Can naltrexone and Suboxone (buprenorphine) be used together for pain control?

Naltrexone and Suboxone Should Not Be Used Together for Pain Control

Naltrexone and Suboxone (buprenorphine/naloxone) should not be used together for pain control as they have opposing pharmacological actions that would interfere with each other's effectiveness. 1

Understanding the Pharmacology

Naltrexone and Suboxone work in fundamentally incompatible ways:

• Naltrexone: A pure opioid receptor antagonist that blocks opioid effects 2

  • Used for opioid and alcohol use disorders
  • Available as daily oral tablets or monthly injections (Vivitrol)
  • Blocks pain relief from opioid agonists 2

• Suboxone (buprenorphine/naloxone):

  • Buprenorphine is a partial opioid agonist with high receptor affinity 1
  • Naloxone component discourages misuse by injection
  • FDA-approved for opioid use disorder treatment 1
  • Has off-label use for pain management 3

Why These Medications Cannot Be Used Together

1. Pharmacological Incompatibility: Naltrexone would block the analgesic effects of buprenorphine in Suboxone, rendering the pain control ineffective 2

2. Risk of Precipitated Withdrawal: Using these medications together could potentially cause severe opioid withdrawal symptoms in patients who are opioid-dependent 4

3. Contradictory Treatment Goals: Naltrexone aims to block opioid effects while buprenorphine provides partial opioid effects for pain relief 1, 3

Appropriate Use of These Medications Individually for Pain

Buprenorphine/Naloxone (Suboxone)

• May provide pain relief in patients with chronic pain who also have opioid dependence or addiction 3
• Can be considered for pain management when:
  • Patient has moderate baseline opioid doses (avoiding very high or very low doses) 4
  • Patient has history of aberrant drug-related behaviors 4
  • A careful transition protocol is followed to avoid withdrawal 4

Naltrexone

• Not primarily indicated for pain management
• Can be used cautiously with non-opioid pain management approaches 5
• Low-dose naltrexone (much lower than addiction treatment doses) is being studied for chronic pain conditions, but this is different from standard naltrexone therapy 6

Alternative Approaches for Pain Management

For patients requiring pain control who are on either medication:

1. If on Naltrexone:

   • Focus on non-opioid analgesics (acetaminophen up to 3g/day) 2
   • Consider multimodal approaches including ketamine, lidocaine/bupivacaine, duloxetine 5
   • For severe pain requiring opioids, naltrexone may need to be discontinued (with careful planning)

2. If on Suboxone:

   • Continue maintenance dose for patients with both pain and opioid use disorder 1
   • For acute pain, additional short-acting opioid analgesics may be added with careful monitoring 1

Special Considerations

• Liver Function: Both medications can affect liver function; monitoring liver function tests is recommended 2
• Gender Differences: Women may experience more affective pain symptoms than men when on these medications 7
• Perioperative Management: Special considerations are needed for surgery in patients on either medication 1

In conclusion, while both medications have individual roles in either pain management or addiction treatment, their concurrent use is contraindicated due to their opposing mechanisms of action and potential for adverse effects.