Buprenorphine: A life-saving medication that’s being overlooked in the opioid crisis

The Centers for Disease Control and Prevention (CDC) has taken the unusual step of issuing a clarification letter to three major cancer organizations that states it does not want to deny appropriate opioid therapy to cancer and sickle cell patients, or those undergoing cancer treatment and survivors of cancer with chronic pain. In short, the CDC recognized that their original guidelines for prescribing opioids for chronic pain had the unintended effect of denying or limiting pain medications for many patients who need them.

This clarification was long overdue.

{mosads}As I and many other doctors have witnessed, this tactic of reducing prescriptions of pain medications to combat the opioid crisis, including the involuntary tapering of high dose opioids, has caused a considerable amount of suffering. So much so that some chronic pain patients, including veterans, have attempted suicide, as documented in a recent Human Rights Watch report. 

Moreover, the decrease in opioid prescribing in recent years, coupled with restrictions by health insurers to cover pain medication  and pharmacy chains reducing their supplies of opioids, has not had any effect on the death toll from opioid overdoses. In fact, it has continued to rise. In 2017, there were 47, 000 deaths from opioid overdoses in the U.S., a 12 percent increase from 2016.

One reason this opioid limiting strategy has not decreased overdoses is now clear: individuals who were no longer able to obtain pain medications resorted to illicit means of getting them. This led to the so-called, “second and third waves” of opioid related deaths — mostly, from heroin and illegally purchased fentanyl and other synthetic opioids. Indeed, over 80 percent of heroin users admit to first misusing prescription opioids. 

The assumption inherent in this public health strategy is that you cannot treat pain with opioids without also contributing to opioid addiction and its fatal consequences. The two are inextricably linked.

This assumption is false.

Experts in pain management know this, but for some reason there is a disconnect when it comes to devising a public health intervention to address the opioid epidemic. It may be politically more expedient to blame someone for the crisis: bad doctors, greedy pharmaceutical companies, or a wealthy family intent on selling their product.

The reality is that some opioids can be — and have been — prescribed for both the treatment of pain and addiction. Methadone and buprenorphine are well established treatments for opioid addiction (now known as “opioid use disorder”), and both drugs are also used for treating pain.

Methadone had long been a favorite among pain and palliative care physicians when treating patients with pain in the context of a serious illness, like cancer or HIV/AIDS, or for patients on methadone for maintenance therapy, or with a history of opioid addiction, to mitigate risk of future opioid abuse. However, due to its risk for sudden cardiac death, its long list of drug-drug interactions, and its unique pharmacological properties, which could lead to unintentional overdoses, methadone is not recommended for doctors to prescribe unless they have proper training or supervision.

Like methadone, buprenorphine is effective as medication-assisted treatment (MAT) in reducing mortality among individuals with opioid use disorder. And like methadone, it can also be used successfully as a potent analgesic. However, most providers are not familiar with buprenorphine as a pain reliever. But this is starting to change.

At this year’s American Academy of Hospice and Palliative Medicine National Assembly, 14 abstracts or presentations described the successful use of buprenorphine in a range of patient populations, from patients with pain from muscular dystrophy, or sickle cell disease, to veterans with cancer-related pain, and patients struggling with pain and addiction at the end of life.

The National Institute of Health (NIH) is taking notice too, with calls for research proposals to investigate interventions using buprenorphine for treating chronic pain and reducing opioid dependence in specific populations.

Unlike methadone and all other opioids, patients on buprenorphine can tolerate increasing doses of the drug without causing respiratory depression, which is how individuals die from an opioid overdose. The brain essentially develops tolerance to the respiratory depressing effects of the drug, but not to its analgesic, or pain-relieving properties. In other words, it is highly unlikely to overdose on buprenorphine.

As a pain medication, buprenorphine has additional advantages — it is effective for both cancer and non-cancer pain. It is associated with less tolerance, less cognitive dysfunction, and, unlike other opioids when taken for years, does not seem to cause immune suppression or hormone dysfunction, such as testosterone deficiency. It is also safe in the elderly and in patients with kidney failure or on dialysis. Moreover, it may be better than other pain medications in treating long standing chronic pain, which typically has some neurologic transformation–buprenorphine targets the mechanism by which this kind of pain is maintained in the brain and spinal cord.

When I mention these benefits of buprenorphine to my colleagues, I get the same response: “Why don’t we just treat chronic pain patients with buprenorphine and avoid all the problems with opioids?”

To be sure, there is no evidence that buprenorphine is superior to other opioids or should be used as the preferred medication for debilitating, chronic pain.  That being said, in my clinical experience and that of my pain and palliative care colleagues who prescribe buprenorphine for chronic pain, we have observed excellent pain control in the majority of patients, consistent with published studies, with no observed behaviors suggestive of addiction, and no opioid overdoses. 

It can also be tricky to switch patients from other opioids to buprenorphine, as there is often an uncomfortable “withdrawal syndrome” that patients experience. But this can easily be treated and should not discourage providers from using this drug.

Further, as buprenorphine is not a familiar pain medication for clinicians outside of pain medicine and palliative care, a nation-wide clinical educational program would need to be developed to insure proper dosing, prescribing, dispensing, and monitoring patients when this drug is used for pain, as opposed to solely treating addiction, which requires a separate DEA waiver. 

While a balanced public health strategy to address the opioid epidemic requires — at a minimum — systematic monitoring of inappropriate opioid prescribing, increased access to mental health and addiction programs, harm reduction and preventive strategies, and education of clinicians treating chronic pain; the use of buprenorphine should not be overlooked.

Craig Blinderman M.D. is the director of the Adult Palliative Care Service at Columbia University Medical Center.