Saturday, March 13, 2010

Treat Physical Pain Safely With Buprenorphine

"Authorities: Haim had illegal prescription" reads the headline on Other news media regularly feature stories about deaths from overdose with legally prescribed narcotic analgesics like hydrocodone, the narcotic analgesic in Vicodin, and oxycodone, the narcotic analgesic in Oxycontin, Percodan and Percocet. At high enough doses these drugs can make you stop breathing and die.

Doctors, long familiar with prescribing these drugs, are damned if they do, damned if they don't. When medical boards threatened to revoke our licenses for prescribing them too freely, we cut back. Then we were accused of withholding indicated analgesics and allowing our patients to suffer needlessly. But even if the doctor happens by some stroke of luck to get it just right the patient can take too much and die, even unintentionally.

What doctors (or patients) need is an analgesic that is effective but safe, one that attenuates pain but will not get you high or euphoric, but especially one that, even if you took the whole bottle, would not kill you.

I wish I could tell you FDA approval of such a drug was just around the corner, or maybe that I could announce that FDA just approved it, but in fact the FDA approved just such a drug, buprenorphine, in 1981 as Buprenex. Buprenex, now available as generics, comes only as a parenteral (injectable) preparation, but FDA approved a formulation that dissolves under the tongue in 2002. Although only approved for treating opiate dependence doctors can prescribe it to treat pain off label quite legally.

Why don't more physicians prescribe buprenorphine for injuries or post-surgical pain? Even though I have prescribed the drug for treatment of opiate addiction since it became available in 2003 I only realized within the past year or so that physicians can prescribe it legally off label. I suspect few other physicians realize this, but even if I were to tell them they would be reluctant to try something unfamiliar. I also believe many patients would object to having to take the drug sublingually, and most patients dislike the flavor. Of course the good thing about all that is the fact that often NSAID's like ibuprofen adequately control pain in those situations, and the bad taste might push many patients to take a drug from that class rather than the narcotic.

I hope I haven't missed something in this, but I plan to start encouraging my colleagues (and maybe even my dentist) to consider prescribing buprenorphine for pain instead of the -codone's. It might save some lives.


  1. thanks, I didn't know it was approved for use in pain syndromes! jlebenzonmd dlfapa

  2. Joseph:
    It is NOT approved, but can be used off label.

  3. Would you recommend this for people with pain unrelated to mood disorders? I have recurring back pain due to a herniated disc which seems to not heal properly (every so often I sneeze or pick up something and reinjure it). While it is likely I will one day have surgery, for now we are trying the conservative route. Unfortunately, the narcotics, while dulling the pain, seem to exacerbate depression.

  4. I recommend discussing it with your doctor for sure. Some patients claim buprenorphine helps depression, but they tend to say that about all narcotics. I'm skeptical, but who knows?