Are you looking for alternatives to taking opioids for pain?
As regulations for pain clinics and opioid medications become increasingly more restricted, patients are looking for alternatives. While there is a stigma these days surrounding medical pain management, the fact is that chronic pain exists, and sometimes opioid medications provide the best solution. Yet, when your doctor cuts your dosage in half for administrative reasons, or your pharmacy refuses to fill your prescription without explanation, it may be time to try something else.
A patient approached me recently and asked for my advice. He told me that his pain management doctor gave him three options for ongoing treatment for his cancer pain. First, he could continue taking oral oxycodone tablets as needed for the pain. Second, he could switch to Suboxone to help him get off of the oxycodone. Third, he could try medical cannabis to manage the pain. In this particular hospital-based clinic, there was a different doctor for each approach. There was an opioid doctor, a Suboxone doctor, and a cannabis doctor. When my patient asked me for advice, it seemed like the clinic did not give him much guidance in making a decision. What were the risks and benefits of each alternative? Let’s examine each option to see what might be involved in deciding with these circumstances.
Staying on pain medication is one option.
First, the patient has the option to stay on pain meds. In the case of the patient in question asking for my advice, this would mean staying on oxycodone for pain. Staying on the pain pill is a viable option because he had no problem with being addicted to oxycodone or misusing it. If it continues to provide adequate pain relief and helps him to function better in his daily activities, there is no problem here. However, if he is having problems with side effects, constipation, or sedation, for example, he may want to ask the doctor to lower his dose or try something different. Another concern with the long-term use of opioids, such as oxycodone, is tolerance. Many patients find that, over time, a prescribed opioid for pain does not work anymore. The solution is often to increase the dosage to overcome tolerance. As a result, eventually, the patient is on a very high dose of narcotics for pain. By repeatedly increasing the opioid dosage, the patient is also at risk for hyperalgesia. Hyperalgesia is an unusual effect of increasing opioid dosage. Rather than reducing pain, the medication causes pain levels and pain sensitivity to increase. The treatment for opioid-induced hyperalgesia is to lower the opioid dosage. Lowering the dosage can be counterintuitive because patients get used to getting an increase in dosage when their pain is worse.
Another way to address opioid tolerance is to switch to another opioid. For example, the doctor who is prescribing oxycodone to a patient could switch to morphine. While patients tend to build a tolerance to all opioids as resistance to the medication’s effects grows, there is what is known as incomplete cross-tolerance. Incomplete cross-tolerance means that switching to a different opioid will help a bit, though there will be some tolerance to the new opioid.
What about the second option, switching to Suboxone?
Suboxone is not FDA approved for treating pain, so this would be what is known as off-label prescribing. Yet, the Suboxone doctor in question in our scenario at the pain clinic may prescribe Suboxone to the patient for the diagnosis of opioid dependence. Remember that our patient is not addicted to opioids and is not misusing them. However, it is common for patients who take prescribed opioids long-term to become physically dependent on opioids. Physical dependence means that the patient will get physically sick if they stop taking the opioid abruptly. Physical dependence can occur with a variety of different types of medications and is not at all the same as addiction. So, it is possible for the patient to be opioid-dependent but not addicted to opioids. What about the pain? The active ingredient in Suboxone, buprenorphine, is a mixed opioid antagonist and partial opioid agonist. What that means is that buprenorphine has opioid effects, including pain control. In addition to helping the patient come off of oxycodone, the Suboxone will also help with the pain.
Suboxone is a different kind of opioid.
The buprenorphine in Suboxone works like an opioid and has opioid-like effects, but it is not like other opioids. Buprenorphine strongly binds to the opioid receptor. Addiction experts believe that buprenorphine binds permanently to the receptor. How is this possible? Keep in mind that opioid receptors have a life-span of about 72 hours. Opioid receptors are constantly undergoing turnover. The body makes new ones and reclaims the old ones. While the molecule is bound to the receptor, blocking other opioids from attaching to it, buprenorphine also partially activates that receptor continuously. This mixed blocking/activation action is far different from most opioids. Oxycodone molecules, for example, will bounce on and off of receptors many times per second. With each binding, the oxycodone molecule will fully activate that receptor, producing pain relief and euphoria. The different actions of buprenorphine molecules are likely responsible for some of its unique properties. Buprenorphine has a ceiling effect. The ceiling effect means that, in most cases, if a person took too much buprenorphine, they would likely not overdose. The drug’s effects level off at a certain point and do not increase, even if the patient takes more. Also, tolerance does not occur nearly as readily with buprenorphine compared to other opioids. Rarely does a patient on Suboxone complain about tolerance. Suboxone also does not produce addicting behavior in people who are prone to opioid addiction.
So why not switch all patients from other opioids to Suboxone?
With all of the advantages listed above, it seems like the buprenorphine is Suboxone is far superior to other opioids. Why not do away with all other opioids and switch all patients to Suboxone? There are some downsides to keep in mind. When it comes to pain, Suboxone will work well for many patients, but for other patients, it will not give them adequate pain relief. Another thing to keep in mind is the issue of physical dependence. When stopping an opioid, patients often experience physical opioid withdrawal symptoms. These symptoms can be very unpleasant. Doctors can help their patients to have minimal withdrawal symptoms by lowering opioid dosages gradually and to as low a dose as possible.
Additionally, they can prescribe medications to help minimize the severity of withdrawal symptoms. Suboxone also has a withdrawal syndrome. Unfortunately, for some patients, the withdrawal symptoms after stopping Suboxone can be more severe and even more prolonged than the withdrawal from other opioids. The non-addicted patient deciding whether or not to go on Suboxone after pain medication must consider this. For our patient, if he is ready to come off of his oxycodone, he may have an easier time being tapered gradually off of oxycodone by his pain doctor. The final tapering of the opioid is part of the process of completing medical pain management.
For a patient who is addicted to opioids, this is a very different situation. The patient who is addicted is at risk of having a life-threatening overdose if left untreated. And, it is against the law for doctors to use opioids to treat opioid addiction. The only exception to this is the use of methadone and buprenorphine products, prescribed by doctors with additional training and certification.
What about cannabis?
Finally, what about the third option, going to the cannabis doctor to manage chronic pain? Cannabis, or Marijuana, is now legal in many states. It is, however, illegal at the federal level. Why are dispensaries and growers allowed to operate when the federal government has categorized marijuana as an illegal drug with no known medical use? I do not fully understand the legal complexities that justify medical and recreational marijuana in some states. At the same time, the federal government fights fiercely against proven methods of harm reduction that would save lives in the US. I refer specifically to the case of a facility in Philadephia, attempting to open a supervised consumption site. Such a place would allow heroin users who are not ready to go in for treatment to use their heroin safely. Clean supplies, including syringes and needles, are provided, and overdoses, are treated and reversed on-site.
Putting aside the issues of the legalization of marijuana, let’s consider its usefulness in pain management. Marijuana can help patients to tolerate chronic pain and cancer-related pain better. However, there are drawbacks. Cannabis has significant side effects for some patients. It can affect memory, cause paranoia, and anxiety. The drug has many strains, and the active ingredient, THC, can vary from one plant to another. Depending on the type of pain and severity, cannabis may help partially, but it may not be as effective as pain medications.
Marijuana has specific medical uses where it excels.
It helps with a particular type of glaucoma. When it comes to chemotherapy-induced nausea and HIV wasting, pot works great. Otherwise, I feel as if cannabis is more of a solution looking for a problem to solve. Marijuana has quickly become big business, and medical marijuana is how the industry gets its foot in the door in individual states. Here, in Florida, medical cannabis was approved for a minimal number of health conditions. Then, the state passed an amendment that opened up medical cannabis use for nearly any health problem. Nevertheless, marijuana products may provide significant pain relief for some patients. For these patients, it may be an appropriate option.
What is the best decision, continuing the opioid for pain, switching to Suboxone, or switching to marijuana?
It is important to remember that there are other options for pain relief. There is exercise, stretching, massage, acupuncture, biofeedback, physical therapy, meditation, and much more. If you are ready to come off of a prescribed opioid for pain, ask your doctor if they can give you a tapering plan. If you have no issues with addiction or misuse of your medication, tapering off of your opioid for pain should be part of the program. In some cases, it will be best to make the switch to Suboxone or a similar medication. Keep in mind that there are forms of buprenorphine that the FDA has approved for pain. A seven-day patch, Butrans, delivers a steady dose of buprenorphine through the skin. And marijuana is another option if it is legal in your state. The use of marijuana is a personal choice. You will have to decide if you are comfortable with it.
Should you choose telemedicine in the age of social distancing?
Another consideration is telemedicine. Have you had an online visit with your doctor yet? With the concerns of the Covid-19 pandemic, people are deciding to stay home whenever possible and do business by phone or video call. Many doctors are relying on telehealth technology, if at all possible. You may want to check with your pain management doctor if telemedicine is a possibility for you. Keep in mind that many opioid drugs are schedule II, which may restrict your doctor from prescribing them over telemedicine. Suboxone, on the other hand, can be prescribed by telemedicine doctors. So, if making the decision is difficult, this may be your final deciding factor.