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PostPosted: Sat Oct 01, 2011 11:29 am 
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This is a letter from Reckitt-Benckiser on how to treat pain in sub patients. I just thought you all and Dr. Junig might find this a bit interesting to read, especially considering who it's coming from! LOL ... rphine.pdf

November 22, 2004

«Prof_First_Name» «Prof_Last_Name»
«City», «State» «Zip»

Ref / PAI2137 Pain Management in Patients taking buprenorphine

Dear Dr. «Prof_Last_Name»,

This letter is in response to your inquiry regarding pain management in patients
maintained on Suboxone® (buprenorphine and naloxone) and/or Subutex®
(buprenorphine). The information presented here is intended to aid in your assessment
of the appropriate use of Suboxone® or Subutex® in your specific patient. It should not be
used to replace sound medical judgement.

Pain Management in Buprenorphine-maintenance Patients

Pain management is perceived as a potential issue in patients who are maintained on
buprenorphine-containing medications such as Subutex® or Suboxone®. This need not
be the case when the issue is addressed pragmatically. There is a paucity of reported
formal trials of clinical practice in this area. However, the following guidance is a
practical recommendation based on current generally accepted clinical practice. It
contains general principles in the management of chronic and acute pain in
buprenorphine-maintained patients as well as recommendations on possible strategies
for analgesia in these patients.
General principles:

Chronic pain
Management of chronic pain in the Subutex®/Suboxone®-maintained patient includes
consultation with a specialist in pain medicine when possible and appropriate. Patients
with chronic pain disorders and physical dependence are best managed by
multidisciplinary teams that include pain and addiction medicine specialists. The site of
such treatment will depend on patient need and the best utilization of available

Acute pain
Management of acute pain in the Subutex®/Suboxone®-maintained patient entails:
a. Continuation of the regularly scheduled Subutex®/Suboxone® dose.
b. Additionally prescribing adequate doses of appropriate medications.

The basic issue with analgesia in the buprenorphine-maintained patient is that while
buprenorphine has analgesic properties, it is a partial agonist. This means that not only
will it block the cravings associated with opioid dependence, but because of the high
affinity of buprenorphine for opioid receptors it may also block the analgesic effect of
other opioids. Current practice circumvents this problem in a number of ways:
1. In an emergency situation, the patient’s pain may be managed by regional
anesthesia, conscious sedation with a benzodiazepine, use of non-opioid analgesics,
or general anesthesia (excluding halothane).
2. If a patient is experiencing pain but it is not an emergency situation, the
recommended first course of action is for the physician to treat the pain with a nonopiate
medication, such as ketorolac, NSAIDs or COX-II inhibitors.
3. If this is not adequate it may be possible for the limited period of time that the pain
situation exists, depending on the dose of buprenorphine, to increase the dose of
buprenorphine to obtain an analgesic effect.
4. In a situation requiring additional opioid analgesia, the dose of the full opioid agonist
required may be greater than usual. It is known that, depending on the effect
measured, using higher doses of a full agonist opioid may overcome the blockade
caused by buprenorphine. While there is little literature on this phenomenon in
relation to the analgesic effects of opioids, anecdotal evidence suggests that this
strategy may be effective in some patients. A rapidly acting opioid analgesic, which
minimizes the duration of respiratory depression should be used. The dose of opioid
medication should be titrated against the patient’s analgesic, physiological
(especially respiratory) responses, with close monitoring by trained staff.
5. In the case of elective surgery, the physician may titrate the buprenorphine dose
down or transfer the patient to a full opioid agonist prior to surgery. Afterward, the
buprenorphine level may be titrated back up to the therapeutic level. The transition
back to buprenorphine should be easier if a short-acting full opioid agonist is used.
6. Use of regional anesthesia such as epidural blockade may also be considered in
non-emergency situations.
7. Alternative methods of pain control, such as TENS, may be suitable for some

Tim Baxter, MD
Global Medical Director
Reckitt Benckiser

Comments? I think they're really trying hard to make it seem much easier than it really is. (Obviously)

-As I have grown older, I've learned that pleasing everyone is impossible, but pissing everyone off is a piece of cake.

-I'm only responsible for what I say, not for what you understand.

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Dr. Jeffrey Junig, M.D., Ph.D.

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