Pain Management Options for Patients on Suboxone (Buprenorphine/Naloxone)
For patients on Suboxone (buprenorphine/naloxone), non-opioid medications such as NSAIDs, acetaminophen, and adjunctive therapies like muscle relaxants and topical agents are the preferred options for managing back pain.
Understanding the Challenge
- Buprenorphine has high affinity but low efficacy at mu-opioid receptors, making it a partial agonist that can block or compete with full opioid agonists, creating challenges for pain management 1
- The naloxone component in Suboxone is intended to discourage misuse but has minimal effect when taken sublingually as prescribed 2
First-Line Treatment Options
NSAIDs
- NSAIDs are recommended as first-line treatment for back pain and provide effective pain relief for assessment periods ranging from 2 to 12 weeks 3
- Examples include naproxen, ibuprofen, and diclofenac 4
- Caution is needed in patients with history of gastrointestinal bleeding, cardiovascular disease, or chronic renal disease 4, 5
Acetaminophen
- Acetaminophen is a first-line option for mild to moderate pain 5
- Multiple guidelines recommend acetaminophen as first-line pharmacotherapy for low back pain 3
- Lower doses should be used in patients with advanced hepatic disease, malnutrition, or severe alcohol use disorder 5
Second-Line and Adjunctive Options
Muscle Relaxants
- Skeletal muscle relaxants can be used as adjunctive medications for acute low back pain 3
- Tizanidine combined with acetaminophen or an NSAID has been found to provide greater short-term pain relief than acetaminophen or NSAID monotherapy 3
- Be aware that muscle relaxants have a high incidence of sedation 6
Topical Agents
- Topical agents (e.g., lidocaine, capsaicin) are recommended for peripheral neuropathic pain 3
- These can provide relief for peripheral neuropathic pain for assessment periods ranging from 3 to 6 weeks 3
Antidepressants
- Tricyclic antidepressants (TCAs) may be an option for chronic low back pain 6
- Duloxetine has shown a small improvement in pain intensity and function compared with placebo 3
Medications to Consider with Caution
Benzodiazepines
- Evidence for benzodiazepines in chronic pain is limited to one case report indicating they can provide pain relief for up to 2 months for neuralgic pain syndrome 3
- For acute or subacute radicular pain, low-quality evidence showed no difference between diazepam and placebo 3
Anticonvulsants
- Anticonvulsants like gabapentin may be considered for radicular pain (pain with a neuropathic component) 3
- Alpha-2-delta calcium-channel antagonists (like pregabalin) provide effective neuropathic pain relief for assessment periods ranging from 5 to 12 weeks 3
Special Considerations for Suboxone Patients
- Continue the patient's regular Suboxone maintenance therapy while adding non-opioid analgesics 1
- For patients with severe pain not responding to non-opioid options, consider splitting the daily Suboxone dose and administering every 6-8 hours to maximize its analgesic properties 1
- Avoid mixed agonist-antagonist opioids (pentazocine, nalbuphine, butorphanol) as they can precipitate withdrawal 1
Common Pitfalls to Avoid
- Discontinuing Suboxone unnecessarily can lead to withdrawal symptoms and increased relapse risk 7
- Assuming traditional opioid analgesics won't work is incorrect, but they would require higher doses to overcome buprenorphine's receptor competition and should be used cautiously 1, 7
- Failing to communicate with all healthcare providers involved in the patient's care can lead to suboptimal pain management strategies 7