Suboxone Use in Chronic Pain Management

Suboxone and how it works

Suboxone is an opioid prescription medication containing buprenorphine and naloxone. It is a Schedule III controlled substance, approved by the Food and Drug Administration (FDA) to treat opioid use disorder (OUD) as a detoxification or maintenance treatment. ^[1]

Suboxone is available as a sublingual film and a sublingual tablet, which should be placed under the tongue or in the cheek where it dissolves. ^[1]

Buprenorphine is a partial opioid agonist that can provide relief from opioid withdrawal and cravings without causing a euphoric high. Naloxone is an opioid antagonist that blocks the intoxicating effects of opioids and helps to deter misuse of the medication. ^[1][2]

Does Suboxone work for pain relief?

Suboxone is increasingly used off-label to treat chronic pain and can be an effective analgesic. This use has been recognized by the Drug Enforcement Administration (DEA) as a legal off-label use, with sublingual forms of Suboxone. ^[3]

Buprenorphine works as a partial agonist at the mu-opioid receptor. This receptor is responsible for many functions, including pain relief. Drugs that affect the mu-opioid receptor can have adverse effects, including respiratory depression, sedation, and nausea. Buprenorphine is less likely to cause these effects due to its partial agonist mechanism. ^[4][5]

Mu-opioid receptor agonists are also likely to result in tolerance and addiction, which is of lower risk with Suboxone. As such, its pain-relieving properties can remain effective long term, with low risk of adverse effects, abuse, and addiction. ^[2][5]

Suboxone is not currently approved by the FDA for chronic pain management, but some formulations, including Suboxone, have been approved for this use. Buprenorphine formulations have been approved by the FDA in a buccal film, injection, and a transdermal patch for severe pain management. ^[4]

Some of the available studies have investigated the effectiveness and safety of Suboxone in individuals with chronic pain who have been utilizing other opioid treatments. ^[2][3]

One such study found a 2.2, 2.5, and 3.7 point decrease in pain (on a 0-10 scale) when individuals changed to Suboxone from fentanyl, oxycodone, or morphine, respectively. ^[3]

How Suboxone dosing differs for pain vs. OUD

Suboxone is a combination of buprenorphine and naloxone available in sublingual tablets and films, which are produced in 4:1 (buprenorphine: naloxone) doses, such as 4 mg/1 mg or 2 mg/0.5 mg. ^[1]

For OUD, people will typically be commenced on around 2 mg buprenorphine per day, to be taken in one dose. This can then be increased gradually, often reaching a maintenance dose of up to 12 mg per day. ^[1]

For pain conditions, Suboxone may need to be administered in three or four divided doses, as the analgesic effect lasts 6-8 hours. However, the daily dose will typically be similar to the dose needed for OUD, often starting at around 2 mg and increasing to up to a maintenance dose of 16 mg/4 mg per day, in divided doses. ^[1][2]

Benefits of using Suboxone for chronic pain

Studies show the following potential benefits of Suboxone for chronic pain: ^[2][3][4]

• Less potential for dependence, abuse, and diversion than other opioid analgesics.
• It may improve chronic pain more effectively than other analgesics. 
• Other analgesics build tolerance, thus requiring increasing doses. 
• Other opioids have been found to cause paradoxical pain increase, known as opioid-induced hyperalgesia, in some individuals. Suboxone is potentially anti-hyperalgesic and can be beneficial for individuals who develop hyperalgesia with other analgesics. 
• There is less risk of harmful side effects and overdose with Suboxone compared to other analgesics.
• Suboxone can be used to manage chronic pain in individuals with substance use issues or OUD, without compromising their recovery.
• Compared to other opioid analgesics, Suboxone is less likely to cause impairments in functioning and cognition.

Limitations and challenges of using Suboxone for pain

Suboxone may be a valuable medication in the management of severe and chronic pain. However, some limitations and challenges of this use may include: ^[2][4]

• Suboxone is not currently approved by the FDA for pain relief, which can impact its accessibility. However, buprenorphine is approved for pain relief in buccal film and transdermal patches.
• Currently, research into the use of Suboxone as a pain relief is limited, although there are increasing numbers of studies around this and buprenorphine-only formulations. More research into Suboxone is required to clarify its safety and effectiveness in long-term use.
• People may experience stigma due to its use as an OUD medication.
• People may experience issues around the availability and accessibility of Suboxone, such as pharmacies not stocking the medication.
• Suboxone is a schedule 3 controlled substance, meaning it carries some risk for addiction, abuse, and dependence.
• People who choose to discontinue suboxone use will likely experience uncomfortable withdrawal symptoms, making it difficult to come off this medication.

Who should consider Suboxone for pain?

People who may benefit from Suboxone for pain include:

• People who have chronic pain and OUD.
• People who have chronic pain that is not well managed by other medications.
• People who have been on an analgesic for a long time and have developed a tolerance, thereby requiring increasing doses.
• People who experience hyperalgesia with other opioids.
• Elderly patients with chronic pain.

Alternatives to Suboxone for pain management

Alternatives to Suboxone for pain management include: ^[7][8]

• Physical therapy: Initially, individuals with pain conditions should be offered some form of physical treatment, such as massage, exercise, or physical therapy, to help improve movement and strength. 
• Psychological therapies: Psychological therapies such as cognitive behavioral therapy (CBT) and mindfulness-based stress reduction (MBSR) can help improve functioning, reduce distress, anxiety, and depression, and provide coping strategies. 
• Alternative therapies: Approaches such as mindfulness, acupuncture, and heat therapy can be utilized alongside a comprehensive treatment plan to enhance treatment outcomes. They can also help address stress and other psychological aspects of pain.
• Non-opioid pain relief: Medications such as acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) may help reduce chronic pain.
• Other medications: Some medications, such as antidepressants and anticonvulsants, have been developed for other purposes but can provide analgesic properties.
• Prescription opioid pain relief: Opioid pain relief, such as morphine and oxycodone, should only be commenced if other options have been ineffective. Opioids are typically effective at reducing pain, but have limitations to their use, such as reduced efficacy with prolonged use, risk of abuse and addiction, and drug interactions. 
• Other medical treatments: Surgeries, injections, and devices such as transcutaneous electrical nerve stimulation (TENS) may be required to help manage pain, depending on the cause.

For many people with chronic pain, the most effective treatment will include a comprehensive and integrated approach, utilizing a range of therapies. The treatment plan should be tailored around the needs of the individual and will vary from person to person.