Buprenorphine for pain management physicians: A dilemma or a therapeutic alternative?

The recent approval of office-based treatment for opioid addiction using buprenorphine expands treatment options for opioid addiction. However, the utility of this drug in controlling chronic pain in those suffering with chemical dependencies, although intuitively elegant, has yet to be fully explored. Buprenorphine's clinical efficacy results from its unique molecular structure: it is a partial μ opioid agonist and a weak antagonist. Although it has a high affinity for the μ receptor, with slow dissociation resulting in a long duration of action and an analgesic potency 25 to 40 times greater than morphine, most physicians outside the addictions field have yet to exploit buprenorphine as a therapeutic alternative, particularly in patients with a family history of addiction, or past history of opiate abuse or dependency. The primary reason to consider the drug in populations with addictive predisposition is that, at higher doses, its agonist effects plateau and antagonist effects predominate limiting the drugs desirability as a substance of abuse and decreasing the potential for respiratory depression resulting in a high safety profile. Even so, abstinence syndromes do develop and withdrawal symptoms, although mild constitutionally, can be as psychologically harrowing as with other narcotics. Thus, cessation after prolonged administration should be monitored. In conclusion, buprenorphine both structurally and clinically provides an elegant alternative to the dilemma of treating legitimate chronic pain in the patient with whom addictive predilections may be an issue. Physicians using the drug should consider getting the special DEA number to protect themselves in those cases where the fine line between treatment of chronic pain and management of opioid addiction is ambiguous.