What are your thoughts on the VA’s flourishing use of the drug Suboxone to treat Chronic Pain?

PO3 Jay Rose — Mon, 20 Jul 2020 22:56:22 -0400

For some time now, the VA has been ushering in a new regimen for the management of chronic and severe pain with the medication known by its brand name as Suboxone (Buprenorphine/Naloxone). For those of you that are not familiar with the drug, Buprenorphine was first synthesized by then Reckitt & Colman (now Reckitt Benckiser) in 1969 after over a decade of research with the goal in mind of creating an opioid that is much stronger than morphine, with minimal side-effects, to treat severe pain. There are various studies, however milligram for milligram, 1mg of Buprenorphine is roughly equivalent to 12.5mg to 25mg of morphine, and will bind much better than morphine to the mu-opioid receptor, and for a much longer duration. Buprenorphine is also widely used in veterinary medicine to treat post-operative pain.

By the late 1970s, Buprenorphine was approved as an injectable to treat pain in the UK, and a sublingual (SL) formulation soon followed (also to treat severe pain). It was subsequently approved for medical use in the United States in 1981, but it wasn’t until much later, 2002 to be exact, that the US Food & Drug Administration approved its use to treat opioid addiction under the brand name Suboxone. Since the release of Suboxone just after the turn of the millennium, and its rescheduling to a more restrictive C-III medication, we have not seen it used much for pain until recently. Some of the most recent studies as of 2020 suggest that Buprenorphine is most therapeutic when prescribed for pain thrice daily, and that is the current recommendation by the VA for long-term pain management, especially in conjunction with chronic opioid dependence. However, being a complex and highly individualistic drug, prescribers must tailor a dosing schedule that works best for each individual patient. Buprenorphine is by no means a ‘one size fits all’ medication, especially when contrasted against morphine and other traditional opioid analgesics.

There are some other unique benefits of Buprenorphine with one of the most notable features being that it is much easier on the liver than the “combination drugs” such as Vicodin or Percocet. These “combination drugs” contain Acetaminophen (Brand Name: Tylenol) which overtime will generally wreck havoc on the liver. Additionally, Buprenorphine is a k-opioid receptor antagonist which yields some amazing psychological benefits from the drug including both antidepressive and anxiolytic properties. It is also widely believed that Buprenorphine has a “ceiling effect,” this means that by adding more-and-more of the medication, it will stop binding to the receptors in the brain once a certain amount of the drug is taken. This “ceiling effect” is important because it means that Buprenorphine has a much lower risk of respiratory depression (and theoretically overdose) than almost all other narcotic pain medications on the market today!

Simply, the VA has segued away from those traditional opioid analgesics to Buprenorphine because they feel that it’s a safer alternative treatment for chronic pain, and so far they seem to be right. The VA further recommends an integrated, multidisciplinary approach to treating chronic pain utilizing services such as physical & occupational therapy, pain psychology, clinical pharmacy evaluations, and more in conjunction with Buprenorphine therapy for chronic pain. These changes occurred after the CDC published an updated “Guideline for Prescribing Opioids for Chronic Pain” in March 2016. The main takeaway from this “guideline” which was a rude awakening for both pain patients and physicians alike was the “recommendation” that patients should no longer be prescribed daily in excess of 90 MME (morphine equivalent dose). I’m not going to delve further into this specific topic as it calls for a detailed post in its own right, but I will interject with a thought, and that is how I’ve seen firsthand the VA Pharmacy labels on pill bottles read “...for complex opioid dependency,” but who wouldn’t get dependent on the many years of diversified narcotic medications that were keeping these veterans even somewhat functioning while meandering through their daily lives?

As per an official VA “Patient Guide,” the VA states that they see three types of responses from patients that have tried Buprenorphine (for a period of at least two months), and they are:

1. A third of veterans show dramatic improvement in both pain and function.

2. A third of veterans show moderate improvement in pain, but their emotional life and function improves considerably. They also report relieved that they don’t have to “clock-watch” for the next dose, worry about patches falling down, or missing a dose. Buprenorphine is such a long acting medication that you will rarely get withdrawals even if you miss a dose.

3. Among the rest, there is moderate improvement in pain or the pain remains stable at the previous level. We will still continue Buprenorphine/Naloxone treatment because it is a safer option and is the recommended treatment for opioid dependence.

This certainly sounds like a modern medical miracle, especially for those of us veterans who have been suffering with the debilitating effects of chronic and severe pain for many years or even decades, but is it all that the VA makes it cracked up to be? After all, Suboxone became more-or-less famous for the treatment of opioid abuse, such as dependence or addiction for at least the previous decade. This could lead to unexpected assumptions by medical practitioners in a ‘one-off’ scenario as they could very well assume that a veteran “must be an addict” because they are prescribed this particular medication, which could then lead to some very bad consequences (and potential outcomes) if the veteran is in an emergency room and assigned a doctor making these assumptions. (Note: Some VAMCs are rolling out a “Buprenorphine for Pain” card that could be presented to medical staff in just a scenario.)

I also explained above that Buprenorphine has an unusually long duration (with a mean half-life being around 36-hours). This would generally work in favor of the veteran being treated for pain, however there is another downside with regard to Buprenorphine for this very reason, and that is other narcotic medications generally cannot be administered even under emergency care as they simply will have no meaningful effect on the patient being treated. Buprenorphine has such a strong binding affinity to the receptors in the brain that other narcotic medications will just not bind alongside. When narcotic pain medications are carefully administered in an emergency, they must be in very high doses in order to override the hefty binding affinity of Buprenorphine, and as a precaution a subsequent 24-hour stay in the intensive care unit is medically necessary. So, what happens if the veteran breaks a leg or is in a motor vehicle accident?

Buprenorphine most definitely has many unique advantages over traditional medical pain management treatments, but as you see it also has a wide array of issues from the social stigma of the veteran being prescribed it to the questions that will arise during the treatment of a bona fide medical emergency. With the plethora of positives, how negligible are the negatives?

I’m not a physician, but I’ve done a hell of a lot of research on Buprenorphine therapy, and I personally believe that the VA’s use of Buprenorphine as a frontline treatment for debilitating chronic pain will open up doors to those veterans taking it that alternative opioid medications just cannot offer. The simple fact that Buprenorphine will in most cases considerably improve a veteran’s emotional life and function (in addition to pain) equates to potentially getting their life back, at times even after the thought was quite possibly abandoned. To me, this is what practicing medicine is all about, not just doing no harm, but doing considerable good for the welfare of the patient. Sure, there are some potential social stigmas attached, ignorance begets ignorance, but let people think what they want as long as the veterans being treated have a newfound opportunity at actually living a meaningful life again.

I must again say that the multidisciplinary approach to treating chronic pain utilizing services such as physical & occupational therapy, pain psychology, clinical pharmacy evaluations, and more in conjunction with Buprenorphine therapy for chronic pain is vital. One therapy alone of any kind will most likely result in failure, and this is partially how we got to this particular juncture (read: mess) in the first place. A prescriber cannot just write a prescription for a pain medication and hope for the best. The world doesn’t work like that, at least outside the periphery of a pricey medical school. I personally tried all of the above for my own debilitating rare genetic refractory disease that I didn’t even receive an official diagnosis on from the VA until about two years ago when not far from turning 40. The diagnosis was “Ehlers-Danlos Syndrome - Hypermobile Type” for our inquisitive friends reading this, and don’t feel bad if you never heard of it as nearly every single primary and specialist missed the mark too. Most of the docs that I’ve asked simply asked back “what the hell is that?!” What I discovered is that the addition of physical therapy will make or break any treatment plan as receiving the **correct therapy** for my condition literally turned my life around. The multidisciplinary approach worked in treating my chronic pain, but it did not work 100%, and being the realist that I am, I wasn’t expecting full-blown mitigation at the start of my personalized treatment plan. What I did find was a substantial amount of liberation from the bonds of my chronic pain, a pain that has been exponentially increasing in both quality and quantity for the better part of the last two decades.

The new PACT Team (Indigo Team, Philadelphia VAMC) structure at the VA helped me set priorities, organize my thoughts, and set realistic goals. They then busted their asses to make things happen expeditiously for me from getting necessary tests scheduled at high priority levels to arranging 6+ months of Community Care-based Physical Therapy! I remember the day that I started PT there, I could barely walk, was exhausted, easily had 7/10 pain, and could barely even rely on my cane to hobble in for my initial assessment. Six months later I was a “new me,” I was biking again, much of my balance was restored, the strength in my nerve damaged feet were now a ‘happy’ 5/5, and I only needed the cane at that point for when a leg literally goes out on me (read: fully numb before you could blink to see it). I’ve said it before, some VAMCs operate phenomenally well, yet we see others that operate at sub-optimal levels. As veterans, we must remember that the VA is a very big system with many people and technologies dispersed around our great nation, it is only natural to see such mixed results. I’m hoping, making suggestions, and writing advocacy letters to try to ensure that once a program like this shows promise, that they deploy the same program with trainers that have worked on a successful team within the program to other VAMCs around the country to help the veterans there who need it most. All considered, the VA is, in my humble opinion, one of our country’s finest health organizations!

Though I do need to get back on track with my “Home PT Regimen” that I started to lose focus on around the time that COVID-19 was turning into a full-blown pandemic, I **know** that I could regain those accomplishments once again as I did so very successfully the time before, when I put my mind to it, and had more of a “Coach” than a Doctor of Physical Therapy guiding me. The worsening chronic fatigue may try to get in the way, but I am a fighter, and will try my hardest to win each battle concerning my health, and eventually win the war to the best of my abilities. Again, thanks to the VA for arranging such quality Community-based Care!

This is both a complicated and sensitive subject, and these are my two cents on it. I would love to hear some insights and experiences from the RP community in regard to how the VA’s sea change in the treatment of chronic pain impacted you. I’m also curious if anyone knows if the military is using Buprenorphine therapy for those service members on active duty. Sadly, I would only imagine how many active duty members are dealing with bona fide chronic and severe pain after coming home from deployments. If you have a story to share, and feel comfortable sharing it, please write it up as a comment.

The more ideas and information that we get here could be used by any of us veterans or service members as a tool to present to their respective organization.

As always, thank you all for your service, and for all you do!

~ Jay

Response by Capt Raymond Sonoda REALTOR® CA Broker CRE ITAR made Jul 20 at 2020 11:03 PM

Capt Raymond Sonoda REALTOR® CA Broker CRE ITAR — Mon, 20 Jul 2020 23:03:32 -0400

Thanks for the info. I will let my father-in-law know about this so he can talk with his doc.

Response by SSG Roger Ayscue made Jul 20 at 2020 11:05 PM

SSG Roger Ayscue — Mon, 20 Jul 2020 23:05:01 -0400

A stronger Opioid. wow

Response by SPC Nancy Greene made Jul 20 at 2020 11:26 PM

SPC Nancy Greene — Mon, 20 Jul 2020 23:26:54 -0400

Excellent Information PO3 Jay Rose!
Thank You for sharing in regard to your chronic pain. I also deal with chronic pain on a daily basis. I have ‘done’ the Schedule IV opioid treatments. I developed an allergic reaction to acetaminophen, ibuprofen, and Motrin due to ‘overuse’ while in Active Duty. I have been totally narcotic free for over two years. This is totally due to a phenomenal pain treatment developed by Dr. Thomas J Van de Ven at the Durham VAMC and Duke University Hospital. His injections every 6 months, combined with aquatic physical therapy and my swimming program; I am able to manage my pain 2/10! I feel it is imperative to assess pain on an extremely individual basis. I suffer from deteriorating discs (L3 -S1) caused by stress fractures to right anterior and superior pubic ramus bones.This occurred in January 1984 in Basic Training at Ft Jackson. This injury was not properly diagnosed until June 1984. I actually graduated Basic and AIT with these broken bones. Overcompensation caused the deteriorating discs. I find aquatic exercise and therapy is much easier on the back and spine.

Response by SGT Robert Pryor made Jul 21 at 2020 12:06 AM

SGT Robert Pryor — Tue, 21 Jul 2020 00:06:17 -0400

We all respond to various pain meds differently. The VA injected me with morphine and it did nothing. I asked if they gave me a placebo. The assured me they had not. Then they gave me Tylenol III for my headaches and it took three days of that carp, there times a day, to make the headaches go away. I felt like crap for a few days afterwards. Then, out of desperation, I took some Ibuprofen -- voila! The VA experimented with different dosages and discovered one 800 mg tablet and the headaches are gone in 15 to 20 minutes with no after effects. I take one or two Ibuprofen tablets per month -- that's it. Opioids? I don't need those steenkin' opioids. A damn over the counter drug solved the problem. Your mileage may, and will, vary.

Response by SSG Dennis R. made Jul 21 at 2020 12:31 AM

SSG Dennis R. — Tue, 21 Jul 2020 00:31:40 -0400

My late wife was dealt a bad hand at the health table when she was born. We were together just over 20 years and for about a dozen of those she was on some flavor of pain med. Her health cratered - pulmonary embolism, then a small stroke, and finally a major stroke, all in 11 months The woman was also allergic to just about everything on the planet, just to complicate things. She was oxygen support and 18 different meds but walking around the house when stroke #2 hit.

I'm really curious - those of you on chronic pain meds - have you ever tried marijuana in any form?

Response by CSM Darieus ZaGara made Jul 21 at 2020 6:39 AM

CSM Darieus ZaGara — Tue, 21 Jul 2020 06:39:35 -0400

Not being a health care professional, I do know that pain meds have been scarce at the VA and across the country. While many have proven capable of doing without there is a real need. If this medication works in the ways that I have read about, then the real question is, is this worth trying. Anyway, I hope that it, or some other is a safe effective way to manage the extreme pain that many Vets
Have.

Response by SGT Paul Turnbull made Jul 21 at 2020 8:36 AM

SGT Paul Turnbull — Tue, 21 Jul 2020 08:36:16 -0400

I suffer from chronic pain, but not enough to warrant the use of suboxone. Given I don't fully understand the pain level others live with, nor the affects of suboxone, I won't speculate on the pros and cons. I just hope those who use it find the relief they are looking for and that the good outweighs the bad.

Response by CPT Private RallyPoint Member made Jul 21 at 2020 12:00 PM

CPT Private RallyPoint Member — Tue, 21 Jul 2020 12:00:43 -0400

Good afternoon,
I was unaware that any provider was using suboxone for chronic pain. I enjoyed your well worded write up.
My only concnern, is that outside the VA system, there is a definite stigma associated with Suboxone use. I live and work in a rural town, and the only suboxone prescriptions in the region are for opiate use disorder. I would hate to see a vet with chronic pain get lumped into an undeserved stereotype.

Response by LTC Private RallyPoint Member made Jul 23 at 2020 12:27 PM

LTC Private RallyPoint Member — Thu, 23 Jul 2020 12:27:21 -0400

It is like giving full fat cream to starving kittens.

Response by PFC Curtis Adams made Sep 13 at 2020 1:01 PM

PFC Curtis Adams — Sun, 13 Sep 2020 13:01:45 -0400

Outstanding writeup, it's something I deal with and am shopping a new provider as my last one 4 years "fired" me for asking him to increase me back to pre-opiod epidemic times.

I go in for neck surgery this coming Friday and will discuss this with the surgeon to seek his advice.

The last time I moved VA hospitals from NM to Texas they wanted to run me thru a gauntlet of doctors to determine if I could take Vics or Percs after having been on them for a decade, mostly prescribed by VA Doctors. I refused to sit thru that shit show, my PTSD won't allow it and I'll end up in a padded room lol.

Semper Fi my brother from another Navy mother

Response by SP5 Lewis Miller made Sep 18 at 2020 6:22 AM

SP5 Lewis Miller — Fri, 18 Sep 2020 06:22:08 -0400

I would like anything from the dysfunctional VA I go to. I get no relief from opiates on my pain. I fought with them for years to stop prescribing them as they did no good. Now they only say get you some cannabis. I wish cannabis was legal in Texas I would surely try it.

Response by SSgt Russell Stevens made Sep 21 at 2020 1:46 AM

SSgt Russell Stevens — Mon, 21 Sep 2020 01:46:11 -0400

I can't speak for this drug, but opiods in general are bad news.