What medication can be used to control pain in a patient already taking Suboxone (buprenorphine/naloxone) and Nortriptyline (nortriptyline)?

Pain Management Options for Patients on Suboxone and Nortriptyline

For patients already taking Suboxone (buprenorphine/naloxone) and nortriptyline, the most effective additional pain management option is gabapentin or pregabalin, particularly for neuropathic pain components.

Understanding the Current Medication Profile

• Suboxone (buprenorphine/naloxone) is a partial mu-opioid receptor agonist used for opioid dependence treatment with some analgesic properties 1
• Nortriptyline is a tricyclic antidepressant commonly used as a first-line treatment for neuropathic pain 2
• This combination already provides some pain relief but may be insufficient for adequate pain control 3

First-Line Additional Options

Anticonvulsants

• Gabapentin: Start with 100-300 mg nightly and increase to 900-3600 mg daily in divided doses (2-3 times daily) 2

  • Dose increments of 50-100% every few days, with slower titration for elderly or medically frail patients 2
  • Requires dose adjustment for renal insufficiency 2

• Pregabalin: Start with 50 mg three times daily; increase to 100 mg three times daily 2

  • Maximum dose of 600 mg in divided doses three times daily 2
  • More efficiently absorbed through GI tract than gabapentin 2
  • Requires dose adjustment for renal insufficiency 2

Rationale for Anticonvulsants

• The combination of nortriptyline and gabapentin has been shown to be superior to either medication alone for neuropathic pain 2
• Anticonvulsants work through different mechanisms than both opioids and tricyclic antidepressants, providing complementary pain relief 2

Second-Line Options

Topical Agents

• Lidocaine patch 5%: Apply daily to the painful site with minimal systemic absorption 2
• Topical NSAIDs: Consider diclofenac gel (apply 3 times daily) or diclofenac patch (180 mg, once or twice daily) 2

Tramadol Consideration

• May provide additive analgesic effect when combined with buprenorphine in patients with opioid use disorder 3
• Start with low dose (50 mg three times daily) and monitor closely 3
• Caution: potential for serotonin syndrome when combined with nortriptyline 2

Important Considerations and Precautions

Drug Interactions

• Avoid medications that may cause QT-interval prolongation when combined with buprenorphine 2
• Be aware of potential serotonin syndrome risk when combining multiple serotonergic agents 2
• Monitor for increased sedation when adding anticonvulsants to existing regimen 2

Pain Assessment

• Determine if pain has neuropathic components, which would respond better to anticonvulsant therapy 2
• For inflammatory pain components, consider adding NSAIDs if not contraindicated 2

Dosing Strategy

• Start with low doses and titrate slowly to minimize side effects 2
• Allow adequate trial periods (at least 2-3 weeks) to assess efficacy 2
• Consider the combination of existing medications plus an anticonvulsant before adding other agents 2

Monitoring and Follow-up

• Monitor for side effects including sedation, dizziness, and cognitive impairment 2
• Assess pain control using standardized pain scales at each follow-up 2
• Evaluate for potential drug-drug interactions at each medication change 2
• Consider referral to pain specialist for interventional approaches if pharmacological management is inadequate 2