From the Guidelines
No, suboxone should not be used as a breakthrough pain medication on top of regular suboxone dosing for patients on opioid agonist therapy (OAT) experiencing acute on chronic abdominal pain. According to the study published in the Annals of Internal Medicine 1, buprenorphine maintenance therapy should be continued, and short-acting opioid analgesics should be used to treat the painful condition. The use of mixed agonist and antagonist opioids, such as suboxone, may precipitate an acute withdrawal syndrome. Instead, conventional analgesics, including opioids, should be used to aggressively treat the painful condition. The study recommends dividing the buprenorphine dose to every 6–8 hours or discontinuing buprenorphine maintenance therapy and using opioid analgesics, and then converting back to buprenorphine therapy when acute pain no longer requires opioid analgesics.
Some key points to consider when managing acute pain in patients on OAT include:
- Continuing the usual dose of OAT
- Notifying the addiction treatment program or prescribing physician regarding the patient’s admission and discharge from the hospital
- Informing the addiction treatment maintenance program or prescribing physician of any medications given to the patient during hospitalization
- Using conventional analgesics, including opioids, to aggressively treat the painful condition
- Avoiding the use of mixed agonist and antagonist opioids
It's also important to note that buprenorphine has a ceiling effect for analgesia, and adding more will not provide additional pain relief once receptor saturation occurs. Therefore, alternative options for breakthrough pain management should be considered, such as non-opioid analgesics or adjuvant medications, under close medical supervision. The pharmacology behind this recommendation relates to buprenorphine's partial agonist properties and strong binding affinity for mu-opioid receptors, which blocks other opioids from effectively binding while not providing full analgesic effects itself at higher doses, as discussed in the study 1.
From the Research
Use of Suboxone as a Breakthrough Pain Med
- Suboxone, which contains buprenorphine, is a partial opioid agonist that can be used for chronic pain management 2, 3.
- The use of buprenorphine for acute pain has been studied, and it has been found to be effective in providing analgesia after abdominal surgery 4.
- However, the use of buprenorphine as a breakthrough pain medication on top of regular suboxone dosing is not well-studied.
- One study compared the analgesic effects of hydromorphone and buprenorphine in buprenorphine-maintained individuals and found that high doses of IV hydromorphone were most effective in achieving analgesia, but also displayed higher abuse liability and more frequent adverse events 5.
Considerations for Use in Acute on Chronic Abdominal Pain
- Chronic abdominal pain is a complex medical condition that can be challenging to manage, and opioid medications are commonly used to treat it 6.
- The use of opioid medications, including buprenorphine, requires careful consideration of the potential risks and benefits, as well as monitoring for adverse effects and abuse liability 6, 2, 3.
- The unique pharmacodynamic and pharmacokinetic properties of buprenorphine may make it a useful option for managing chronic pain, but its use as a breakthrough pain medication requires further study 3, 4, 5.