A Doctor Explains How Buprenorphine Is a "Stealth Medicine" for Both Addiction and Chronic Pain

Mar 31 2016

A Doctor Explains How Buprenorphine Is a “Stealth Medicine” for Both Addiction and Chronic Pain

“Doc, I need some help getting off this stuff.”

My new patient Marshall*, a pale 63-year-old man who lugged around a portable oxygen tank for his breathing problems, had been stuck on pain pills for years. Sharp pain from a gruesome factory injury to his shoulder 25 years ago had evolved into a nightmarish, shock-like nerve pain down his arm to his fingertips. A succession of medical treatments culminated eight years ago in prescriptions for daily use of oxycodone.

It had worked well at first. But after a few years, he descended into a continuous state of opioid withdrawal. At best, he felt mildly anxious and tremulous. Two hours after each dose, he would skid into a wretched state of sweats, gut-knots and dread. His whole body screamed with a pain unrelated to his injury. He craved relief from the next dose.

Sometimes, out of desperation, Marshall would take the next dose early. In exchange for the immediate comfort, he would accept a guaranteed anguish starting days before the next refill was due. His previous doctor had attempted to help by increasing his dose. Symptoms would subside for a month or so, then return with a roar, growing ever more intense. His arm pain had been relegated to a minor annoyance.

The best solution to his cyclical torment was clear to me. I would transition him to a medicine called buprenorphine.

Opioid task forces springing up in the US at the local and national level have begun to cast a spotlight on the surging opioid epidemic and its deadly consequences.

Unfortunately, a sharp focus on the target of opioid “abuse”—non-medical use of pain pills that has led to addiction in an estimated 2 million people in the US, and to heroin use in 1 million—misses a fundamental problem of a much larger scale. Roughly 17 million US adults living with chronic pain are prescribed opioids for daily use. Many, perhaps most, are not thriving.

Yet without these pills, many find life intolerable. Neither patients nor doctors know what to do about it.

A readily available solution—buprenorphine—is a secret weapon largely still waiting to be discovered. And President Obama’s strong emphasis this week on medication-assisted treatment—especially buprenorphine—in his announcement of his plan to combat the opioid crisis, is therefore particularly welcome.

As a family physician, I am in the trenches with patients battling chronic pain. I have seen Marshall’s story played out again and again. Sometimes people are referred to me for help after limping along on opioids for years. Buprenorphine is often the best choice.

Some make the transition seamlessly. Others traverse a rocky road that tests their mettle. Ultimately, most arrive at our intended destination, experiencing a calm normalcy they can hardly believe. A tolerable vestige of their original pain is still present. Opioid withdrawal and its accompanying super-pain, sometimes known as “opioid-induced hyperalgesia,” have vanished.

Patients describe a sense of release from a box or a locked cage. One said, “I felt like a little troll trapped inside a bottle, a horrible feeling. And now I’m free. I’m absolutely thrilled.”

Buprenorphine is better known by one of its brand names, Suboxone, an under-the-tongue film laced with naloxone to deter non-prescribed use. In 2002, buprenorphine–alone or combined with naloxone—was approved by the US Food and Drug Administration as a treatment for people like another of my patients, Luke.

A gentle giant in a black leather jacket, Luke is a 20-year-old convenience store employee who casually enjoyed a Percocet now and then while hanging out with friends. Then he began enjoying one for relaxation daily after work, “like having a beer or two.” Eventually he found himself entangled.

To avoid the agonizing withdrawal symptoms, Luke began spending most of his income buying pills illegally. He risked arrest. He arrived late for work. He could not afford to move out of his parents’ home. The drug’s negative impacts on his life landed him the diagnosis of opioid use disorder—the latest medical term for the condition most people recognize as addiction.

Buprenorphine is often, in my experience, like a magical key that frees people from their seemingly inescapable dungeon. It is an opioid medication with a unique profile that fits the lock precisely. It blocks withdrawal symptoms and craving. There is no drug “high.” Patients trade sluggishness for a fresh energy. Best of all, the hovering risk of overdose death vanishes.

Buprenorphine was developed decades ago and approved by the FDA in 2002. Yet it remains nearly invisible, despite its potency against a fiendish trio of adversaries: withdrawal symptoms, craving and overdose death. That’s why I call it the Stealth Medicine. It is hidden behind the term “medication-assisted treatment,” which also includes methadone and naloxone. Buprenorphine is the only one doctors can use to treat opioid use disorder in their patients with chronic pain.

Any doctor can prescribe buprenorphine for opioid use disorder, after undergoing a brief training required for authorization, known as a “waiver,” from the Drug Enforcement Agency. Only a tiny minority obtain the waiver, however. Due to federal rules, the number of patients each one can treat is strictly limited—to 100, although President Obama’s plan will increase that to 200—and other prescribers (nurse practitioners and physicians’ assistants) are not eligible for a waiver.

Ironically, there is no such bottleneck on access to the opioid pain pills involved in the deaths of 19,000 people in the US in 2014.

Read more from The Influence:

Meet the Victims of Russia’s War on Methadone

The Anatomy of a Heroin Relapse

…and follow us on Facebook and Twitter.

There are strict rules constraining use of the waiver. For one thing, the patient has to have a diagnosis of opioid use disorder. This diagnosis implies a stark but false distinction between “legitimate pain patients” like Marshall and “drug abusers” like Luke.  The same dreadful craving afflicted Marshall, who lost his struggle to use pills as prescribed, and Luke, who never had a prescription. Buprenorphine brought relief to both.

“Off-label” prescribing for chronic pain is perfectly legal without a waiver. The limited research available supports this practice: It shows that a switch to buprenorphine improves pain and quality of life.

But here’s the catch: Without a diagnosis of opioid use disorder, buprenorphine is rarely covered by insurance. With the diagnosis, it usually is. Under Obamacare, insurance companies must provide coverage for treatment of substance use disorders. Luke pays roughly $10 per month for this otherwise pricey drug, which can run to hundreds of dollars without insurance.

The case of Marshall, the patient with arm pain, illustrates the awkwardness of this situation. He never once used opioids for euphoria or relaxation. He never committed a crime, never harmed a relationship with family or friends, never even pressured his medical providers to obtain more of his drug. A diagnosis of opioid use disorder was a stretch. But I made the diagnosis based on his unwelcome craving, and his inability to resist taking doses earlier than scheduled despite known consequences. This diagnosis allowed him access to this life-saving treatment.

Other insurance quirks can create frustrating obstacles. Lily is a trim and perky middle-aged homeowner, a responsible caregiver to two grown children with special needs. For years, Lily had been prescribed oxycodone for arthritis in her spine. She described what happened.

“The longer you take them, the more they make you hurt. It creates pain. You get tolerant to it. And then you think, I’ll take just a little more, and then you take a little more, and pretty soon you hurt worse than you did before you started taking them. The brain creates this fake pain, a magnified pain that really isn’t there. In between doses you would get a depressed feeling, because you knew you weren’t supposed to take another dose, but you hurt, and this becomes cyclic. When you take buprenorphine, you get your whole mental stability back. You don’t have to worry about driving or feeling dopey. It gives you your life back on a plate.”

Since starting buprenorphine for opioid use disorder, Lily had begun walking two miles a day. For two years, she often had no pain at all. Insurance coverage was in place.

Then the insurance company discovered she was not enrolled in a chemical dependency program. She was thus deemed noncompliant with their requirements for buprenorphine coverage. Payment for the next refill was denied.

A formal treatment program would be overkill even for a patient like Luke, the convenience store employee, although he could certainly benefit from having a counselor. But what about Lily? Such a program would be an irrelevant intrusion.

I re-prescribed buprenorphine for Lily, this time using a diagnosis of pain. Coverage was denied. I appealed. Ultimately I talked with the medical director. He politely informed me, “Buprenorphine is not a good medicine for chronic pain, so it is not an option for your patient. But we will cover oxycodone.” Lily has since switched to a more flexible insurance company.

Robin, a stylish business executive, got coverage because she met criteria for opioid use disorder; after discovering buprenorphine’s unique effectiveness for her fibromyalgia, but before she found me to prescribe it, she had guiltily resorted to buying it off the street.

But what about Sally, a sweet 50-year-old lady on opioids for many years after an injury to her lower back? In a classic example of opioid-induced hyperalgesia, she described intolerable shoulder and neck pain after a demanding night at the community center playing bingo. She has always been meticulous about using her pain medicine as instructed, so she doesn’t meet criteria for opioid use disorder. But with exaggerated pain sensitivity, she might still benefit from buprenorphine.

The tides are turning. Many national leaders are now recognizing opioid addiction as a disease and not a crime. Now we need a more nuanced view of the challenge people face when their chronic pain is poorly controlled by opioids. Many struggle to use their prescribed pain pills as directed. Whether they succeed or fail, buprenorphine may improve their quality of life.

A sea change would be possible if millions of patients with chronic pain were switched to buprenorphine from daily pain pills. This would dry up the flood of opioids leaking out to the streets. Fewer young people would find pills and be tempted to try them. Fewer still would graduate to a gritty life of heroin use, or risk a death from overdose.

Doctors, patients, insurers and policy makers: Take note.

*Patients’ names have been changed.

Lucinda Grande, MD is a board-certified family physician who practices in Lacey, Washington. She specializes in chronic pain and addiction medicine. She has prescribed buprenorphine for opioid use disorder for four years, and currently prescribes it to 70 patients.

  • This stuff seems too good to be true. More good news – you can get it for about $130/month with good rx. (No I am not a paid spokesperson.) That’s about $4/day – cheaper than a dime bag. I also like how the underlying threat is – “Give us free opiates or we’ll commit crimes.” It’s the same hostage-taking strategy as AA – “Don’t question our methods or we’ll drive drunk and kill your family.” The fact is, most people are happy to pay for their drugs. It’s usually the do-gooders who want to keep them dependent.

    • michael


    • Matt

      I am currently on buprenophine, and it is helping me for pain just as much as the 30 mg three times a day of morphine I was taking. But i still have some pain from fibromyalgia that the buprenophine does not help and have to use gabapentin to treat that.There are currently three generic brands of buprenophine, and I have tried all three. The best is the one Roxane makes, and Walmart carries it. The next best is made by Teva pharmaceuticals. Walgreens carries this one. The last is pure garbage and barely works. It was made by a company called Hi Tech, but a new company now makes it. It is a very small white pill with an 8 on one side, and an arrow down the middle on the other side. My buprenophine doctor sells this shit brand out of his office for $5 a pill. If you are in terrible withdrawals it will help, but only lasts a few hours. So avoid this brand if you can. Like a poster above said you can use good Rx to get the Roxane brand at Walmart for around $130 for 60 pills. Also another coupon on line you can get from meds chat web site. It will save you about the same as good Rx. Hope this helps somebody.

  • Forester22

    I can’t tell you how much I appreciate this article. Buprenorphine can be a god-send when prescribed correctly. What opiate addicts need to understand, however, is that buprenorphine is only a tool. While they are on it their addiction is basically in remission and they need to use that time to work on recovery. Some addicts may be able to come off buprenorphine someday, but only if they use their time on the drug to get help with the issues that made them vulnerable to addiction in the first place. Part of the reason is genetic susceptibility, but there are things that an addict can work on, such as healing trauma from their past and understanding how they are triggered to use.

  • You are right about the absurdity of the comparative ease of getting coverage when buprenorphine is prescribed for an opiate use disorder. Trying it, instead of the usual opiates, seems a no-brainer. Insurance companies need better information and more enlightened policies. Some concerns:

    1) What you call a “false distinction” between addicts and pain patients is not really false. They are trying to manage entirely different symptoms. Addicts have the alternative of detox, tapering or medication. They also have the option of using buprenorphine short-term than tapering or detoxing from it. Living drug-free is a worthwhile goal for them and these alternatives should be carefully considered as part of the treatment process. Chronic pain patients do not have the same options, as a life of pain is their reality if they don’t medicate. Which, of course, means that buprenorphine ought to be higher on the list of possible treatments for pain patients. But you can’t lump these two groups together.

    2) Others are not as sanguine as you are about either the impossibility of getting high on buprenorphine or the danger of suffering overdoses. It appears that it is indeed an abusable drug.

    3) You may also be overstating the contentment and freedom from side effects experienced by buprenorphine patients. Your information about life on buprenorphine is largely anecdotal rather than more rigorously evidence-based. It sounds sort of utopian. The only reference to evidence is “The limited research available supports this practice: It shows that a switch to buprenorphine improves pain and quality of life.” What is this research? How long does this research say it continues to improve pain and quality of life? Indefinitely? I’d like to read this research. If there is no good research, appropriate agencies need to be pressured to fund it.

    In one sense, all opiate users have something in common. The CDC and other watchdogs seem to be out to punish pain patients as well as addicts and potential addicts. I really hope you’re right and buprenorphine can improve the lives of chronic pain patients, because getting the usual pain medications is getting harder and harder. I recently heard a PCP say “This practice does not prescribe street drugs.” Good luck!

    • Forester22

      Buprenorphine is only abusable by opiate naive people and people who aren’t ready to be in recovery. It only causes enough respiratory depression to result in death if it’s combined with benzos and/or alcohol. Or if it is taken by an opiate naive person. I think you are overestimating the amount of choices an opiate addict has. The relapse rate from a 12 step program is 95%. The relapse rate of opiate addicts who spend a year on buprenorphine is still 90-95%. The research on quality of life improvement for opiate addicts on bupe is available and quite clear, but I don’t know that research has been done for chronic pain patients on bupe. By the way, I suffer from neck pain and migraines, so I dose my bupe differently on the days when I’m in pain. The analgesic property of bupe only lasts for 4 to 6 hours, so on pain days I split my dose. As an opiate addict and a pain patient buprenorphine has improved my life an incredible amount. I know many like myself on a recovery forum. Still anecdotal, I know. The one area I know that buprenorphine helped me as a pain patient is that I am never in withdrawal any more, which I used to be when my tolerance would bump up.

    • Cindy Grande

      Huey, Thank you for your thoughtful comments.
      1. Regarding the “false distinction” – there are indeed many who have used opioids recreationally who have no problem with pain. Their issues are often different from those who use opioids primarily to treat pain. The point was that withdrawal symptoms are unpleasant for all of these people, regardless of their reason for using opioids, and buprenorphine is equally effective in treating those symptoms regardless of the reason for using opioids. Incidentally, there is a large overlap group where it is difficult to identify whether the primary problem is pain or addiction.

      2. Limited research: only observational reports are available so far, but it is indeed promising. There is no evidence any better than this in support of long term use of traditional opioids (and plenty of evidence of harm)- yet that practice is widespread. Here is the buprenorphine evidence:

      Daitch et al., “Conversion from High-Dose Full-Opioid Agonists to Sublingual Buprenorphine Reduces Pain Scores and Improves Quality of Life for Chronic Pain Patients.” Pain Medicine 2014; 15: 2087–2094. Conclusion: “Average pain scores decreased from 7.2 to 3.5, and quality of life scores increased from 6.1 to 7.1 for 35 patients converted from high-dose full-opioid agonists to SL buprenorphine therapy for more than 60 days.”

      “Daitch et al., “Conversion of Chronic Pain Patients from Full-Opioid Agonists to Sublingual Buprenorphine,” Pain Physician 2012; 15:ES59-ES66. Conclusion: Patients continuing buprenorphine SL therapy for more than 60 days reported significant decreases in pain (2.3 points).

      • Dr. Grande;

        Thank you very much for responding. I’ll read the articles ASAP.

        I’m most concerned that pain patients have effective medications available to them, whatever that may be for particular individuals. If buprenorphine for pain becomes the accepted standard you suggest it should be (and stands the test of time), I’ll be cheering. Of course, no good deed goes unpunished so a couple more questions:

        In your article, only your patient Lily appears to have been on buprenorphine for very long (two years). Is buprenorphine a reasonable treatment strategy for the long haul (years rather than months) or are we likely to see increased pain, tolerance, unpleasant side effects, interdose withdrawal, etc.? Does the dose have to be increased steadily? It would be strange if, alone among the opioids, buprenorphine has none of these negatives. (You mention that patients on standard opioid meds do OK for a few years.)

        You treat 70 patients for SUD (i.e. non-pain patients). Do you attempt eventually to get them off the buprenorphine or are they in for the duration? I’m thinking of Luke here. Is buprenorphine keeping him from recovering from his SUD the old-fashioned way—by maturing out? (I have the same concern with the promiscuous prescribing of antidepressants, which seems to have turned an episodic problem into a chronic disease with medication now needing to be topped off by Ability [now one of the top-selling prescription drugs] or some such.).

        Why is prescribing buprenorphine for pain “off label”? In sublingual form, it was approved by the FDA last year. I’m usually ready to blame big pharma and gov’t agencies for most irrationality in the drug/health care system, but this one seems more the fault of insurance companies and your fellow pain physicians.

        p.s. I jotted this down after rereading your excellent article, which The Influence seems to have buried, and doing a bit of surfing on the topic. The article is now so hard to find that probably no one will read this, so feel free not to respond. 🙂

        Best. Huey (huey7788@yahoo.com)

        • MV resident 40+yrs

          Thank you Huey. I was just prescribed the lowest dose patch (which will likely strip the skin off wherever it’s placed because I’m allergic to the adhesive) to replace Ten 30mg pills of Oxycodone IR. Honestly, I’ve called my Dr. and left a message because if he had to label me an addiction or an abuser to try this ‘experiment’ which probably won’t work, I’m going to lose my nut! I’m a legitimate CP patient with no history of abuse, drug seeking behavior, Dr. shopping etc. I do have a high tolerance but that is to all sedative, anastetic, CBS depressant type meds and that’s been my whole life. I don’t have any discs left that aren’t fusing naturally, blown knees, migraines and Lupus. On top of it all, I stupidly had bariatric surgery a few years back with the hopes that losing the extra 60lbs (yes sixty, not six hundred) would help my spine. No one mentioned that time release meds would not longer be effective and that even IR meds wouldn’t be as effective. Everyone hears Oxy… and assumes that you must be an addict. I have never had a problem in my life, relationships, work (more like career) that was effected by narcotic medication taken as prescribed and I’ve never taken it any other way. People need to take a moment to determine the very distinct differences between an Addiction (no matter what started them on their way) and a compliant patient just trying to get through the day. Any legitimate CP patient will tell you, we’ve no expectations of ever being pain free. We just don’t want to be miserable. That line isn’t fine or blurry and all involved need to look at little closer. These labels, they stick and they don’t just disappear, just because we can’t afford a medication unless a physician labels us an addict, gives the establishment no right to do so without our consent.

      • Mike Dickerson

        Hi Cindy. I live in North Carolina and had major hip and shoulder surgery in the past. I have chronic pain from them. A friend let me try a subutex and WOW. it works better than the oxycontin/oxycodone. So I asked my internist if he could cut the oxy and prescribe subutex. He said no…..he was not allowed because a special DEA number was required. Is this true? Am I thinking wrong or wouldn’t it be better to be on subutex than the oxycontin?

        • Cindy Grande

          Mike, if your internist is legally able to prescribe opioids, then he is legally able to prescribe buprenorphine for pain. It only requires the special “X” DEA number if he is prescribing it for the purpose of treating addiction. Buprenorphine and buprenorphine-naloxone are FDA approved for treatment of opioid addiction, and it would be an “off-label” use for treatment of pain. Off-label prescribing is common for many medications.

  • BarleySinger

    I have to wonder which percentage of people get hyperalgesia. You see my wife and I both went through the pain management nightmare. Both of us nearly died from the side effdcts of untreated severe pain. I carried her into the hospital in 1992 (she was unable to walk down to 95lbs, weight falling fast, unable to keep food down from pain enduced anorexia, unable to sleep due to the pain ,.. and on nothing for pain because of the political climate).

    Many years later we heard about opiod hyperalgesia, but no pain doc (except the utter hacks who saw a lot of things that were not there) had evet seen a case of it. They spoke of itvas real but rare. Our diagnostician had been treating pain for 37 years by his retirement & gecnever saw it (but considered it real) Oh he had met a few addicts, and of course people who found the nerve and rebound pain from dropping a dose that had becone too high (recovery) very painful (incudentally methadone has the worst withdrawls and us NOT a good drug, oxycontin is next worst, Lyrica has bad withdrawl ussues of nany kinds but its horrible side effects and lasting damage in users puts it into another sort of category).

    Incidentally, I was on 180mg ms contin for abot 13 years, and I dropped my dose on n y bown as I got thecpain under control. But of course that happened because I chose to read a lit of study abstratcs on the 7 chronuc pain problems I have. I am now on a lot of amino acids and some naturalmcox inhibitors and no opiates. My wife (whose pattern matches a cytochrome P450 problem with available mecications) was on a number ofvpain meds whichbworked poorly until she wound up on 320 mg ocycontin a day. Then I put her on the protocols which I had learned about. She is now on about 30mg oxy a day and in a few more m I ntgs will be off It. Oxy was a godsend as it saved her life … but I find it interesting that in both of our cases there was solid science that even I (a non physician, though very science minded) could find and make use of.

    No doctor did this. Of dozens … and this is telling – of so many spec ialusts, only our diagnostician read any research papers or studies. Most of our soecialists were 2 decades behind, andcbased their treatments on disproven (often politically motivated) discredited ideas. Why?

    It seems to me that when it comes to pain the first response in a doctor is denial/disbelief. As if you walk that way (if you can walk), look that bad, have your long medical record as a form of mythology. The second reaction is anger at the patient for being hard to treat … for having been inflicted on them. It is as if the doctor is going through a variant on the stages of grief. And bargaining is indeed next. And as patients we get all of these stages as we just try to SURVIVE and get some help. The thing is, the stages of grief are innapropriate for the doctor becayse OUR pain is not about them.

    Andd most curious at all.. tomcome backmto the far more sucessful treatment we are on now (which I found and I put us on) … and at no point is there a reaction of curiosity.

    There is no drive to understand. To findnthe CAUSE of fhe pain, or at lest treat it further down in the patient’s biochemistry(closer to the source).

    I have never had that little curiosity about anything. Inread constantlymabout everything I can and I have had multiple brain inuries (the kast 16 months back when I temporarily died from a pulmonary embolism – whichbwould never had happened had any of my last several dcotors been willing to treat my polycythemian with a simple, in office venusection every few months). This is the doctors job, but they do not do it.

    • Michelle

      Sir, I would really like to know where to begin research for my husband’s chronic pain. His knee was slammed into the dash when we were rear ended, and somehow this caused his femur to shatter at the base, leaving many bone fragments floating in the knee area, which destroyed a lot of connective tissue and got wedged into some bad spots. After surgery his pain no longer his as many spikes that cause vomiting and exhaustion along with pain related anorexia, however his pain is at a constant “dull roar”. Please, if you ever see this, write me at chelle dot everett at g mail d ot c om. The email address is spaced out like that to avoid spambots finding it. It doesn’t stop the more sophisticated ones but it’s worthwhile. My husband has a strong, sick reaction to opiates and his doctor(s) do indeed treat him like he’s being deliberately difficult when tramadol, percocet, vicodin, gabapentin don’t help. There were a lot of other opiates and they make him really, really ill. The treatment is worse than the injury, yet they treat him like an addict… when he is willing to have a script of two or three pills per type and return unused meds (they never let him return them to the pharmacy or office). This can’t be our entire lives. For now, I am going to try to figure out what amino acids may help him, and discover what “cox inhibitors” are, then look at what Threonine and GABA are. Thank you for your post. Please write me any time if you are willing.

  • Randy Levine

    Of course a non-habit forming safe medication like Buprenorphine is restricted to 200 patients per doctor… Wouldn’t want to move addicts away from a multi-zillion dollar money maker like Oxycontin! … (Our government is literally trying to kill us!)

    • Pete McNeil

      Non habit forming? That is not true; buprenorphine is extremely addictive. But in these cases it is beside the point….

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  • Michael McGrath

    thanks Lucinda. To Huey: there is more research than listed. Look into Butrans patch data. The brain changes in both chronic pain and addiction are very similar (look at Garland et al ’13). A recovery approach for both chronic pain (check out Las Vegas Recovery Center, Sierra Tuscon, Silver Hill and others) and addiction is state of the art and medication assisted treatment with a “harm reduction” approach (with buprenorphine) is also cutting edge management. I have 125 pain/addiction spectrum patients doing exceedingly well on buprenorphine. Would be happy to answer more questions offline. Lucinda we should start a Facebook page to address this issue.

    • Penelope

      Read about Belbuca!

    • Cindy Grande

      Michael – just catching up with all the comments. Thank you. So glad you have been offering buprenorphine to your patients. I really like the term you have used: “pain/addiction spectrum.” There is no clear boundary line distinguishing people with pain from those with addiction.

  • Julie S

    Good article. I went on suboxone 8 years ago for debilitating PAWS after 10 years of opioid treatment for pain. For me it worked fantastic for the post acute withdrawal syndrome and for pain. I now take approximately 0.75 mg/day, ( 1/12th of an 8mg strip) and am slowly tapering down. My physician will not prescribe this for me if I leave the suboxone therapy group in his practice even though technically I don’t really qualify to be in it( he apparently does not understand off label prescribing) Monthly visits and urine drug screens are becoming too expensive for me as a self pay patient. Right now I have no idea what I will do after I am off Suboxone if my chronic pain is not managed by Advil. Opioids are not an option in my opinion. Local pain management docs will prescribe it but require the same monthly visit and drug screen. I have always been compliant and not once ever failed a drug screen, and am disappointed that my physician won’t treat me as an individual as opposed to grouping me in the drug addiction category. Quite a conundrum.

    • Penelope

      Try Belbuca.

  • Glen Bear Heinsohn

    Thank you doctor. I count myself very lucky. I have severe low back pain from an auto accident and failed surgery. I am free of alcohol nearly 30 years and never felt as though I was a drug abuser while on opiates (well save for some moments I allowed the views of others to blur the truth) I did however know that I could not go on with higher and higher doses of morphine/oxy’s etc I was at the point of having withdrawal symptoms and hour or two after my last dose! I searched the web for “safer narcotics” and came upon a clinical trial of buprenorphine for pain patients (2008 Columbia/NYSPI NY) Wow! I thank God for it. I weaned off after two years but alas the pain remained and after being free of buprenorphine for a year, I found a good doctor in NY who would write me suboxone prescriptions-He got to know me and decided subutex off label was a better choice (less paperwork too) He gradually with my help got me to my current 4mg every 6 hours. The increase was slow over 6 years and I may ask for 4mg more in the future as the “ceiling effect” has not acted on less effect on my pain. I live my life now retired but happy and with some pain but it is well controlled-the side effect I have is easily relieved with laxatives. Thank God there are voices out there for it’s use.

    • Penelope

      Belbuca is now approved for chronic pain and only $25 with copay card and a prior auth from your doc!

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  • Penelope

    What about Belbuca? No one mentioned it for Chronic Pain.

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  • Brian Smith

    Can any doctor prescribe generic Buprenorphine for chronic pain? Have the laws changed recently?

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  • Bruce

    I am a Trauma survivor with
    chronic pain throughout my entire body. For 7 years opiods where the first thing I thought of when I woke up and controlled every part of my life. 3 years ago I was introduced to Suboxone. Now Suboxone is the first thing I think off when I wake up. You know the rest. Suboxone is going from one addiction to another. Yes, it works just as good for chronic pain as any other opiod. I know because I’ve taken them all. Suboxone does give you a feeling of euphoria. Just like oxycodone or percocet . That’s why I take another Suboxone tab to feel normal. Like everyone else I know that’s on Suboxone. Im going to have chronic pain for the rest of my life. I can’ live the rest of my life feeling like a ” junkie.” Ive been winging off Suboxone for over 1 year. It’s more challenging than getting off Suboxone. I’m not attempting to discredit the doctors opinion regarding Suboxone. I want others who didn’t chose addiction to know the reality of Suboxone. From the words of a survivor, chronic pain survivor, and because of opiods, including Buprenorphine, an addict. When big Pharma or the FDA create and approve a non addictive medicine for pain then we can celebrate. Until then you are only creating more suffering for those who already suffered to much.

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  • Dave Sollars

    I am going to a clinic to get off of opiats and I also have diabetes and PTSD so my Dr first prescribed me Suboxon, lyrica and Zoloft and I was taking a half mg of colonipin 2x day but the Dr said taking the colonipin would kill me so she wanted me off of it , but I have got to take it or I will have very bad panic attacks. So being on the Suboxon caused my blood sugar to go way high and I had to use insulin anywhere from 3 to 6 times a day to get it down, but when I first called down at the clinic I asked would the Drs let me take my colonipin and they said some Drs do so I got another Dr at the same place and he asked me several questions and I told him that since I started the Suboxon my blood sugar goes way high and I have to use insulin to bring it down, so he put me on subutex 8mg 3x day and a half mg of colonipin 3x day and my lyrica and 100 mg of Zoloft and after the first month he asked me about my blood sugar going up and I said no it does not go up and I don’t have to use insulin and my body is producing some insulin, he said Great and is everything else good I said yes. So I have been on these same meds for around 3 years but after the first year I was taking subutex the place wanted me to prove that I needed to be on it so I went to my diabetes Dr and told her that they needed proof that I needed to be on subutex, and she wrote out a document, then I turned it in at the clinic and they never said no more about it. Well this September my Dr was leaving the practice but he referred me to another Dr at the same place and I asked him would the New Dr change my meds and he said no you are doing great on what I have prescribed you and I promise he will not change your meds, so I didn’t have an appt in October but the nurse called in my meds then in November I did not have enough money to go to my appt so the nurse called them in again for me, but my preautherization ran out so they had to get the subutex preautherized again and they did. So my next appt was on December 21st but the nurse called me the day before and told me that the New Dr looked at my records and he wants me to take Suboxon and stop the colonipin and the lyrica, I told the nurse that my old Dr promised me that this new Dr would not change my meds and she said that he told all of his patients that and if I did not want to take what the new Dr wants me to take that they would give me one months worth of my meds and I would have to find another Dr that would prescribe what I have been taking for 3 years. I think that this is unethical and that my old Dr promised me that the new Dr would not change my meds, so I need a new Dr but I feel that the clinic should have not released me because I have been doing great for 3 years and I haven’t had to take any insulin maybe 7or 8 times within the 3 yr period. So does anyone know if I can do anything to this clinic or force them to take me back and keep me on my same meds, so far I cannot find another Dr to help me with my addiction, and when my meds run out at the end of the month I will have to go back to heroin again just so I won’t have the withdraws and the cravings, I need some help please

  • Jeffrey Campbell

    Thank you for the article. I am also board certified in family medicine and addiction medicine and my experience in treating addiction and chronic pain is identical to yours. I am still trying to figure out the neurobiology. Any thoughts? I think that the QOL scores may be linked to the kappa antagonist properties and the OIH decrease may be secondary to the increased binding and partial agonist properties at the mu receptor. Anyway, thanks for being brave enough to speak out. I wrote an article for my patients that outlines the science but have been hesitant to release it outside the practice because treating addiction and chronic pain puts me in an unfavorable light with the rest of the local medical community and regulatory bodies. I am trying to educate other physicians on a one on one basis at this point.

    • Cindy Grande

      I think the science has not advanced enough to say for sure that the kappa antagonist effect is responsible for blocking the craving, withdrawal symptoms or OIH, although that may play a role. There is also some literature showing a potential role for a receptor called ORL-1 (ORL stands for “opioid-like receptor”) that buprenorphine activates. I don’t think the blocking of craving, withdrawal symptoms or OIH are from the partial agonist effect at the mu receptor. Mu receptor activation triggers or exacerbates central sensitization that leads to OIH, but I think it is probably a separate process, mediated by a different receptor type, that is responsible for blocking central sensitization. I’m sorry you feel you are being viewed in an unfavorable light by your medical community and regulatory bodies for prescribing buprenorphine for pain. In my community, people seem to think what I’m doing is fine, even admirable, but they are very hesitant to offer it to their own patients. Physicians are conservative and slow to change.

      • Howard G. Downing

        I’ve a couple of questions for Ms. Grande. Please, please reply when you get a chance. Someone in this comment section wrote: “…..The analgesic property of bupe only lasts for 4 to 6 hours,….” I have read about this need to take bupe/suboxone in divided doses, when taking it FOR PAIN, before. While most addiction docs insist that their patients need only take suboxone once daily. I know that buprenorphine stays in the body for a while, and that it’s generally considered long lasting. Which doesn’t automatically mean that it would be effective for that entire time, but that does seem to be the general conclusion when used for opiate/opioid addiction. —-So,..what would account for the difference when it comes to analgesic use? It seems illogical that bupe’s mu receptor agonism, as well as its kappa antagonism wouldn’t act for the same time period in both those taking if for pain and those taking it for addiction. Perhaps it has something to do with the ORL-1 receptor that you mention above? —I get that QOL stands for quality of life, but what does OIH mean? Opioid induced High,..perhaps? Anyway, do you believe that taking one’s bupe in multiple doses is the “best” way to take it for both addiction AND pain management? Are you saying that kappa antagonism and ORL-1 receptor activation are the dominate components that make bupe effective? —I actually take low dose suboxone(1.5Mg) for depression. This is another off-label use, as you probably are aware. The FDA is currently deciding the fate of Alks-5461 as an augmenter for those with treatment resistant depression. Alks-5461 is a pill that combines buprenorphine with samidorphen. The samidorphen blocks bupe’s mu agonism, so that the anti-depressant effect comes from kappa antagonism(and perhaps ORL-1 is involved?). No mu agonism,…no addiction possibilities, no withdrawal….or so I’m told. The effective dose is 2mg/2mg buprenorphine/samidorphen. They are promoting it as a once daily dose pill. Which brings me back to my question about the reason(s) for multiple doses of bupe. for pain management, while once a day dosing is being encouraged for addiction and for depression.—-My doctor now has me taking a low dose of naltrexone(1.5mg) along with low dose suboxone. There have been a couple of small studies showing this combo. works well for depression. These two drugs are , in theory, doing exactly what the new AD med (Alks-5461) will be doing. There is a delivery problem with the naltrexone/suboxone co-administration. Naltrexone must be taken 10 to 20 minutes prior to taking suboxone in order for the naltrexone to properly act as a mu antagonist. This is inconvenient, and involves serious trial and error to insure that naltrexone is actually blocking the mu receptor. I’m not entirely sure that this method totally blocks suboxone’s mu activation. But, I will continue to employ it, until Alks-5461 is approved, because I want kappa antagonism to be the action that is helping me,..not mu agonism. I go through this dosing routine twice a day. I find that this is necessary to get the best AD benefit through the entire day. My doctor thinks that I should only need to dose once a day, but he is fine with twice a day. Whatever works and doesn’t harm you or others…..do it!! That’s pretty much his motto,…and mine. I wish more doctors were empathetic like him, and like you seem to be! What you are doing IS admirable!! Patients need to be treated as individuals and, most importantly, MDs need to do a risk/benefit assessment when deciding whether a non-traditional or progressive treatment might be necessary. Especially with those of us who have been suffering for decades from conditions/diseases that no living being should ever have to endure. Slow change and conservatism aren’t options for us. –Oh well,…sorry for the aside, and for the length of this reply. Mainly, I’m interested in the discrepancy between bupe.’s length of action for different conditions. I’ve looked and looked, but I still don’t understand why, if chronic pain relief usually requires dosing b.i.d. or t.i.d. then, shouldn’t addiction maintenance (and depression) also be best served by multiple dosing? I would certainly prefer a single daily dose! I guess part of me wonders if my need to take this med twice a day is somehow “in my head”…and maybe I would be fine taking it once a day? —Any answers and advice that you can provide regarding the science/chemistry(or…whatever) is greatly appreciated!! My email is howarddowning@yahoo.com if you would rather reply that way. Otherwise, I will be checking on here. Thank you…Thank you…thank you!

      • Howard G. Downing

        An add on to my other questions. Why is Belbuca given as a once daily dose for pain? Most research I’ve read advises 2 to 3 daily doses when taking buprenorphine for pain. This confuses me even more.

  • Andrew Krumm

    I went to a psychologist for help with my opiad addiction. The doctor did not accept insurance, but my insurance did cover my the suboxone he prescribed me. Suboxone saved me, and after 1 year I no longer felt the need for it so I discontinued treatment. That was 2 years ago. I recently tried to enroll with healthcare.com. (not gov) The company rep asked if I had ever been treated for drug addiction and I was honest about my suboxone treatment. He told me no private insurers would accept me with my history… is this legit? I make too much for subsidies and my insurance was such a ripoff last year through the government website… Is that really my only option? Suboxone is a wonder drug in my eyes. Government should be giving it away, no questions asked!

  • Howard G. Downing

    In Kentucky and Tennessee, and in some other states, suboxone can no longer be prescribed off-label …for pain,..or for depression. To the best of my knowledge, this is the only fda approved drug that cannot be prescribed for off label uses. And/or, pharmacists in these states aren’t allowed to dispense suboxone, except for addiction. This is a horrible joke. —-Oh well,….does anyone have advice on how to get one’s doctor to contact your insurance company and try to get them to pay when suboxone is prescribed off-label (in states where this off-label suboxone prescribing is allowed)?? The author, of this article, seems to say that her patient was able to switch to an insurance co. that would do this. My insurance is Anthem BCBSHield, would my doc. be able to “convince” them to pay for the off-label use?!? —If the author, or anyone else, knows,…..please contact me!—Getting my doctor to actually “go out of his way” —(do more than the absolute minimum to help a suffering person out) and contact my insurance co. is another matter. Again,… any suggestions on how to get my MD off his butt and initiate contact with insurance, would also be greatly appreciated.——I have a more scientific question about suboxone(buprenorphine), but I will post that separately. Thanks, in advance. —-howarddowning@yahoo.com is my email. I don’t like giving it out, and this site may not allow me to..? But, the answers to my questions are EXTREMELY important to my continuing ability to get life saving medication at an affordable price. I have a more scientific question about suboxone(buprenorphine), but I will post that separately.

  • Teri Morgan

    Does anyone have a track specifically designed for patients that are dependent but do not identify as “addicts” transitioning from Long term RX Opioids to Bup in an existing treatment program that provides supports and education for this population?

  • Ashley Castleberry

    I have 18 herniated and bulging discs and thought butrans was a miracle rug until 4 month later when it was completely useless for my pain however i have seen most everyone ive meet have an easier time getting pain meds even with my documents aying the discs spondylolthesis and half a dozen other problens so think this article doesnt show any form of knowledge of the real world and should be looked into further as since it worked at first they dont take me seriously that it seriously did stop working even with an increase o 20mg and all i want is to do things the legal right way and also have factor v ledien causing TIAs from the pain and I’m lmost positive gis drugs is causing congestive heart failure which my doctors are trying to look into but since i have Medicaid s i went to college and am a credit short of real insurance only have 12 visits total regardless of reason nd have to choose not killing my self from pain over what most people including myself would agree has higher priority but as a mother i dont have the luxury of choosing. Before stating how awesome things are maybe learn of the mothers who get written suboxone to sell it to get money when they nly pay 3.90 for it and it has triple the street value and cause a 5 prescription limit which makes me have to pay out of pocket for my blood thinners and other drugs and put the pain in front of what should be a maintenance med but isnt because of those people who abuse it and sell it while abusing it.

    • Kathy

      I’m sure you’re making a good point but it is lost because you opine all your thoughts into one tremdously long run on sentence.

  • Kathy

    Fantastic article! I pray to God this administration drafts a panel of experienced medical professionals to combat this tragedy from all angles. Bless you doctor, keep fighting the good fight!

  • pat

    I just read this article for the first time but I am left with a pit in my stomach because I am 72 years old and have been on Oxycodone 10 mg 3x per day. I have spinal stenosis. I do agree with the theory of the article about taking the meds a little earlier. I think this is a big problem for the elderly who still want a life and get around but can’t because of pain. There must be a better answer than to detox from the meds your on and take a drug that is just as addictive. What is the real answer for someone who follows the law and goes every month to get a refill? Can anyone answer what to do?