Chronic Pain Elevates Risk for Opioid Use During Buprenorphine Taper

• Prescription opioid addiction in adults with chronic pain has become increasingly common and problematic in many developed nations.
• Chronic pain patients are now prescribed opioids for longer durations and at higher doses than in previous decades, putting them at greater risk for physiological tolerance and potential addiction.
• Additionally, treatment of this population is complicated by complex medical and psychiatric problems that often intensify upon opioid withdrawal, prompting relapse.

Both clinical recommendations and empirical studies suggest that buprenorphine-naloxone (BUP-NLX) is a viable pharmacotherapy for chronic pain patients with prescription opioid addiction.  Compared to full opioid agonists like methadone, it offers improved safety and diminished abuse liability.
Because persistent pain is often associated with relapse following addiction treatment, it could also  trigger a return to opioid use during or following treatment with BUP-NLX.

This study, a secondary analysis of data from the CTN’s Prescription Opioid Addiction Treatment Study (POATS), estimated whether changes in pain over time and pain volatility (unpredictable fluctuations in pain severity) during BUP-NLX maintenance would predict opioid use during the BUP-NLX taper.

Study participants, from community clinics affiliated with POATS in 10 U.S. cities, were subjects with chronic pain who entered the BUP-NLX taper phase (N=125), with enrollment occurring from June 2006 to July 2009 (52% male, 88% Caucasian, 31% married). Controlling for baseline pain and treatment condition, increased pain and greater pain volatility predicted greater odds of positive opioid urine screen during BUP-NLX taper. Increased pain and greater pain volatility also predicted greater frequency of self-reported opioid use.

Conclusions: Adults with chronic pain receiving outpatient treatment with buprenorphine-naloxone (BUP-NLX) for prescription opioid addiction have elevated risk for opioid use when tapering off maintenance treatment. Those with relative persistence in pain over time and greater volatility in pain during treatment are less likely to sustain abstinence during BUP-NLX taper. These findings suggest that stabilizing and/or reducing subjective pain prior to discontinuation of BUP-NLX maintenance may be a means to improve treatment outcomes in this population.
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