 1

By following this structured approach to dose adjustment, patients with chronic pain on Suboxone can often achieve improved pain control without transitioning to more risky full opioid agonists.