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Safer Opioid Ignored


Under pressure to avoid prescribing opioids for acute postoperative pain and pain related to serious injury, U.S. physicians, dentists and other medical providers increasingly prescribe acetaminophen (Tylenol) or non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen (Motrin) when they believe they will provide adequate pain control.

However, when prescribers believe only an opioid will control the pain, and despite the known dangers of addiction, overdose and diversion, they still almost exclusively prescribe potentially lethal drugs like oxycodone (found in Percodan and Percocet) and hydrocodone (found in Vicodin), ignoring a safer alternative: buprenorphine.

Almost every day I read about new efforts touted as likely to reduce overdose deaths by restricting the prescribing of opioids. But no one has encouraged providers to prescribe, for acute injuries or routine postoperative pain control, the one opioid that rarely causes death with overdose: buprenorphine.

Physicians in Europe and some other parts of the world have prescribed this safer pain reliever (analgesic) for decades. Temgesic brand buprenorphine, for example, comes in the appropriate 0.2 mg. dose. The U.S. Food and Drug Administration (FDA) has never approved Temgesic or equivalent at this low dose appropriate for treating acute postoperative pain. But a patient (or helper) can cut a film strip of buprenorphine 2 mg. combined with minimally absorbed naloxone 0.5 mg. (Suboxone or generic equivalent) into 10 small pieces with scissors to yield the 0.2 mg. dose. (Several YouTube videos already demonstrate how to do this.) The patient then dissolves the tiny piece of film under their tongue. In many cases a single film strip will suffice.

The Drug Enforcement Administration (DEA) requires prescribers to undergo special training and certification for prescribing of buprenorphine, alone or in combination with naloxone, for treatment of addiction, but not for treatment of pain.

Medicine has yet to find a perfect treatment for pain. Like other opioids, buprenorphine has adverse effects, but in prescribing the drug for addiction, starting when it was released in 2003, patients I treated with doses as high as 32 mg. per day experienced almost no side effects and no interference of day-to-day functioning. Buprenorphine does not magically eliminate all pain in all who suffer from pain, but if we want to make a substantial dent in the rate of deaths due to overdose with opioid drugs, we should use this safer compromise rather than waiting for big pharma and the FDA to make something better available. 

Prescribers should offer buprenorphine to appropriate patients, and pharmacists should dispense the film strips enthusiastically, knowing that in doing so they may have contributed to significant reduction in risk of overdose. Patients should ask their physicians and dentists now to prescribe buprenorphine instead of oxycodone, hydrocodone and similar drugs for short term treatment of acute pain after procedures or injuries.

Berry Edwards, MD

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12/7-10 AAAP