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Lofexidine, ketamine, cannabinoids: possible alternatives to opiates for chronic pain

SAN DIEGO — Thomas Kosten, MD, Waggoner Chair and Professor of Psychiatry, Pharmacology, Immunology, and Neuroscience, and director of the division of addictions at Baylor College of Medicine, spoke about the potential of nonopioid alternatives for chronic pain in a video interview.

Chronic opioid use can lead to tolerance complications, withdrawal and hyperalgesia. For a patient who has been on opioids for chronic pain, the first thing to do is discontinue the opioids, Kosten said.

“You might think that this is not something that mental health professionals might get much involved with, but unfortunately the primary care doctors who have been managing these types of chronic, low-grade pains over the last 50 years ... are referring them to mental health professionals to get their treatment because they’re considering all of them potential addictive personalities or addictive persons that they’re afraid to get involved with, and manage the opioid withdrawal and any subsequent pain management,” he explained.

Opiate withdrawal can last anywhere from 7 to 10 days and the usual treatment involves discontinuing either by tapering down or another approach of the opiate, but Kosten suggested an alternative approach: take patients who are on a short-acting opiate and transition them to buprenorphine.

According to Kosten, first, discontinue the acute opiate quickly then when the patient begins to show moderate withdrawal symptoms, place them on buprenorphine. After they begin buprenorphine, start them on a fixed dose of lofexidine, which has good safety and efficacy on reliving these symptoms. On day two of lofexidine, when the buprenorphine is discontinued, start naltrexone at a low dose.

After the patient is opiate-free, the most effective treatment for chronic pain is tricyclic antidepressants, like desipramine and duloxetine, Kosten said. These antidepressants will take up to 4 weeks to be fully effective for chronic pain, so the question of what clinicians can do acutely may be addressed with ketamine or cannabinoids.

“I think that it offers some opportunities for management of pain with potentially abusable substances of ketamine and cannabinoids, but at the same time, are relatively safe and probably can be used in patients who have a history of substance abuse as well as having the chronic pain,” he said.

Disclosures: Kosten reports consulting for Alkermes, Opiant and U.S. Worldmeds as well as grant/research support from the U.S. Department of Defense.