I've wondered why partial opioid agonists like buprenorphine are never used for pain management, they only seem to be used for withdrawing from opioid addiction. If it was used then addiction would be unlikely, since it's used to get people to quit opioids. Is buprenorphine just not effective for pain management?
This is actually a good question. I think to some extent medicine is often arbitrary and there's a lot of inertia about changing how things are done. We actually send home buprenorphine in veterinary medicine all the time for pain relief. And we do use it in humans for pain relief when morphine isn't cutting it because it's 100 times more potent than morphine, i.e. in cancer patients.
Sometimes these things are arbitrary. Like, in the US they use morphine during labour and in the UK they use diamorphine (heroin). I don't think there's a logical reason for the difference, just a cultural difference between the US and UK.
Codeine probably got started as the take-home opioid because it's 1/10th the potency of morphine and people just stuck with it. It's a full agonist but it's also a much weaker one. I don't think we have any case controlled studies on whether very low doses of bupe would be less addictive and as effective for home management, even though there's reason to think it would be. There is less risk in changing stuff up in veterinary medicine so less institutional inertia.
(There is still potential for buprenorphine abuse, though, so it's not a panacea!)
Buprenorphine started to be used in the UK when I was a House Doctor (intern). I learned how to use it in pain relief, which was its marketing authorisation. It was very effective, had little ‘buzz,’ so wasn’t seen as anything like as addictive as morphine or diamorphine (which was rarely prescribed because of rapid tolerance). Only decades later is buprenorphine now used in addictions management.
It is used, though it's weird that it's not more often the 1st choice.
One reason is probably that if you have surgery you get potent full agonist during the surgery and sometimes people need substantial doses post surgery. Swithing form a full -> partial agonist is trickier than full agonist. One could imagine this is explain some of the practice even if you've not hade surgery.
NSAIDs are painkillers and more effective than opioids in i.e. dental pain and post-operative dental pain. They're also equipotent for post-operative pain in abominal surgery. They are now a first threatment for post-operative pain for some procedures in some countries. So- certainly not first.
I know opiates are classified as painkillers but IMO they are more pain *relief,* as is gas and air. Both contribute to altered mental state and mostly work by altering perception of pain. In light or medium sedation, opioids are used during medical procedures to make people minimally conscious or unconscious. They mostly make you feel good in small doses, and then sleepy in larger ones, not pain free.
I've wondered why partial opioid agonists like buprenorphine are never used for pain management, they only seem to be used for withdrawing from opioid addiction. If it was used then addiction would be unlikely, since it's used to get people to quit opioids. Is buprenorphine just not effective for pain management?
This is actually a good question. I think to some extent medicine is often arbitrary and there's a lot of inertia about changing how things are done. We actually send home buprenorphine in veterinary medicine all the time for pain relief. And we do use it in humans for pain relief when morphine isn't cutting it because it's 100 times more potent than morphine, i.e. in cancer patients.
Sometimes these things are arbitrary. Like, in the US they use morphine during labour and in the UK they use diamorphine (heroin). I don't think there's a logical reason for the difference, just a cultural difference between the US and UK.
Codeine probably got started as the take-home opioid because it's 1/10th the potency of morphine and people just stuck with it. It's a full agonist but it's also a much weaker one. I don't think we have any case controlled studies on whether very low doses of bupe would be less addictive and as effective for home management, even though there's reason to think it would be. There is less risk in changing stuff up in veterinary medicine so less institutional inertia.
(There is still potential for buprenorphine abuse, though, so it's not a panacea!)
Buprenorphine started to be used in the UK when I was a House Doctor (intern). I learned how to use it in pain relief, which was its marketing authorisation. It was very effective, had little ‘buzz,’ so wasn’t seen as anything like as addictive as morphine or diamorphine (which was rarely prescribed because of rapid tolerance). Only decades later is buprenorphine now used in addictions management.
It is used, though it's weird that it's not more often the 1st choice.
One reason is probably that if you have surgery you get potent full agonist during the surgery and sometimes people need substantial doses post surgery. Swithing form a full -> partial agonist is trickier than full agonist. One could imagine this is explain some of the practice even if you've not hade surgery.
This piece was amazing -- I welcome others like it that introduce a niche process and explain it from A to Z.
NSAIDs are painkillers and more effective than opioids in i.e. dental pain and post-operative dental pain. They're also equipotent for post-operative pain in abominal surgery. They are now a first threatment for post-operative pain for some procedures in some countries. So- certainly not first.
I know opiates are classified as painkillers but IMO they are more pain *relief,* as is gas and air. Both contribute to altered mental state and mostly work by altering perception of pain. In light or medium sedation, opioids are used during medical procedures to make people minimally conscious or unconscious. They mostly make you feel good in small doses, and then sleepy in larger ones, not pain free.
Is the title a mistake or deliberate click-bait? There are many non-opioid painkillers.
Seems to me this is a wonderfully well-written article thank you and I hope there's more
Great article, excellent level of detail and fling through the process