Ten Gripes of Buprenorphine Doctors

I recently gave a lecture to medical students about opioid dependence and medication assisted treatment using buprenorphine, methadone, or naltrexone. I was happy to see their interest in the topic, in contrast to the utter lack of interest in learning about buprenorphine shown by practicing physicians. In case someone from the latter group comes across this page, I’ll list a few things to do or to avoid when caring for someone on buprenorphine (e.g. Suboxone).

1. Buprenorphine does NOT treat acute pain, so don’t assume that it will. Patients are fully tolerant to the mu-opioid effects of buprenorphine, so they do not walk around in a state of constant analgesia. Acute pain that you would typically treat with opioids should be treated with opioids in buprenorphine patients. Patients on buprenorphine need higher doses of agonist, usually 2-3 times greater than other patients. Reduce risk of overuse/overdose by providing multiple scripts with ‘fill after’ dates. For example if someone needs opioid analgesia for 6 days, use three prescriptions that each cover two days, each with the notation ‘fill on or after’ the date each will be needed.

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Buprenorphine Overdose After Naltrexone Treatment

Naltrexone induces mu-receptor hypersensitivity.  Buprenorphine’s protective ‘ceiling effect’ may not prevent overdose in patients with this ‘reverse tolerance’.

A new patient described his recent history of respiratory failure several days into buprenorphine treatment.  He was told by his doctors that he experienced an allergic reaction to Suboxone. The rarity of buprenorphine or naloxone allergy led me to look deeper into his history, and my conclusion differs from what he was told by his last treatment team.

The patient, a man in his mid-50s, has a history of significant opioid use over the past 20 years.  He used a variety of opioid agonists over the past year, mostly prescription opioids, with an average daily dose greater than 200 mg of oxycodone per day.

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Opioid Induced Hyperalgesia Prevented by Buprenorphine?

“Buprenorphine is a kappa receptor antagonist. For these reasons, buprenorphine might be unique in its ability to treat chronic pain and possibly OIH.”

The opioid crisis has been fueled by the use of opioids to treat chronic pain.  Practice patterns have changed, but doctors are still criticized for their roles in the overuse of opioids.  I’ve sat through community ‘heroin forums’ (sometimes on stage) as sheriffs, politicians, and ‘recovered addicts’ firmly pointed fingers at health professionals.  I, meanwhile, kept my finger under the table, but had the thought that some of the people pointing would be the first to complain if they were forced to stop pain medication prematurely for their own good or ‘for the good of the community.’

Doctors can’t see into the future.  I suspect most cases of opioid overuse began with well-intended efforts to provide temporary pain relief.   But then for a variety of reasons things didn’t go as planned.  Maybe the planned knee or back surgery never took place because of patient indecision or insurance problems.  Maybe the lumbar strain didn’t heal after 6-8 weeks the way it was supposed to.  In any case, doctors who work with pain patients know what happens next.  Before the next appointment, the doctor plans to tell the patient that the time has come to stop opioids.  But after that suggestion, the patient replies that the pain is even worse now than when the pain meds were started.  “Actually (says the patient) I was going to ask you to increase the pain medication!”

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Benzos and Buprenorphine

The high safety of buprenorphine, except when combined with a benzodiazepine, has been twisted in comments about the drug (and in the minds of regulators) to buprenorphine being uniquely dangerous when combined with benzodiazepines, which is not true.

I’ve heard more and more from insurers, regulators, and well-meaning agencies about the dangers of combining buprenorphine and benzodiazepines.   Some insurers protest paying for buprenorphine if patients are taking benzodiazepines.  Medicaid recently sent a letter that described a ‘severe risk’ of using benzodiazepines in patients on buprenorphine.  And the state drug database contains a graph for each patient of the morphine-equivalent narcotic dose over time, and shades the data in red if benzodiazepines are also prescribed.

Readers of my blog know I’m no big fan of benzodiazepines (read this for example).  But in an era of ‘fake news’, I’m even less of a fan of incorrect statements by doctors.   The drug database also ignores the ceiling effect of buprenorphine, and extrapolates the morphine equivalency of low doses of buprenorphine as if the dose response ‘curve’ was a straight line.  That ridiculous calculation leads the graph of opioid use to show buprenorphine patients as taking the equivalence of 900 mg of morphine per day.  The harm is minor I suppose by limitations on access to the database, but the error leads to misperceptions among doctors, and could potentially lead to mistakes in treatment decisions.

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Congress Acts on Opioid Dependence (ugh)

I won’t weigh in on the upcoming election, for fear of being barraged with insulting tweets by one candidate or ‘offed’ by the other.  But the current opioid dependence crisis provides a great chance to learn whether you stand on the side of ‘limited government’ or the alternative.

The TREAT Act takes 5 minutes to read, that would have increased the cap on buprenorphine patients.  President Obama undermined the TREAT Act by announcing his own plans to raise the cap soon after the TREAT Act was presented in the Senate.  After 7 years without mentioning heroin or opioid addiction, it’s hard to believe Obama’s actions were a coincidence.   Only a master politician can ignore 200,000 deaths, and then claim to solve the problem single-handedly despite a do-nothing Congress!

As I wrote earlier, few doctors will make use of Obama’s lousy offer.  Today Congress approved a bipartisan bill that will reportedly signed ‘begrudgingly’  by President Obama– who complained that the Bill ‘doesn’t go far enough.’  I wonder how many pages HIS Bill would be.

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