SuboxoneAcute pain management in the ED is challenging. For patients on buprenorphine, it can be even more difficult. What if a patient on buprenorphine presents to the ED with a painful condition that requires a short course of opioid therapy?

First, a little pharmacology [1, 2]

  1. Buprenorphine is a partial agonist at the mu-receptor. What this means is that buprenorphine binds to the same receptor as a full agonist, such as morphine, but does not stimulate the receptor as strongly. The classic mu-receptor effects of pain relief, euphoria, and respiratory depression will be less with a partial agonist.
  2. Buprenorphine has very high affinity for the mu-receptor– one of the highest of all the opioids. This means that any other opioid occupying the mu-receptor will be kicked off and replaced by buprenorphine. Thinking clinically, if a patient used heroin (a full agonist) and then was administered buprenorphine  (a partial agonist), the patient would experience withdrawal signs and symptoms. The buprenorphine has a higher affinity than heroin and will replace it at the receptor, providing only partial stimulation.

Potential Issues [3]

  • Patients on buprenorphine actually do not receive adequate analgesia from the maintenance opioid therapy. It’s quite complex as to why this occurs, but may be in part due to the phenomenon of opioid-induced hyperalgesia. That being said, it is probably best to avoid opioids altogether if possible.
  • Do patients taking maintenance opioid therapy have higher rates of relapse if given opioid analgesics for acute pain? There isn’t a whole lot of data on this, and the data that does exist is with methadone (not buprenorphine). Patients do not seem to have increased rates of relapse, but caution is advised.
  • The risk of severe respiratory or CNS depression in

    patients receiving buprenorphine is potentially problematic, but so far has not been clinically demonstrated.

  • Any use of opioids in patients on buprenorphine should be chosen and implemented in close collaboration with the physician treating the patient’s opioid addiction.

Using Opioids for Acute Pain [3]

Non-opioid options should first be considered in patients on buprenorphine presenting with acute pain. Some would argue that if the pain is severe enough to require opioids, the patient probably should be admitted. If it is determined that a patient absolutely must have a short course of opioid therapy, there are several options to manage this complex situation depending on the anticipated duration of pain, treatment setting, and response to therapy. However, only one approach is potentially feasible for the ED provider caring for a patient who will be discharged: Continue buprenorphine maintenance therapy and titrate short-acting opioid analgesics.

Pearls

  • Expect that a higher dose of opioid will be needed. More is required to compete with and overcome the high affinity of buprenorphine for the mu-receptor. We must be cognizant that this is a slippery slope. Expert consultation is advised and follow up should be soon.
    • Instead of the usual oxycodone 5 or 10 mg every 4-6 hours, 15 or 20 mg may be needed. PO hydromorphone may be another option.
    • The shortest course feasible should be prescribed. If a patient were to stop taking their buprenorphine, its effects would wear off after 24-48 hours. A patient continuing to take a higher opioid dose could experience respiratory and CNS depression without the buprenorphine present to compete for the mu-receptor.
    • The obvious disclaimer here is that individual patients are individual patients. Alford et al state:

“Caution should be taken if the patient’s buprenorphine therapy is abruptly discontinued. Increased sensitivity to the full agonist with respect to sedation and respiratory depression could occur.”

  • Do not use combination products with acetaminophen. The 4 gram daily limit will quickly be exceeded if the patient needs 15 or 20 mg of oxycodone every 4-6 hours. The patient may use acetaminophen concomitantly as a separate product, but be sure to educate them.
  • Arrange follow-up with the patient’s primary care provider and/or pain/addiction specialist as soon as possible.

References

  1. Heit HA, et al. Buprenorphine: new tricks with an old molecule for pain management [pdf]. Clin J Pain 2008;24(2):93-7. [PMID 18209513]
  2. Jones HE. Practical considerations for the clinical use of buprenorphine [pdf]. Sci Pract Perspect 2004;2(2):4-20. [PMID 18552728]
  3. Alford DP, et al. Acute pain management for patients receiving maintenance methadone or buprenorphine therapy [pdf]. Ann Intern Med 2006; 144(2): 127-34. [PMID 16418412]
  4. Johnson RE, et al. Buprenorphine: considerations for pain management. J Pain Symptom Manage 2005;29(3):297-326. [PMID 15781180]
  5. Mercadante S, et al. Safety and effectiveness of intravenous morphine for episodic breakthrough pain in patients receiving transdermal buprenorphine. J Pain Symptom Mange 2006;32(2):175-9. [PMID 16877185]
  6. Center for Substance Abuse Treatment. Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction. Treatment Improvement Protocol (TIP) Series 40. DHHS Publication No. (SMA) 04-3939. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2004.
Bryan D. Hayes, PharmD, FAACT, FASHP

Bryan D. Hayes, PharmD, FAACT, FASHP

Leadership Team, ALiEM
Creator and Lead Editor, Capsules series, ALiEMU
Attending Pharmacist, EM and Toxicology, MGH
Assistant Professor of EM, Harvard Medical School
Bryan D. Hayes, PharmD, FAACT, FASHP

@PharmERToxGuy

EM Pharmacist & Toxicologist @MassGeneralEM | Asst Prof @HarvardMed/@EMRES_MGHBWH | @ALiEMteam leadership | Capsules creator, ALiEMU | President, ABAT | #FOAMed