What pain medicine can you take with Suboxone?
What pain medicine can you take with Suboxone? The answer is the same two things most people reach for anyway, acetaminophen (Tylenol) and the anti-inflammatory drugs such as ibuprofen (Advil, Motrin) and naproxen (Aleve). They work, and they do not interfere with buprenorphine.
Mark Leeds, D.O. has over two decades of experience in treating medication and drug dependence and addiction, and this is a question patients on buprenorphine ask often. Someone has a toothache, a sprained ankle, or a surgery on the calendar. Can they take Advil? What about after a root canal? What happens if they need an operation?
Underneath those questions is a fear that Suboxone has taken every option off the table, and it has not. In fact, a person on buprenorphine has most of the same options as anyone else, and the buprenorphine itself is one of them.
When this article says Suboxone, it means any buprenorphine medication used for opioid dependence, including ZubSolv, the generic films and tablets, and buprenorphine on its own. Suboxone itself is buprenorphine plus a little naloxone. While the naloxone is there to discourage injection, it is barely absorbed under the tongue, so buprenorphine is the only ingredient that matters for pain.
So, if the drugstore shelf still works, what is different about pain when you take buprenorphine? Quite a lot, and it changes what belongs in the rest of your medicine cabinet.
Why is pain different when you take buprenorphine?
Buprenorphine is a partial agonist at the opioid receptor. That means that it turns the receptor on, but only part of the way, and it holds on to the receptor and does not let go.
Because it only turns the receptor part of the way on, there is a ceiling on how far it can slow your breathing. That ceiling is a large part of why it is so much safer than oxycodone or fentanyl.
The holding on is what matters for pain. Think of your opioid receptors as a parking lot with a fixed number of spaces. Buprenorphine parks in nearly all of them and stays parked long after the meter runs out.
A tablet of oxycodone or hydrocodone arrives looking for a space and mostly circles the lot. While this is not a perfect analogy, it explains two things at once.
A full opioid painkiller gives a Suboxone patient far less relief than it gives anyone else, because it cannot find a receptor to act on. And, the old advice to stop Suboxone for a few days “to make room” for pain pills is exactly backwards.
Emptying the lot also lowers your tolerance, and it leaves every space open. The large doses that were needed to get past buprenorphine become deadly once it is gone. So, do not empty the parking lot. Keep taking your buprenorphine, and build the pain plan around it.
Can you take ibuprofen with Suboxone?
Yes. There is no recognized interaction between buprenorphine and ibuprofen, naproxen, or aspirin. These are the nonsteroidal anti-inflammatory drugs, or NSAIDs, and they relieve pain by a route that has nothing to do with the opioid receptor, so buprenorphine neither blocks them nor adds to them.
You may have read that ibuprofen adds drowsiness on top of Suboxone, or that it can “mask” a Suboxone complication. It does neither in any meaningful way. The cautions that apply to ibuprofen are the ones printed on the box, and they apply to you exactly as they apply to a neighbor who has never heard of buprenorphine.
Those cautions have nothing to do with Suboxone. But, they are real. NSAIDs can irritate the stomach lining and cause bleeding, especially at higher doses, over longer stretches, or in people who take blood thinners or drink.
They can strain the kidneys, particularly if you are dehydrated, older, already have kidney disease, or take certain blood pressure medications. And, the label warns about heart risk with long-term use.
In practice, that means taking ibuprofen or naproxen with food, at the lowest dose that works, for days rather than weeks without checking with your doctor. For a sore knee or shoulder, a diclofenac gel (Voltaren) puts the anti-inflammatory where the pain is, with far less of it reaching the stomach.
Ibuprofen is fine. The stomach and the kidneys set the limits, not the Suboxone.
What about Tylenol?
Acetaminophen, or Tylenol, is the other first-line choice, and it has no interaction with buprenorphine either. While it is gentler on the stomach and the kidneys than the NSAIDs, which makes it the better choice for many people, it has a limit of its own. Its limit is the liver.
How much acetaminophen is too much? The package says, and the number on the package is the limit. It drops lower for people who drink regularly, who have liver disease, or who weigh very little.
The trap is that acetaminophen hides inside hundreds of other products, from cold and flu remedies to prescription pain pills. So, a person can pass the limit without ever opening a bottle of Tylenol.
Fortunately, acetaminophen and an NSAID work by different routes, so taking both, or alternating them through the day, often relieves more pain than either one alone. Dentists lean on that combination after extractions for exactly this reason. For most everyday pain on Suboxone, that combination is the whole plan.
Does Suboxone itself relieve pain?
It does. Buprenorphine was a pain medication before it was an addiction medication, and it is still sold for chronic pain under the names Belbuca and Butrans. The buprenorphine in your Suboxone film is the same molecule, and it is already relieving pain that you would otherwise notice.
So, why does a Suboxone patient hurt at all? Timing.
While a single daily dose of buprenorphine holds off withdrawal for a full day and longer, its pain relief lasts a matter of hours. Someone who takes the whole dose at breakfast may be comfortable at lunch and hurting by dinner, while feeling no withdrawal at all.
That is why the usual approach to a painful week is to split the same daily amount into three or four smaller doses, or to raise the dose for a short time, so that the relief covers the whole day. It is a framework to arrange with your prescriber, not a change to make on your own.
There are no large studies that settle the best way to do this, and doctors who do it every day each do it a little differently. What they agree on is the direction.
The one thing that is never the answer is lowering the dose. Less buprenorphine means less pain relief and a shakier tolerance, and it does not make other painkillers work any better.
What if the pain is severe, such as a fracture, a tooth extraction, or surgery?
Keep taking your buprenorphine, and tell the surgical or dental team as early as you can. For years, patients were told to stop Suboxone a week before an operation so that the anesthesiologist could use ordinary opioids afterward. That advice left a lot of people in withdrawal, in pain, and at risk on the far side of surgery.
Yet, in medicine, we retired that advice years ago. Not every office got the memo. The current approach in anesthesiology is to continue buprenorphine through the procedure and plan around it.
A surgical team has tools you do not have at home, including nerve blocks, local anesthetics, intravenous non-opioid drugs, and, when they are truly needed, full opioids at higher doses under monitoring. While those are hospital tools, none of them require you to stop your medication first.
How that works, and what to say to the anesthesiologist, is covered in Can You Have Surgery on Suboxone? If you have already been told to stop, do not simply comply and do not simply refuse. Ask the surgeon to speak with your buprenorphine doctor, because two doctors talking before the operation solves nearly all of it.
And, if severe pain comes with chest pressure, a fever, a head injury, or a limb you cannot use, go to the emergency room. Tell them what you take.
Suboxone is never a reason to stay home.
Which pain medicines should you avoid while on Suboxone?
Start with the ones that look like a middle path and are not. Tramadol is a weak opioid with a serotonin effect bolted on, and codeine, whether in Tylenol #3 or a cough syrup, has to be converted by the liver into morphine before it does much of anything.
Buprenorphine blocks the opioid side of both, so you get little relief. It does not block tramadol’s other side, and that side carries its own risk of seizures and serotonin syndrome.
Of course, a stronger full opioid from someone else’s cabinet is worse. It is mostly blocked, so it is mostly wasted, and the temptation is to skip a dose of buprenorphine so that it works. Skipping the dose to make a pain pill work is the entire danger.
The other category is anything that slows breathing on its own. Benzodiazepines such as Xanax (alprazolam), Klonopin (clonazepam), Ativan (lorazepam), and Valium (diazepam), alcohol, and sedating muscle relaxants or sleep aids all add their sedation to buprenorphine’s, and the combination of an opioid with a benzodiazepine carries a boxed warning for that reason.
If you already take a prescribed benzodiazepine, that warning is not a reason to quit it on your own. Never stop a benzodiazepine suddenly. Abrupt discontinuation can trigger seizures and can be life-threatening, and the right step is to make sure both of your prescribers know about each other.
The wider list of what does and does not mix with buprenorphine is in Suboxone and Medications: What Not to Take Together. For pain, opioid painkillers are mostly wasted on you, and sedatives are dangerous.
Why do some doctors still tell Suboxone patients to tough it out?
Unfortunately, the chart says “opioid use disorder,” and in some emergency rooms and surgical offices that phrase gets read before the X-ray does. A Suboxone patient with a broken wrist has a broken wrist.
Patients have described being handed ibuprofen and a lecture, or being asked whether the pain was “real,” while the person in the next bed with the same fracture got a proper plan. The lecture is about a problem they have already solved by taking their medication every day.
Physical dependence on buprenorphine is not addiction. It is the body’s adjustment to a medication taken every day, and asking for a pain plan is not drug seeking.
In that moment, the patient does not have a drug problem. They have a wrist problem.
While most of these doctors are not cruel, they are working from a chart, in a hurry, with training that may be a decade behind on buprenorphine, and they are afraid of doing harm. The fix is usually one phone call to your prescriber, made before the argument starts. Bring the number with you.
How should you and your doctor plan for pain before it happens?
Keep a current list of everything you take, including the over-the-counter bottles, on your phone. It is not a bad idea to ask your buprenorphine doctor about pain at your next visit, even if nothing hurts today.
Before a dental appointment or a scheduled surgery, ask what the plan will be, so that the divided dosing, the acetaminophen and ibuprofen, and the call to the surgeon are arranged before the swelling starts. While no plan covers every emergency, most pain on Suboxone is not an emergency. It is a root canal with a date on it.
Pain on Suboxone is treatable, and it is treated best by the doctor who already knows your dose. Your doctor would rather hear about a sore tooth on Tuesday than a scramble on Saturday, so do not worry about being a nuisance.
Dr. Leeds treats patients on buprenorphine through concierge telemedicine in Florida, with weekly video visits and text access between them. A tooth extraction or an orthopedic appointment gets its pain plan the week before, not the night after.
To ask about Suboxone treatment by telemedicine, contact Dr. Leeds.
This article is educational. It is not medical advice, and reading it does not create a doctor-patient relationship. Decisions about starting, continuing, or tapering any medication should be made with your own physician.
