Buprenorphine Catch-22

Although the FDA approved buprenorphine as the parenteral preparation Buprenex more than 30 years ago for treating cancer pain and approved a transdermal patch more recently for treating pain, most still think of the drug only as Suboxone brand for maintenance treatment of addiction to opiates.
Consider the (fictional) case of a woman suffering from restless leg syndrome, a condition that often responds to treatment with opiates. Non-opiate drugs like gabapentin, pramipexole, or ropinirole usually work, but in her case these drugs either failed to help or produced unacceptable adverse effects and interactions with other drugs she takes. Her primary care physician refers her to me knowing that I can prescribed buprenorphine. However, I see no evidence that she suffers from an addiction to opiates. Not only do the demands of my buprenorphine "program" seem excessive and unnecessarily burdensome for such patient, but I do not treat sleep disorders like restless leg syndrome.
I recommend that the patient consult a sleep disorder medicine specialist who has indicated to me that he might prescribe a drug like codeine or hydrocodone. Knowing what I know about the safety, excellent side effect profile, and reduced abuse potential of buprenorphine, I suggest to him that he consider treating her with buprenorphine off label. However, since he does not possess the DEA waiver for prescribing sublingual preparations he would do so at risk of inviting unwanted scrutiny by the Drug Enforcement Administration.
DEA should back off when it comes to off label prescribing of buprenorphine in lieu of other opiates.

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