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.
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.
This is certainly not a common reaction could indicate a genetic probelm with opioid metabolism.
This patient was quite likely a “fast metabolizer”, who was burning through the extended release tablet too quickly in just a few hours, after which he would go into withdrawals.
Clearly, this doctor’s prejudice against true opioids and hist strong bias made this doctor overlook what was was clearly an anomaly in this patient’s reaction to the medication.
Instead of invetigating, he ignored it (as though this were a “standard” patient with a normal reaction to opioids) and pushed his own favorite solution upon the patient.
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.
This is a textbook case, as described in Screening for Defects in Opioid Metabolism:
“The fast metabolizer will cause a rapid clearing of opioids from the blood.
These patients will show a very low or even negative opioid blood level as soon as 1 to 2 hours after they take their regular dosage.”
As an “expert” in opioids for both addiction and pain, Dr. Grande should have been able to recognize this patient’s opioid metabolism problem at least as quickly as I did.
However, once a doctor has found a treatment they truly “believe in”, they tend to stop looking at alternatives and become prejudiced against other options. The danger of this is expressed in the common saying:
“if all you have is a hammer, everything looks like a nail“
Dr. Grande seems so enamored with buprenorphine treatment, she will use it even when facing problems that can be managed better by other means.
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.
The best solution to his cyclical torment was clear to me. I would transition him to a medicine called buprenorphine.
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.
As a family physician, I am in the trenches with patients battling chronic pain
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.
Buprenorphine 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.
My experience has been exactly the opposite: when in pain I’m unable to concentrate and I’m exhausted from the constant assault on my nervous system.
When my pain is reduced, all the energy I was using to deal with the pain and is now freed for productive and enjoyable activities.
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
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
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.
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.
This is NOT a false distinction. There is a huge difference between taking opioids to relieve pain and taking opioids for recreation and to get the “high”.
“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.
It seems both pain and addiction treatment are controlled more by the insurance companies (and the government) than by medical personell.
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.
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.
Again, treatment is determined by insurance company.
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.
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.
Many? Only 3%-5% of legitimjate pain patients become addicted.
Whether they succeed or fail, buprenorphine may improve their quality of life.
Author: 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.
More about Buprenorphine from Wikipedia:
Buprenorphine is a semisynthetic opioid derivative of thebaine. It is a mixed partial agonist opioid receptor modulator that is used
- to treat opioid addiction in higher dosages,
- to control moderate acute pain in non-opioid-tolerant individuals in lower dosages and
- to control moderate chronic pain in even smaller doses
Buprenorphine has a slow onset, mild effect, and is very long acting with a half-life of 24 to 60 hours.
“Mild Effect” will not be strong enough for some chronic pain. Opioids are used for “moderatge to severe” pain.
Buprenorphine behaves differently than other opioids in this respect, as it shows a ceiling effect for respiratory depression
Benzodiazepines, in recommended doses, are not contraindicated in individuals tolerant to either opioids or benzodiazepines
There is another consequence of high-dose buprenorphine treatment that often goes overlooked by both physicians and patients when electing to use buprenorphine (in the form of Butrans transdermal patches) for chronic pain management
Because buprenorphine binds so tightly to μ‑opioid receptors in the central nervous system, it takes an extremely large dose of potent opioid pain medication to displace the buprenorphine from those receptors and provide additional pain relief in the acute setting
Patients on high-dose buprenorphine therapy may be unaffected by even very large doses of potent opioids such as fentanyl, morphine, or hydromorphone.
Sufentanil (trade name Sufenta) is an extremely potent opioid analgesic (5 to 10 times more potent than fentanyl and 500 times more potent than morphine) for use in specific surgeries and surgery in highly opioid-tolerant or opioid-dependent patients that has a binding affinity that is high enough to theoretically break through a “buprenorphine blockade” to provide pain relief in patients taking high-dose buprenorphine.
The problem is that sufentanil is frequently not available in the emergency room or acute care setting because of its highly specialized indications, thus making it very problematic for acute care practitioners to manage severe acute pain in persons already taking high-dose buprenorphine. It is also difficult to achieve acute opioid analgesia in persons using buprenorphine for opioid replacement therapy. Here, fentanyl, which has a higher affinity for μ‑opioid receptors, can successfully overcome buprenorphine blockade.
Buprenorphine also blocks voltage-gated sodium channels via the local anesthetic binding site, and this underlies its potent local anesthetic properties.
In the United States, buprenorphine (Subutex) and buprenorphine with naloxone (Suboxone) were approved for opioid addiction by the United States Food and Drug Administration in October 2002
In the European Union, Subutex and Suboxone, buprenorphine’s high-dose sublingual tablet preparations, were approved for opioid addiction treatment in September 2006
In recent years, buprenorphine has been introduced in most European countries as a transdermal formulation (marketed as Transtec) for the treatment of chronic pain not responding to non-opioids.
Suboxone (a controlled substance) contains buprenorphine as well as the opioid antagonist naloxone to deter the use of tablets by intravenous injection