Treating Acute Pain in Patients Prescribed Buprenorphine Products for Opioid Use Disorders

 

 

 

 

 

 

 

Many physicians still get confused about how to treat acute pain in patients who are prescribed buprenorphine products for opioid use disorder.

While buprenorphine products (whether Suboxone, Subutex, Zubsolv, Bunavail, or the generic forms of these) are partial opioids, when they are prescribed long-term for treatment of opioid use disorder, they don’t work very well for moderate or severe pain. These patients usually also need treatment with short-acting opioids.

Buprenorphine has a high affinity for the opioid receptors in the brain, which means this medication sticks to those receptors like glue. Other opioids, with lower affinities, have more difficult time exerting their effects in the central nervous system. This high affinity for receptors is one feature of buprenorphine that makes it work so well for patients with opioid use disorder, but we’ve worried that it also can complicate the treatment of acute pain in those patients.

If the pain is mild, sometimes pain relief can be improved by splitting the dose of buprenorphine. The anti-withdrawal effect of buprenorphine usually lasts longer than 24 hours. That’s why once -daily dosing works fine for this purpose. However, the analgesic (anti-pain) effect lasts from eight to twelve hours. That’s why patients with both opioid use disorder and chronic pain issues may feel better when they split their doses and take half in the morning and half at night. This approach may also help patients when experiencing mild to moderate acute pain.

Sometimes when patients on medication-assisted treatment for opioid use disorder have mild pain, non-opioid measures can help the patient. For example, many dental procedures are well-treated with anti-inflammatories like ibuprofen, rather than with opioids. Or a long-acting version of Novocain can give sustained numbness to the area.

Any of the three following methods can be used to treat acute pain in buprenorphine patients:

In the past, many experts recommended patients stop their dose of buprenorphine 24-36 hours prior to an expected painful procedure. (Of course, many things happen without warning, so this option isn’t always possible.) Patients were then treated with short-acting opioids such as oxycodone or hydrocodone until the pain situation resolved or improved. After the patient stopped taking short-acting opioids for 12-24 hours, the patient re-started buprenorphine.

Currently, a simpler process is being used. Many experts recommend buprenorphine patients stay on their usual dose and add short-acting opioids on top of the maintenance medication. Patients still get some analgesia, because buprenorphine rarely blocks the effects of other opioids completely.

A third option is to reduce the dose of buprenorphine to 2-8mg per day, then use short-acting opioids on top of this reduced dose. This way, reduction of the buprenorphine allows for some open opioid receptors, but the patient doesn’t have to come off buprenorphine completely. Plus, the buprenorphine still available appears to block some of the euphoria that short-acting opioids may cause.

Some patients do better with one of these options than the others, so I always ask about past experiences.

Years ago, one of my patients dosing on Suboxone films 24mg per day had to have emergency cardiac bypass surgery. I was worried, fearful that he would have inadequate pain relief after this big surgery. But he did very well. He had no significant pain post-operatively, and decided he only needed 8mg per day. He has done very well on this lower dose with no withdrawal.

Problems do arise. Some of my patients tell their other doctors, surgeons for example, that they are taking buprenorphine for pain. Perhaps they are embarrassed to tell these physicians that they are being treated for opioid use disorder, or maybe they are confused. But that information makes the surgeons think I’m going to manage pain postoperatively, which will not be the case. Most times a phone call can straighten out the misunderstanding.

Providers prescribing buprenorphine products need to help their patients manage the supply of short-acting opioids which may be prescribed by other physicians for acute pain. For example, I ask my patients if a dependable person in their household can hold on to the pill bottle and give medication to the patient as prescribed. We don’t want that person to be stingy or to overmedicate – merely to give out the medication as directed on the bottle’s label.

Buprenorphine prescribers can ask the patient to come back earlier than planned, perhaps a few days after a procedure, to check in about how things are going and get an extra counseling session if any cravings are triggered by either the short-acting opioids or the pain.

As I tell other physicians, just because my patients have opioid use disorder doesn’t mean they can never have opioids for acute pain. In some situations, pain medications are essential. But we can mitigate the risk with careful, short-term prescribing and good communication.

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2 responses to this post.

  1. Reblogged this on Wayne Macfadden's WordPress Blog and commented:
    Interesting, as pain control is a often a challenge for physicians treating patients taking buprenorphine

    Reply

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