Ask an Expert: What If I Need Acute Pain Relief While I'm on Suboxone?

By Jessica Gregg MD 01/30/17

There are various options for pain control while on an opioid-blocking medication.

A back view of someone holding their hands on their back in pain.
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I'm on Suboxone, and wondering what would happen if something happened to me—like an accident—and I need relief for severe pain? I know that Suboxone offers some pain relief, but I'm not sure if it's enough for post-surgical or acute pain. What's the protocol for this type of situation? 

Jessica Gregg MD: That is a great question. There is currently no consensus around the best way to control pain for patients taking Suboxone, but pain control is possible.

Suboxone is a combination of two medications: buprenorphine and naloxone. Naloxone blocks opioids, but it is not well absorbed under the tongue or when swallowed. So, someone taking Suboxone correctly doesn’t need to worry that the naloxone will enter their system and interfere with pain control.

Buprenorphine, however, is more complicated. It is a partial opioid agonist at the mu opioid receptor. This means that buprenorphine binds to and activates the mu receptor, but is not able to produce the maximum possible response at that receptor. Pain medications like morphine or oxycodone are full agonists and are able to produce the maximal response at the receptor. However, they are unable to bind to the receptor to give pain relief if buprenorphine—which binds very tightly—is already there. As you note, this can be concerning if someone needs acute relief of severe pain.

Some experts suggest that patients on Suboxone who need acute pain relief should have their Suboxone immediately discontinued, and should be provided higher than usual dosages of full agonists until the Suboxone leaves their systems. When possible, they should also receive non-opioid medications like gabapentin, Tylenol, and non-steroidal anti-inflammatories while waiting for the full agonists to kick in. 

Other experts advocate for continuing the buprenorphine during the period of acute pain. They note that buprenorphine binds to many kinds of opioid receptors, not just the mu receptor. As a result, it can behave in surprising ways. For instance, although it is only a partial agonist, buprenorphine has been found to be seven to ten times as potent as morphine when used as a painkiller. So, it is possible to use buprenorphine for some post-surgical pain—just in higher, more frequent doses. 

It is also possible to add other opioids on top of buprenorphine. Hydromorphone binds to the mu receptor almost as tightly as buprenorphine does, and can often be successfully used in conjunction with buprenorphine for acute pain control. In more severe cases, Sufentanil—which is a strong opioid most often reserved for surgeries—can overcome the buprenorphine binding and provide even greater pain control.

Finally, pain can sometimes be controlled without opioids at all, through the administration of local anesthesia or regional anesthesia. Local and regional anesthesia block the nerves that carry pain and can be very effective in the right circumstances.

Here are some references if you’d like to read more:

Silva MJ and Rubinstein A. Continuous Perioperative Sublingual Buprenorphine
Center for Substance Abuse Treatment. Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction

For more information on how to deal with acute or post-operative pain while on Suboxone or other buprenorphine-based medication, please read this article by another one of our experts, Dr. Jeffrey Junig.

Dr. Jessica Gregg is a diplomate of the American Board of Internal Medicine and a diplomate of the American Board of Addiction Medicine and has clinical practice in Portland, Oregon. Full bio.

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