In part one of our series we explored the meanings of science and pseudoscience and the risks of confusing one for the other. We are culturally predisposed to trust news of an advanced medical solution because we assume someone has verified the claim. And we’re naturally attracted to answers that are easy to understand and simply applied. This combination makes us susceptible to marketing claims, even when they lack scientific proof.

Take, for example, all the hub bub about approving buprenorphine containing products for the treatment of addiction. The New York Times published an article in July titled, “Senate Approves Bill to Combat Opioid Addiction Crisis.”  The reporter describes one of the major components of this bill as the greater access to medication assisted treatment, particularly buprenorphine. Legislation is a positive step, yet congress is not doing anything about prevention nor stopping the flow of prescription opioids. In fact, buprenorphine is prescription opioids.

There is some promising science on this drug, but claims about it being an “addiction cure” are misleading and there are questions about this treatment approach that should be addressed. Until then, the limited scientific support for the appropriate role of this medication should not be overwhelmed by pseudoscience regarding where it fits among other treatment strategies.

Separating the Help, Hope and Hype

Buprenorphine is a form of medication assisted treatment, similar to methadone, that substitutes one opioid for another. The prescription opioid is provided so that patients do not have to seek out other opioids such as prescription pain medication or heroin to satisfy their craving. Buprenorphine has two unique properties that contribute to the hope and hype. One is that it causes less risk of fatal overdose in adults due to less preponderance to cause respiratory depression. The other is that there appears to be a dose above which it maxes out its effects (a ceiling effect). However, buprenorphine is an opioid that is 20-70 times as strong as morphine, a fact that is not often advertised.

Buprenorphine does not cure opioid dependence or addiction; rather, it trades one powerful opioid for another. It maintains an opioid dependence. Abusers can still overdose when taking benzodiazepines and/or alcohol or when taking other opioids in lieu of their buprenorphine. So, the science is that there are some improvements in the safety profile, and there may be fewer opioid overdose deaths as a result. The pseudoscience is any claim that this is an addiction cure.

Another pro-buprenorphine argument to scrutinize is that access to the drug should be increased by decreasing current controls and limitations on who can prescribe it. This makes sense in the addiction arena where the science suggests that greater access in our heroin or prescription pain medication addiction communities may lead to fewer deaths. The pseudoscience claim is that increased access will have a net community benefit. However, this cannot be assumed.

Access to buprenorphine has until now been controlled and limited to well-trained prescribers and detox programs for close monitoring. Without these restrictions, it will be easier to “just put someone on buprenorphine”—a significant benefit to drug companies. Will we end up with large numbers of people in our communities who became hooked on opioids via the healthcare system and are now forever dependent on buprenorphine? Who will hold health care providers accountable for offering appropriate rehabilitation and detoxification instead of simply maintaining dependence?

The third science versus pseudoscience quandary is particularly important in workers’ compensation claims and concerns the use of buprenorphine in pain management. Similar to other opioids, there is very limited science that buprenorphine is effective in the long-term management of chronic pain. Buprenorphine is largely for addiction, and is not any more effective for chronic pain than currently available ineffective opioids. Yet that does not stop buprenorphine advocates and some providers from using pseudoscience to justify transition to buprenorphine to treat pain.

Most injured workers do not acknowledge an addiction problem, so our industry will have to confront physicians who prescribe buprenorphine for pain because it is “safer” rather than wean the patient off opioids due to ineffectiveness. Buprenorphine causes the same array of physical side effects as other opioids, its use in chronic maintenance therapy maintains addiction, and drug diversion is a risk unless weaning is an eventual part of the treatment plan.

Science suggests that buprenorphine can be a positive tool in the management of opioid use disorder and dependence. Yet, for many, the science is not there to lose our skepticism about the wholesale use among injured workers with chronic pain.

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About the Author

Steven M. Moskowitz, MD, is the Senior Medical Director and supervisor of Paradigm Outcome’s complex pain program. Dr. Moskowitz is a specialist in physical medicine and rehabilitation with clinical expertise in complex musculoskeletal and neurologic rehabilitation including spinal cord injury, multiple sclerosis and chronic pain.