While Suboxone is not approved by the FDA for pain management, it is increasingly being prescribed for this use off-label.
The FDA originally approved Suboxone to treat opioid use disorder. It is widely used and highly effective for preventing relapse and death from overdose.
Opioid misuse and opioid use disorder are major problems of epidemic proportions in the United States and internationally. Buprenorphine, one of the two active ingredients in Suboxone, is also effective for managing chronic pain. There are other formulas of buprenorphine without added naloxone (Suboxone contains both buprenorphine and naloxone) that are also widely prescribed to manage chronic pain.
Suboxone is a prescription medication predominantly used as a Medication for Addiction Treatment (MAT). This medication is a combination of buprenorphine, a partial opioid agonist, and naloxone, a fast-acting opioid antagonist.
The main active ingredient, buprenorphine, binds to opioid receptors in the brain. It can have some effects like full opioid agonists, including prescription painkillers like oxycodone and hydrocodone, because it weakly activates the brain’s opioid receptors. However, buprenorphine does not cause the same euphoric high as many full opioid agonists, so this medication is increasingly being prescribed to treat chronic pain.
Belbuca is a brand name of buprenorphine buccal, a formula of buprenorphine administered as a film strip absorbed through the inside of the cheek, somewhat like Suboxone. Through its actions at the opioid receptors, it has an analgesic (pain-blocking) effect.
Its analgesic half-life is between six to eight hours, which means it loses half of its potency six to eight hours after taking it. As a result, it is bioactive for over half the day. It also has a much lower risk of misuse than most opioids used to treat pain because it is a partial agonist (weak activator) rather than a full agonist (strong activator) at the opioid receptor.
Belbuca is prescribed for use either once per day, or every 12 hours, depending on your needs for chronic pain relief. Your doctor will start you on the lowest possible dose and increase it as needed.
Butrans, another brand name formula of buprenorphine for chronic pain, is a patch absorbed through the skin and replaced once per week. It was approved by the FDA in 2010 for this use. While Belbuca offers a greater dose variation, it must be taken more frequently than Butrans.
Like full opioid agonists, buprenorphine can lead to physical dependence, but this isn’t the same as addiction. If you no longer need to use buprenorphine for pain relief, you should work with your doctor to taper off the medication. If you stop using it suddenly, you might experience withdrawal symptoms.
Chronic pain and opioid use disorder are often comorbid, meaning they frequently occur together. As many as a third of people being treated for chronic pain also report misusing or becoming addicted to their prescribed opioid pain medications.
The reasons that opioid use disorder and chronic pain co-occur are complex. People who are being treated for chronic pain can quite easily develop a SUD to their pain medications because these medications are addictive. As many as 10% of people prescribed an opioid for pain develop an opioid use disorder.
Furthermore, people who are physically dependent on opioids often experience pain all over their body when going through withdrawal, making things even worse. Insomnia and anxiety during withdrawal can also make existing pain feel more severe.
Finally, there is growing evidence that chronic exposure to opioids might actually cause a pain syndrome, called opioid induced hyperalgesia, which is characterized by diffuse pain in multiple body parts.
People who take Suboxone for opioid use disorder treatment, which eases withdrawal symptoms, reduces cravings, and manages compulsive addictive behaviors, also receive pain relief. While Suboxone is not approved for the treatment of chronic pain, the dose of buprenorphine in Suboxone is higher than the dose of it in Butrans, which is approved for chronic pain relief. One medical study reported that the average dose range for Suboxone for opioid maintenance therapy is 8 to 16 milligrams per day, whereas Butrans patches are available in 5 mcg, 10 mcg, and 15 mcg.
People being treated for both chronic pain and opioid use disorder were reported to do better from the standpoint of the pain if they took the buprenorphine in multiple daily doses, like two to three times a day. By contrast, when buprenorphine is being prescribed for opioid use disorder alone, once-daily administration is usually the recommended dosing schedule.
A 2018 medical survey of buprenorphine formulations for chronic pain relief found that nearly all formulas, including buprenorphine/naloxone combinations like Suboxone, were effective analgesics and had no lasting side effects. This study has encouraged more doctors to call for a “safer” formula of buprenorphine, namely Suboxone, and other formulations that include naloxone, to be used in pain management, to reduce the risk of overdose or medication misuse.
An earlier study, from 2015, found that buprenorphine alone seemed to work better as an analgesic for chronic pain patients who also had addictive behaviors. The survey found that 80 percent of opioid-dependent individuals who switched from buprenorphine alone to Suboxone had a subjectively “bad” experience. They did not believe the two drugs worked the same way.
A third survey-based study reported that 50 percent of participants being treated for opioid use disorder who switched from buprenorphine to Suboxone experienced more adverse reactions, Including fatigue, nausea, and gastrointestinal pain.
Although more research is needed, some studies indicate that for some reason buprenorphine alone might work better than buprenorphine in the presence of naloxone for reduction of pain. On the other hand, as MAT, Suboxone is the preferred drug for opioid use disorder because of its improved safety profile.
Ultimately, providing pain relief for people who have both opioid use disorder and chronic pain disorders is complex. Personalized approaches to pain management are needed.
Some doctors do prescribe Suboxone off-label as a treatment for chronic pain, but this medication is only approved by the FDA to treat opioid use disorder. Approved buprenorphine-based chronic pain treatments typically do not have naloxone included.
However, if you have co-occurring chronic pain and opioid use disorder, you may receive Suboxone with the oversight of a physician as part of an outpatient addiction treatment program. This physician should take your chronic pain into account to help adjust your Suboxone dose.
If you are “opioid-naïve,” or have not taken full opioid agonists before to treat chronic pain, you may be better suited to a buprenorphine-only medication, like Belbuca or Butrans. Buprenorphine has a lower risk of addiction and overdose than other opioids.