Physical Dependence vs. Addiction in Chronic Pain Patients

A question from a reader about taking Suboxone for chronic pain, and about physical dependence vs. addiction:

Thanks for the web page. It gave me a lot of information that I had been searching for. Most of your blog deals with addiction. Will Suboxone work for dependence? I have been on Oxycontin for 7 years due to nerve damage in my back and Fibromyalgia. I have been able to get down to 30 mg per day with the help of RF ablations but unfortunately there aren’t any pain doctors in my area that will take medicare anymore. RFA’s don’t last forever and I’m being forced to increase the Oxycontin again to manage the back pain. The severe cold with snow has made this a very miserable winter which is why I’m looking for a different answer.

From what I’ve read, I don’t believe addiction is as big of a problem as the dependence in my case. I’m using the medication as prescribed and the doctor is working with me and is more than willing to increase the medication if needed. The problem is my life revolves around that once a month prescription. Every time I try to leave the state, it is a major production since the nurses think I’m trying to pull something if I ask to fill my meds early. The doctor trusts me but getting through the technician that handles the refills for the office is like dealing with the Nazi’s…and I’m being kind. I’m not sure that switching to Suboxone will change anything. I’m thinking maybe at least this way I might be able to someday get completely off all this kind of medication. I don’t actually want to increase my medication again and if I understand correctly Suboxone will take some of the pain away.

Any insight would be greatly appreciated.

My Response:

I hear your frustration over the attitudes and hassles associated with opiate treatment.  I find it ironic that many doctors act as if patients are criminals for using the very medications that the doctor prescribed!

You question is a difficult one;  I struggle with deciding the best course of action for patients who are physically dependent on opiates but who haven’t shown signs of addiction.   Just to clarify,  I do think that many pain patients do cross the line without realizing it;  it can be very difficult treating opiate addicts who initially started through legitimate use for pain, as those patients see themselves as ‘unique’—and that feeling of uniqueness gets in the way of the changes that need to occur during the recovery process.  So it is important that you take an honest look at what is happening in your own situation.


Buprenorphine is being studied for use to treat chronic pain, as are other medications (search for ‘oxytrex’ or ‘embeda’).  Partial agonists including buprenorphine (including the medication Suboxone) do offer some advantages over agonists, but have some potential drawbacks as well.  Even a pain patient not ‘addicted’ to opiates would likely notice a profound difference with Suboxone;  the feeling of needing ‘more’ would mostly go away, as would the fear of being without medication.  I use Suboxone for pain patients, and they universally report that in retrospect they see how much the pain medications were controlling their lives, and they are grateful for the change to something that leaves their mind free of those thoughts.  Some people find that their pain lessens—in my opinion because they are out of that cycle of feeling/dosing/feeling that makes up opiate pain treatment.  With Suboxone there is much less risk for ‘dose escalation’; the effect is capped at a level equivalent to 30 mg of methadone, and increases in dose do not provide much more pain relief.

The downsides of Suboxone are related to the benefits;  the ceiling effect that limits dose escalation also limits… dose escalation.  If you really DO need more analgesia, you won’t get it from Suboxone—and you will be blocked from getting it from other medications.  ALTHOUGH—the increase in analgesia from dose escalation is mostly a ruse;  you only become tolerant to the higher dose anyway, so there is little value in being able to increase the dose of oxycodone or other agonists.  Suboxone and other partial agonists present challenges during periods when big increases in analgesia are required, such as after surgery or injury.  Finally, patients taking Suboxone quickly become tolerant to the effects of buprenorphine, so I wonder sometimes whether the medication is truly reducing pain, or whether it is causing a ‘placebo effect’.  ON THE OTHER HAND—a ‘placebo effect’ feels as good as a ‘real’ effect, so the question isn’t that important.  Plus, patients will get tolerant to EVERYTHING—including agonists—and so the tolerance to buprenorphine is not specific to that medication.

A tough call—but in patients who cannot prevent the run-up in dose that occurs with opiate agonists, Suboxone is a better choice.  There is no future in being on runaway doses of oxycodone;  those situations will always end badly eventually.  I believe that for those patients, Suboxone restores a great deal of sanity to the treatment process.  With Suboxone, the patient can free himself/herself from the constant thoughts about pain medicine, and get the person to move forward into the appropriate non-narcotic treatment strategies that are usually the true road to better function.

Good luck!