Integrative Care Best Practices for Chromic Pain & OUD

Discover the benefits of integrative care for individuals dealing with OUD combined with chronic pain and find effective solutions.

Abstract

In this educational article, I, Dr. Alex Jimenez, will guide you through the complex but critical landscape of treating opioid use disorder (OUD) and chronic pain. The complexity of treating these conditions has grown, particularly with the rise of illicitly manufactured fentanyl, demanding a sophisticated, evidence-based, and compassionate approach. This educational post takes you through the latest findings and clinical strategies for managing OUD, drawing on the work of leading researchers in the field. We will explore the latest evidence-based findings from leading researchers concerning the pharmacology and clinical application of key medications: buprenorphine, methadone, and naltrexone.

A significant focus will be placed on understanding the nuances of buprenorphine initiation, including traditional, low-dose (microdosing), and high-dose (or “macro-dosing”) methods, with a special focus on avoiding precipitated withdrawal in patients exposed to fentanyl. We will also explore the pharmacology of methadone, a long-standing and effective treatment, and discuss the critical considerations for its use. Furthermore, we will examine the role of naltrexone and the innovative use of buprenorphine as a tool for chronic pain management. This post is designed to be an easy-to-understand journey, breaking down the intricate science behind these treatments, including their physiological mechanisms, such as mu-opioid receptor activity.

At our practice, Injury Medical Clinic PA, here in El Paso, Texas, we have built a unique multidisciplinary model. As a Doctor of Chiropractic, Advanced Practice Registered Nurse, and certified functional medicine practitioner, I work closely with our Medical Director, Dr. Maria Guadalupe Cardenas, MD (Board Certified in Internal Medicine; NPI #1164426749; Texas MD License #J2933). Dr. Cardenas brings over 40 years of invaluable experience as an internist to our team. This partnership allows us to provide a truly integrative framework that combines medical oversight with chiropractic care, functional medicine, rehabilitation, and personal injury services. This post will show how our integrated approach supports patients on their path to recovery by addressing the musculoskeletal, neurological, and biochemical aspects of their health to create a comprehensive, personalized healing journey.

Our Integrative Care Model: A Collaborative Approach to Healing

Welcome. My name is Dr. Alex Jimenez. I hold a Doctorate in Chiropractic (DC) and am an Advanced Practice Registered Nurse (APRN) and a Board-Certified Family Nurse Practitioner (FNP-BC). My passion for a holistic, patient-centered approach to health has led me to further my expertise, earning certifications as a Certified Functional Medicine Practitioner (CFMP), an Institute for Functional Medicine Certified Practitioner (IFMCP), and in Advanced Thyroid Nutrition (ATN) and Cranial Cervical Spinal Tomography (CCST).

At our practice, Injury Medical Clinic PA (also known as Mission Plaza Injury Medical Clinic) in El Paso, Texas, we have cultivated a unique and powerful healthcare environment. Our model is built on integrative care, blending the best of different disciplines to create a truly comprehensive treatment plan for our patients. The human body is an interconnected system, and treating a complex condition like opioid use disorder or chronic pain cannot be done in a vacuum.

A cornerstone of our practice is my collaborative relationship with Dr. Maria Guadalupe Cardenas, MD. Dr. Cardenas is a highly respected physician, Board Certified in Internal Medicine, with over four decades of invaluable experience. She serves as our Medical Director and Collaborative Physician, providing the essential medical oversight that allows us to operate as a robust multidisciplinary clinic. This structure, where a medical doctor and a chiropractor work in tandem, is a hallmark of progressive integrative and injury care clinics. Her expertise is crucial in safely managing medications for OUD, such as buprenorphine, monitoring for potential complications or comorbidities, and addressing complex internal medicine issues.

Our team’s strength lies in this synergy. We seamlessly integrate:

• Chiropractic Care: As a chiropractor, I focus on the body’s biomechanical and structural integrity, particularly the spine and nervous system. Gentle, specific adjustments can alleviate pain, improve function, and enhance the body’s innate ability to heal. Chronic pain, a common driver of opioid use, often has a significant musculoskeletal component. By restoring proper joint motion and alleviating nerve impingement, we can reduce pain signals and decrease a patient’s reliance on medication.
• Medical Oversight: Cardenas provides the crucial internal medicine perspective, managing complex medical conditions, overseeing prescription therapies, and ensuring our treatment plans are safe and medically sound. She reviews medical histories and comorbidities and guides dosing strategies, ensuring compliance and documentation standards.
• Functional Medicine: We look beyond the symptoms to find the root causes of dysfunction. By analyzing genetics, lifestyle, and environmental factors, we create personalized strategies involving nutrition, supplementation, and lifestyle changes to restore optimal health. This involves advanced lab testing to assess nutritional deficiencies, hormonal imbalances, gut health, and systemic inflammation—all of which can contribute to chronic pain and cravings.
• Personal Injury and Rehabilitation: We have extensive experience in managing injuries from accidents, providing rehabilitative therapies to restore strength, mobility, and function. This includes graded exercise, neuromotor retraining, ergonomic support, and return-to-work planning, helping patients navigate their recovery journey and preventing relapse by improving biomechanics.

This integrated model allows us to address the patient as a whole person—mind, body, and spirit. When dealing with complex issues like opioid use disorder and chronic pain, this approach is not just beneficial; it is essential. Today, I want to share insights from the forefront of medical research on this topic and explain how our integrative philosophy fits into this modern, evidence-based framework.

Medications for Opioid Use Disorder: Understanding the “Why” and “How”

Before we delve into the specifics of each medication, it is crucial to understand why we turn to pharmacotherapy for opioid use disorder (OUD). This is not simply about replacing one substance with another; it is about providing life-saving medical treatment grounded in robust scientific evidence.

The Life-Saving Rationale for Medication-Assisted Treatment

1. Reduces Mortality: The most compelling reason is that medications for OUD (MOUD) dramatically reduce the risk of opioid-associated mortality. Studies have consistently shown that individuals engaged in treatment with medications like methadone or buprenorphine have a significantly lower risk of dying from an overdose compared to those who are not in treatment or who are in treatment without medication (Larochelle et al., 2018).
2. Manages Withdrawal and Cravings: Opioid withdrawal is a profoundly distressing and physically taxing experience characterized by severe flu-like symptoms, intense anxiety, and overwhelming cravings. These symptoms are often the primary drivers of relapse. Both methadone and buprenorphine are highly effective at alleviating acute withdrawal symptoms and stabilizing the brain’s neurochemistry to reduce or eliminate the powerful cravings for opioids.
3. Enables Life Reclamation: By effectively managing the physiological symptoms of the disease, these medications create a window of stability. They free the individual from the relentless cycle of seeking and using opioids. This stability allows patients to begin reclaiming their lives—rebuilding relationships, returning to work or school, and re-engaging in meaningful activities that bring joy and purpose.

Reframing our understanding of OUD is vital. The American Society of Addiction Medicine (2019) defines addiction as a “treatable, chronic medical disease involving complex interactions among brain circuits, genetics, the environment, and an individual’s life experiences.” It is not a moral failing. The medications we will discuss are not a “crutch” but are analogous to insulin for diabetes or an antihypertensive for high blood pressure—they treat the underlying pathophysiology of a chronic disease.

The Role of Behavioral Interventions

While I am focusing today on the pharmacological aspects of treatment, it is imperative to acknowledge that substance use disorders are psychiatric diagnoses. Behavioral interventions, such as cognitive-behavioral therapy (CBT), dialectical behavior therapy (DBT), contingency management, and participation in support groups, are mainstays of comprehensive treatment. These therapies help individuals develop coping skills, address underlying trauma, change thought patterns, and build a supportive recovery network.

However, I must emphasize that participation in a behavioral program should not be a prerequisite for receiving evidence-based medical treatment. Patients present at various stages of readiness and with different capacities to engage in intensive therapy. To be effective clinicians, we must meet people where they are. Our primary goal is to provide the type and level of treatment they are interested in and able to receive when they present for care. For many, stabilizing on medication is the first and most crucial step, creating the foundation upon which further therapeutic work can be built.

The Pharmacology of Opioid Medications: A Tale of Three Receptors

To truly grasp how these medications work, we need to journey into the brain and understand their interaction with a specific type of receptor: the mu-opioid receptor. These receptors are part of the body’s natural pain-relief system. When activated, they modulate a wide range of physiological functions, including pain perception, mood, and, critically, respiration.

The medications used for OUD can be categorized based on how they interact with these mu-opioid receptors. Let’s visualize this with a graph.

 

Imagine a graph where the vertical Y-axis represents the percentage of mu-receptor intrinsic activity, or the “opioid effect,” ranging from 0% to 100%. The horizontal X-axis represents the drug dose, increasing from left to right.

The Full Agonist: Methadone

The top curve on our graph represents a full agonist, such as methadone or other prescription opioids like oxycodone and heroin.

• Mechanism: As you increase the dose of a full agonist, you get a corresponding, dose-dependent increase in mu-opioid receptor activity. This continues until the maximum possible opioid effect is achieved.
• Clinical Effect: This linear relationship means that higher doses produce stronger effects—more pain relief, more euphoria, and, dangerously, more respiratory depression. There is no “ceiling” to these effects, which is why high doses of full agonists carry a significant risk of fatal overdose.

The Partial Agonist: Buprenorphine

The middle line on our graph represents a partial agonist, the category buprenorphine falls into.

• Mechanism: When you administer buprenorphine, it also binds to and activates the mu-opioid receptors. At lower doses, increasing the dose produces an increasing opioid effect, similar to a full agonist. However, as the dose gets higher, something remarkable happens: the effect begins to plateau.
• The “Ceiling Effect”: Even when buprenorphine has bound to and occupied all available mu-opioid receptors, it can never produce the maximum opioid effect. This is known as the ceiling effect. This plateau occurs at a level of receptor activation that is well below the threshold for significant respiratory depression (Walsh et al., 1994).
• Safety Profile: This ceiling effect is the key to buprenorphine’s remarkable safety profile. It makes it incredibly difficult, if not impossible, to cause a fatal overdose from buprenorphine alone in an opioid-tolerant individual. The risk of respiratory depression is substantially lower than with full agonist opioids. This built-in safety mechanism is a primary reason why it has become a first-line treatment for OUD.

The Antagonist: Naltrexone

Finally, the bottom curve, hugging the X-axis, represents an opioid antagonist, such as naltrexone.

• Mechanism: Naltrexone has a very high affinity, or “stickiness,” for the mu-opioid receptor. It binds tightly to the receptor but does not activate it. It effectively occupies the receptor, blocking any other opioid (like heroin or fentanyl) from binding and producing an effect.
• Clinical Effect: Regardless of the dose, naltrexone produces zero mu-opioid activity. It does not provide any pain relief, does not cause euphoria, and does not cause respiratory depression. Its sole function in this context is to block the effects of other opioids.

Understanding these three distinct mechanisms—full agonist, partial agonist, and antagonist—is fundamental to selecting the right medication for the right patient and using it safely and effectively.

Buprenorphine in Detail: Formulations and Clinical Use

Now, let’s focus specifically on buprenorphine, as its unique properties make it a versatile and widely used tool in both addiction medicine and pain management.

A Note on Terminology: Mono-products vs. Combination Products

The term “buprenorphine” is often used as a catch-all, but it’s important to be precise about the specific formulation.

• Buprenorphine-Only (Mono-products): These products contain only buprenorphine as the active ingredient.

• • Subutex: A sublingual tablet approved for OUD.
  • Butrans: A transdermal patch applied to the skin, approved only for chronic pain.
  • Belbuca: A buccal film placed on the inside of the cheek, approved only for chronic pain.

• Buprenorphine/Naloxone (Combination Products): These products contain both buprenorphine and naloxone.

• • Suboxone: The most well-known brand name, available as a sublingual film or tablet.
  • Zubsolv, Bunavail: Other brand-name combination products with different bioavailability and formulations.
  • Generic versions are also widely available.

All of these combination products are approved for the treatment of opioid use disorder.

The Role of Naloxone in Combination Products

A common point of confusion is the purpose of the naloxone in products like Suboxone. It is crucial to understand that the naloxone component is not readily absorbed when the medication is taken sublingually (under the tongue) as directed.

The naloxone is included as an abuse deterrent. Here’s how it works:

• If a patient takes the medication as prescribed, the buprenorphine is absorbed into the bloodstream through the rich network of blood vessels under the tongue, and it exerts its therapeutic effect. Naloxone passes through the digestive system largely unabsorbed and remains inactive.
• However, if an individual crushes the tablet or dissolves the film and injects it intravenously, the naloxone would be fully bioavailable. Naloxone is a potent opioid antagonist (like naltrexone, but shorter-acting). When injected, it would rapidly displace any opioids from the mu-receptors, including the buprenorphine itself, and immediately trigger a severe, intensely unpleasant state of precipitated withdrawal.

This risk of precipitated withdrawal is intended to deter diversion and injection of the medication.

When to Use the Mono-Product (Buprenorphine-Only)

Despite the abuse-deterrent properties of the combination product, there are legitimate clinical reasons to prescribe the mono-product (e.g., Subutex) for a patient with OUD. Even when taken sublingually, a small amount of naloxone might be absorbed, or the formulation itself can cause side effects in some sensitive individuals. These can include:

• Headaches
• Gastrointestinal (GI) upset, such as nausea or constipation

From my clinical experience, I have a very low threshold for switching a patient from a combination product to a mono-product if they report these side effects. The goal of treatment is to help the patient feel well and stable, and if the medication itself causes discomfort, it can be a barrier to adherence and recovery. However, prescribing the mono-product can come with challenges from insurance coverage and provider reticence, which may require prior authorization and a clear plan for continuity of care.

A Summary of Indications

To clarify the landscape of buprenorphine products:

Indication	Approved Buprenorphine Formulations
Opioid Use Disorder (OUD) & Opioid Withdrawal	Subutex (sublingual), Suboxone (sublingual), Sublocade (monthly injection), Brixadi (weekly/monthly injection)
Chronic Pain	Butrans (transdermal patch), Belbuca (buccal film)
Acute Pain (typically in a hospital/monitored setting)	Buprenex (injectable)
Off-Label Use for Chronic Pain (often in complex patients with OUD)	Subutex and Suboxone are frequently used off-label for chronic pain, especially in patients with co-occurring OUD or complex persistent opioid dependence.

Proper Administration of Sublingual Formulations

Correct administration is key to the effectiveness of the sublingual tablets and films. I always take the time to counsel my patients on this process:

1. Placement: Place the tablet or film under your tongue (“sublingual”).
2. Dissolving Time: Allow it to dissolve completely. This should take at least ten minutes. Do not chew, swallow, or move it around.
3. No Talking, Eating, or Drinking: Avoid talking, eating, or drinking while the medication dissolves to maximize absorption.
4. Managing Nausea: Some people experience nausea or an unpleasant taste. If this occurs, it is perfectly acceptable to spit out the accumulated saliva after the film or tablet has visibly dissolved. The medication is absorbed through the mucosal membranes under the tongue, not by being swallowed. This simple trick can significantly improve tolerability.

Initiating Buprenorphine for Opioid Use Disorder: The Critical First Steps

You have evaluated the patient, confirmed the diagnosis of OUD, and decided together that buprenorphine is the right course of action. The next phase—initiation, or “induction”—is arguably the most critical and delicate part of the entire process. Over decades of clinical practice in El Paso, I’ve watched the landscape of opioid use disorder evolve—especially with the rise of illicitly manufactured fentanyl. Today, initiating buprenorphine, a high-affinity partial mu opioid receptor agonist, requires precision, empathy, and a team-based strategy.

The Clinical Problem: Understanding Precipitated Withdrawal

When I initiate buprenorphine in an opioid-dependent patient, I must respect receptor pharmacodynamics. Precipitated withdrawal occurs when buprenorphine’s high affinity displaces a full mu opioid receptor agonist (e.g., fentanyl, heroin, oxycodone) from the receptor, but because buprenorphine is a partial agonist, the net opioid effect falls sharply. Clinically, this leads to a rapid surge in objective withdrawal signs—often described by patients as the worst withdrawal they have ever felt—and at least a 5-point rise on the Clinical Opioid Withdrawal Scale (COWS).

Patients tell me this feels like:

• Extreme restlessness and anxiety
• The urge to jump off the exam table and leave
• Nausea, vomiting, diarrhea
• Pupillary dilation, gooseflesh (piloerection), sweating, yawning, rhinorrhea

Why do I care so much? Because a single instance of severe precipitated withdrawal can erode trust, derail stabilization, and push the patient back into street use, elevating overdose risk. Preventing precipitated withdrawal is essential to patient safety and successful induction. This is not an allergy to buprenorphine; it is a predictable pharmacologic event driven by timing, dose, and receptor occupancy.

The Fentanyl Factor: Why Illicitly Manufactured Fentanyl Changes Everything

Over the last several years, almost all patients using street opioids in our region report exposure to illicitly manufactured fentanyl. Fentanyl is potent and lipophilic—it partitions into fat tissue and leaks back into the bloodstream over time (Huhn & Dunn, 2017). This can mean:

• The timeline to safe buprenorphine initiation is unpredictable. Fentanyl continues to trickle out from fat depots, maintaining enough receptor occupancy to trigger precipitated withdrawal even when we think the patient has “waited long enough.”
• Patients often present with severe restlessness and anxiety as dominant features of fentanyl-related withdrawal, sometimes overshadowing classic physical signs.
• Many individuals have tried buprenorphine before, experienced precipitated withdrawal, and approach another attempt with fear and strong preferences.

In my practice, I discuss these realities openly. We co-design an initiation strategy based on their history, the pattern of use, how they feel, and the clinical setting. Fentanyl demands flexibility.

Pre-Initiation Counseling and Shared Decision Making

Before the first dose is ever given, a thorough informed consent discussion must take place. This is a cornerstone of shared decision-making. I lean on shared decision-making because it centers the patient’s lived experience and priorities. Research and field observations support that patients do best when they understand options, feel empowered to choose, and we anticipate and validate the emotional complexity of withdrawal (ASAM, 2023).

Key Counseling Points:

• Nature of the Medication: Clearly explain that buprenorphine is a form of opioid and that they will become physically dependent on it. This is an expected and manageable aspect of the treatment.
• Challenges with Discontinuation: Be transparent that tapering off buprenorphine can be a long and challenging process.
• The Risk of Precipitated Withdrawal: This is the most important concept to explain for a successful induction.
• Dental Side Effects: The FDA (2022) has warned about potential dental problems. I counsel patients that this risk can be mitigated by swishing with water after the medication has dissolved and practicing good oral hygiene.
• Drug Interactions and Safety: Warn patients about the increased risk of sedation and respiratory depression if they combine buprenorphine with other central nervous system depressants, particularly alcohol and benzodiazepines.

I also consider the patient’s overall health status, especially regarding liver impairment, as the liver metabolizes buprenorphine. For pregnant individuals, buprenorphine is the standard of care, with the mono-product generally preferred.

Key Considerations for Patient-Centered Buprenorphine Transition

The decision-making process must be a collaborative dialogue. Here are critical factors I consider when crafting an initiation plan:

• Psychosocial Situation and Support Systems: A strong support system can be an anchor. A patient in an unstable environment may require more intensive monitoring.
• Past Experiences with Initiation: If they previously experienced severe precipitated withdrawal, I address their fears and explain how a different approach can mitigate that risk.
• Distress Tolerance and Motivation Level: A highly motivated patient might be an excellent candidate for a low-dose initiation to remain functional.
• Clinical Setting: An inpatient/hospital setting allows for maximum control, while an outpatient or ED setting requires a clear, detailed home plan.
• Concurrent Substance Use: I always ask about benzodiazepines, alcohol, or other sedating substances due to the significantly increased risk of respiratory depression. This conversation is about safety, not judgment.
• Safe and Private Environment: I ask patients, “Do you have a safe place to stay? Do you have access to a bathroom?” Withdrawal involves significant GI distress. I also suggest comfort measures like a hot shower or bath, which many patients report provides significant relief from muscle aches.

Clinical Framework: Three Approaches to Buprenorphine Initiation

I use three primary strategies for buprenorphine initiation, especially in the fentanyl era. There is no single “best” method; the most effective approach is individualized via shared decision-making.

Objective Assessment: Using COWS and Patient Experience Together

The Clinical Opioid Withdrawal Scale (COWS) is a tool I use to evaluate 11 items, including restlessness, pupil size, and GI upset. However, I also listen for dominant anxiety, inability to sit still, and feelings of impending doom. Especially with fentanyl exposure, subjective anxiety and restlessness may ramp up before other signs. My protocols recognize this pattern.

Symptom-Targeted Adjunctive Medications: Why I Use Them

During initiation, targeted symptom relief can smooth the process. If there are no contraindications, I often prescribe:

• Clonidine: An alpha-2 adrenergic agonist that reduces autonomic hyperactivity and anxiety by dampening noradrenergic discharge from the locus coeruleus (Minozzi et al., 2011).
• Tizanidine: For muscle cramps or diffuse pain.
• Hydroxyzine: For anxiety, restlessness, and sleep onset.
• Trazodone: Supports sleep architecture.
• NSAIDs or Acetaminophen: For stiffness and somatic pain.
• Ondansetron: For nausea and vomiting.
• Loperamide: For diarrhea without central effects.

Traditional Initiation: Rationale, Timing, and Limitations

Traditional initiation—starting buprenorphine once the patient is in mild-to-moderate withdrawal—was standard before fentanyl. I still consider it for patients switching from short-acting agonists like heroin or oxycodone.

• Timing Since Last Use: For short-acting opioids, ~12–24 hours; for methadone, ~24–72 hours; for fentanyl, often at least ~48 hours. The challenge is that many fentanyl-exposed patients struggle to reach this threshold.
• Initial Dosing: Start at 2–8 mg, then repeat small doses every 2–4 hours up to 16–24 mg on day one.
• Disadvantages: Higher risk of precipitated withdrawal with fentanyl exposure. In 2026, most of my fentanyl-exposed patients prefer alternatives.

Low-Dose Initiation (Microdosing): Gradual Receptor Transition

With low-dose initiation, I gently introduce buprenorphine at very small doses while the patient continues taking full agonists. Over several days, buprenorphine’s high affinity allows it to accumulate at mu receptors without abruptly displacing full agonists. This approach, also known as the Bernese method (Hämmig et al., 2016), targets the fentanyl problem head-on.

• Why It Works: Buprenorphine’s slow accumulation allows progressive replacement of full agonists, and the steady-state partial agonism stabilizes receptor signaling before discontinuing street opioids.
• Four-Day Ambulatory Example:

• • Day 1–3: Very low buprenorphine doses (e.g., starting at 0.5 mg total) in divided intervals. Patient continues full agonist use.
  • End of Day 3: Buprenorphine typically reaches ~8 mg/day.
  • Day 4: Stop full agonist; continue buprenorphine at therapeutic dosing.

• Advantages: Lower risk of precipitated withdrawal; highly preferred by many fentanyl-exposed patients.
• Disadvantages: Requires splitting films/tablets and complex instructions. Outpatient success rates can vary.
• My Observations: In my clinic, low-dose protocols succeed with clear expectations, daily contact, and explicit harm-reduction planning. They have been a game changer amid fentanyl’s dominance.

High-Dose Initiation: Rapid Stabilization with Clear Criteria

Pioneered by programs like California Bridge, this protocol is common in urgent care and ED settings.

• Clinical Criteria Before High-Dose Start:

• • Time since last use: For fentanyl, at least ~12 hours.
  • COWS> 16.
  • At least two objective signs (e.g., dilated pupils, piloerection).

• Protocol:

• • Administer 8–16 mg buprenorphine initially (16 mg often preferred for fentanyl).
  • Observe for ~30 minutes.
  • If tolerated, give an additional 8 mg as needed, up to 32 mg on day one.

• Advantages: Rapid transition; simple dosing.
• Disadvantages: If precipitated withdrawal occurs, it can be severe due to the higher initial dose.
• My Clinical Use: This is excellent when the patient is medically monitored, can demonstrate objective withdrawal, and wants a fast pathway.

Planning for Long-Term Success: Dosing, Follow-Up, and Injectables

Initiating buprenorphine is only the first step. A robust plan for follow-up and long-term management sustains recovery.

Dosing in the Fentanyl Era

A critical observation is that standard buprenorphine doses are often insufficient for patients with high fentanyl use. To manage cravings effectively, many require doses greater than 24 mg/day. Recognizing this, the FDA recently adjusted its approval for buprenorphine dosing, considering up to 32 milligrams daily acceptable in specific cases. Most insurance providers are beginning to align with this guidance.

The Rise of Long-Acting Injectable Buprenorphine

A significant advancement has been long-acting injectable (LAI) buprenorphine, which is becoming a new standard of care for many.

• Sublocade® (Buprenorphine Extended-Release): A monthly subcutaneous injection. Patients must first be stabilized on sublingual buprenorphine (at least 8 mg/day) for a minimum of 7 days. Counsel patients that Sublocade does not reach a steady state for four to six months, and supplemental sublingual dosing is often needed during this period.
• Brixadi® (Buprenorphine Extended-Release): Offers both weekly and monthly injections. There is growing evidence for direct initiation onto the weekly Brixadi injection in patients in active withdrawal. Like Sublocade, supplemental dosing may be needed initially.

LAIs provide more consistent plasma concentrations, eliminating the peaks and troughs of daily sublingual dosing. This stability can improve adherence, treatment retention, and craving control. However, disadvantages include injection site reactions, cost, and complex billing procedures.

Buprenorphine in Special Populations: A Nuanced Approach

• Pregnant Patients: Initiating or continuing buprenorphine is the recommended standard of care. Either sublingual formulation is considered safe, but the LAI form is not yet FDA-approved for use in pregnancy. Due to faster metabolism, pregnant patients often require higher and/or split doses.
• Perioperative Patients: The unequivocal best practice is to continue the buprenorphine throughout the entire perioperative period. Discontinuing it is dangerous and can precipitate withdrawal, increase relapse risk, and complicate pain management.
• Adolescents: Buprenorphine is FDA-approved as a first-line treatment for OUD in adolescents aged 16 and older. A dose of at least 8 milligrams is generally required to achieve opioid blockade, protecting against the euphoric effects of other opioids and overdose.

Methadone: The Gold Standard with Stringent Guidelines

While buprenorphine is more accessible, methadone remains a highly effective option, particularly for patients with a long history of high-dose opioid use.

• Pharmacology: Methadone is a long-acting full agonist opioid. It has a very long and variable half-life (8 to 65 hours), so it can take four to seven days to reach a steady state. This requires very cautious, slow dose titration.
• QTc Prolongation: Methadone prolongs the QTc interval. A reasonable practice is to check a baseline QTc before starting and to have a careful risk-benefit discussion with the patient if it increases significantly with dose escalations.
• Regulatory Considerations: In the outpatient setting, methadone for OUD must be dispensed from a federally licensed Opioid Treatment Program (OTP). During a hospitalization, hospital-based providers can initiate or adjust methadone. Federal law allows a hospital to dispense up to a three-day supply upon discharge to bridge the patient to their first OTP appointment.

A Brief Look at Naltrexone

Naltrexone is an FDA-approved full opioid antagonist that works by completely blocking the mu-opioid receptor.

• Clinical Use: While it effectively protects against overdose, naltrexone is not a preferred first-line treatment for most patients because it does not treat withdrawal symptoms or cravings. This leads to lower rates of treatment retention.
• Initiation Protocol: A patient must be completely opioid-free for 7 to 10 days before starting naltrexone to avoid severe precipitated withdrawal.
• Dosing: It is available as a daily oral tablet (50 mg) or a long-acting monthly intramuscular injection (Vivitrol®, 380 mg).
• Important Counseling Point: Naltrexone will block the effects of any opioids needed for legitimate pain management, which requires careful planning with surgical teams.

The Role of Buprenorphine in Modern Chronic Pain Management

Buprenorphine is also reshaping the landscape of chronic pain treatment, offering a safer and more effective alternative to long-term full agonist opioids for the right patient.

Unique Analgesic Properties of Buprenorphine

• Partial Mu-Agonism and Ceiling Effect on Respiratory Depression: As discussed, its partial agonism provides a ceiling effect on respiratory depression, making it substantially safer than full agonists.
• Kappa and Delta Receptor Activity: Buprenorphine acts as an antagonist at the kappa opioid receptor, which is associated with dysphoria and stress. By blocking this receptor, it may contribute to an improved mood. Its activity at the delta opioid receptor may also add to its analgesic and antidepressant effects.
• Clinical Advantages: Compared to full agonists, buprenorphine has a reduced risk of hyperalgesia, less sedation, lower potential for physical dependence, a milder withdrawal syndrome, and a lower risk of long-term side effects like falls, hypogonadism, and cognitive impairment.

Identifying the Right Candidates for Buprenorphine Therapy for Pain

Transitioning a patient to buprenorphine for chronic pain requires a systematic approach.

1. Step 1: Rule Out Active Opioid Use Disorder (OUD): It is critical to differentiate between physical dependence and OUD, which involves a compulsive pattern of use and loss of control. If OUD is present, the patient should be managed primarily for their substance use disorder.
2. Step 2: Exhaust All Non-Opioid and Less Risky Options: Before considering buprenorphine, other strategies must be tried. This includes integrative chiropractic care, physical therapy, non-opioid medications, interventional procedures, and lifestyle approaches.
3. Step 3: Consider Specific Patient Categories Who May Benefit:

• • Patients with inadequate analgesia from non-opioid options.
  • Patients at high risk from full agonist opioids (e.g., the elderly, patients with sleep apnea).
  • Patients struggling with an opioid taper who are physically dependent but not misusing their medication.

Choosing the Right Buprenorphine Formulation for Pain

The choice is driven by the patient’s recent opioid history, calculated in Morphine Milligram Equivalents (MME).

• For Opioid-Naïve Patients or those on < 100 MME/day: Transdermal buprenorphine (Butrans patch) or buccal buprenorphine (Belbuca film) are appropriate.
• For Patients on > 100 MME/day OR with co-occurring OUD: Sublingual buprenorphine (often off-label for pain) is indicated, as the other formulations are likely not strong enough.

Formulations and Dosing for Chronic Pain

• Butrans (Transdermal Patch): Delivers a continuous low dose over seven days. It is best for patients on < 80 MME/day. The starting dose is 5-10 mcg/hour, with a maximum dose of 20 mcg/hour. It can take up to 72 hours to reach steady state. Patients must be counseled to rotate patch sites and avoid applying direct heat to the patch.
• Belbuca (Buccal Film): Dosed every 12 hours with higher bioavailability (46-65%).Suitable for patients on up to 160 MME/day. Starting doses range from 75 mcg to 300 mcg every 12 hours, with a maximum of 900 mcg every 12 hours.
• Off-Label Sublingual Buprenorphine: For patients on > 160 MME/day or who have failed other formulations, off-label use of Suboxone or Subutex can be considered for pain management. These are often less expensive.

It is vital to set realistic expectations with patients, as the full analgesic effect with buprenorphine can take up to two weeks to achieve.

Integrative Chiropractic Care and Functional Medicine: The Recovery Foundation

Many patients pursuing buprenorphine initiation are also navigating pain, movement dysfunction, and autonomic imbalance. My chiropractic practice integrates with medical oversight to address these components safely.

The Physiological Rationale for Chiropractic Integration

• Opioid withdrawal amplifies sympathetic tone. Gentle manual therapy can downregulate sympathetic output via mechanoreceptor activation.
• Targeted soft tissue work and mobilization can reduce spinal hypertonicity and nociceptive signaling that contribute to pain and stress.
• Proprioceptive input from joint and soft tissue work improves body schema and reduces threat signals, helping patients reinterpret bodily sensations more calmly.
• Movement-based afferent modulation helps restore balance between cortical control and subcortical autonomic responses.

During induction, I focus on low-velocity, low-amplitude mobilization and breath work to minimize stress. From my clinical observations, patients report better tolerance of initiation, reduced anxiety, and improved sleep when we add gentle movement and bodywork.

Functional Medicine Integration: Stabilizing Physiology for Recovery

Functional medicine supports the terrain of recovery by focusing on:

• Nutrition: Ensuring adequate protein, micronutrients (magnesium, B vitamins), and hydration to support neurotransmitter synthesis and reduce inflammation.
• Sleep Hygiene: Structuring circadian cues to restore sleep architecture.
• Stress Physiology: Using targeted interventions (breath pacing, mindfulness) to recalibrate HPA axis output and reduce the allostatic load.
• Inflammation and Metabolic Health: Correcting deficiencies and addressing root causes of inflammation that contribute to pain and mood dysregulation.

Recovery is not only about stopping opioids; it is about restoring physiologic resilience.

Harm Reduction: A Compassionate and Practical Approach to Patient Safety

Harm reduction is an evidence-based, compassionate public health philosophy aimed at reducing the negative consequences associated with substance use. It accepts that abstinence is not for everyone and meets people “where they are.”

Key Harm Reduction Messages for Patients

When a patient discloses ongoing illicit use, shaming is counterproductive. I pivot to a conversation about safety.

1. Assume All Illicit Drugs Contain Fentanyl: The illicit drug supply is incredibly dangerous. I tell patients, “It is very likely that any illicit substances you might encounter contain fentanyl. There is an extremely high risk of overdose.”
2. Naloxone (Narcan) is Essential: I tell patients, “I want you to have Narcan and carry it like you would your phone or your keys.” I prescribe naloxone to every patient on MOUD and to those on full agonist opioids for pain.
3. Safer Use Practices: Smoking vs. Injecting: While no method is “safe,” some carry lower risks. I explain, “Smoking fentanyl carries a lower risk of overdose and a lower risk of transmitting infectious diseases like HIV and Hepatitis C than injecting it.“
4. Hygienic Injection Technique: For patients who inject, I provide non-judgmental education: “always cleaning your skin… always using new, sterile syringes… and making sure that you are never sharing any equipment.”

Embracing a harm reduction framework is about prioritizing life and health over judgment. It is a fundamental part of providing compassionate and effective care.

For more on my clinical approach and observations:

• healthcoach.clinic
• linkedin.com/in/dralexjimenez

With that, I will conclude our educational presentation. Thank you so much for taking the time to journey through this important topic with me. I hope these insights will be valuable in your own practice and for your own health.

References

1. American Society of Addiction Medicine. (2019). Definition of Addiction. ASAM.
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3. American Society of Addiction Medicine. (2023). Clinical considerations for buprenorphine initiation in the era of fentanyl. ASAM.
4. ASAM. (2023). Shared decision-making in OUD care: clinical tools and patient-centered communication. ASAM.
5. California Bridge Program. High-dose buprenorphine protocols for emergency and urgent care settings.
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8. Larochelle, M. R., Bernson, D., Land, T., Stopka, T. J., Wang, N., & Xuan, Z. (2018). Medication for opioid use disorder after nonfatal opioid overdose and association with mortality: a cohort study. Annals of Internal Medicine, 169(3), 137–145. doi.org/10.7326/M17-3107%5D(https://www.annals.org/aim/fullarticle/2723386/medication-opioid-use-disorder-after-nonfatal-opioid-overdose-subsequent)
9. Lintzeris, N., et al. (2021). High-dose buprenorphine induction in emergency settings: outcomes and tolerability. Journal of Substance Abuse Treatment, 122, 108247.
10. [Mattick, R. P., Breen, C., Kimber, J., & Davoli, M. (2014). Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database of Systematic Reviews, (2). doi.org/10.1002/14651858.CD002207.pub4%5D(https://www.nejm.org/doi/full/10.1056/NEJMoa1706785)
11. Minozzi, S., Amato, L., Bellisario, C., Ferri, M., & Davoli, M. (2011). Clonidine, lofexidine, and similar medications for the management of opioid withdrawal. Cochrane Database of Systematic Reviews, 2011(2), CD002024.
12. Nunes, E. V., et al. (2018). Strategies for the treatment of opioid use disorder: buprenorphine best practices. The Lancet Psychiatry, 5(5), 392–403.
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14. Substance Abuse and Mental Health Services Administration. (2021). Treatment Improvement Protocol (TIP) Series, No. 63: Medications for Opioid Use Disorder. SAMHSA.
15. U.S. Food and Drug Administration. (2022, January 12). FDA warns about dental problems with buprenorphine medicines dissolved in the mouth to treat opioid use disorder and pain. FDA.
16. Volkow, N. D., & Blanco, C. (2023). Fentanyl and the evolving opioid crisis: clinical implications. New England Journal of Medicine, 388(9), 793–795.
17. Akeman, S. E., & Barnett, M. L. (2020). Primary care and the opioid-overdose crisis—buprenorphine myths and realities. JAMA Internal Medicine, 181(3), 291-292. doi.org/10.1001/jamainternmed.2020.6272%5D(https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2773533)
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19. Winstock, A. R., & Lintzeris, N. (2020). Buprenorphine initiation strategies in the age of fentanyl: clinical adaptations. Drug and Alcohol Review, 39(3), 236–241.

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