Pain Management: Patients Maintained on Buprenorphine Karen Miotto, M.D. Integrated Substance Abuse Program UCLA 2001

General points regarding pain treatment Acute and Chronic Pain Patients General points regarding pain treatment Treatment of acute pain in patients maintained on buprenorphine Treatment of chronic pain in patients with opioid dependence

General Points Regarding Pain Treatment Buprenorphine is an effective analgesic, but duration of analgesia is relatively short (necessitating multiple dosing daily) In United States, sublingual form has not been developed for analgesic purposes Usual dose regimens are 0.3-0.6 mg q 6-8 hours parenteral and 0.2-0.4 mg q 6-8 hours sublingual 1. It is probable that the sublingual form of buprenorphine could be used for the treatment of pain. However, in the United States this formulation has not been developed for such an indication. (In other countries, a sublingual form of buprenorphine is available for use in the treatment of pain.) In the United States, only the injectable form of buprenorphine is approved for the treatment of pain. 2. If sublingual buprenorphine were used for the treatment of pain, then the dosing frequency would need to be increased. Buprenorphine’s analgesic duration is only a few hours. 3. The treatment of pain in patients maintained on buprenorphine can be complicated, as will be discussed further in the next slides. ***************** NOTE: Additional information on the treatment of patients who suffer from chronic pain can be found in the Appendix to this section.

Treatment of acute pain in patients maintained on buprenorphine Acute and Chronic Pain Patients General points regarding pain treatment Treatment of acute pain in patients maintained on buprenorphine Treatment of chronic pain in patients with opioid dependence

Buprenorphine Bell-shaped dose response curve has been reported for the analgesic effects Relative potency estimates of buprenorphine’s clinical analgesic effects IM buprenorphine 25 x more potent and sublingual 15 x more potent than IM morphine Longer duration of interaction with the receptor contributes with apparent potency ratio Variable reports of analgesic equivalents

Acute pain is not addressed by the maintenance dose of the opioid Acute Pain in Buprenorphine Maintained Patients Make sure some form of opioid maintenance medication is continued (buprenorphine, methadone, LAAM) Acute pain is not addressed by the maintenance dose of the opioid If maintaining patient on buprenorphine, initially try non-opioid analgesics 1. For the buprenorphine-maintained patient experiencing acute pain, management of the pain should first be attempted with non-opioid analgesics. 2. If these are not sufficiently effective, then opioid analgesics can be used; however, it is important to keep in mind the potential for buprenorphine to precipitate withdrawal in a person receiving full agonist opioids (such as morphine). Thus, it may be prudent to switch the patient from buprenorphine maintenance to an alternate maintenance medication, such as methadone. 3. The patient’s acute pain will not be treated by their once daily maintenance dose of buprenorphine. Other management of pain will be required.

Acute Pain in Buprenorphine Maintained Patients Use some form of opioid maintenance medication Acute pain in hospitalized patient provide analgesia as indicated for the condition Caution: avoid high dose analgesic medication compounded with acetaminophen in patient with Hepatitis B or C consider maintenance with methadone

Acute vs Chronic Pain Acute pain serves to preserve life Chronic pain serves no such purpose Chronic pain sufferers suffer for nothing!

Chronic Pain Patients If patient will require opioids for treatment of chronic pain Require high potency opioids: consider the use of methadone or LAAM as the treatment for opioid dependence Avoids complications of possible precipitated withdrawal by buprenorphine Require low potency opioids: monitor use as part of recovery program Opioids are ideally used as part of a comprehensive pain/addiction program

Buprenorphine Partial agonist may antagonize the effects of a previously administered agonist depending on proportion of receptors occupied time interval between the administration of the two drugs Example: Buprenorphine was compared with naloxone for reversal of prepoperative fentanyl (Boysen K et al 1988)

Addicts in Pain An addict in pain suffers thrice: Once from his disease Once from his addiction Once from his physician’s ignorance

Pain in Chronic Opioid-maintained Patients Lessons from methadone Neuropathic pain

Diminished pain tolerance in methadone-maintained patients as compared to controls Compton et al., 1999 p < .002

Pain in Buprenorphine-maintained Patients Pain response in buprenorphine-maintained patients Added analgesia with other opiates and non-opiates Acute pain in buprenorphine-maintained patients Chronic pain in buprenorphine-maintained patients

Cold-pressor Withdrawal Latency

Cold-pressor withdrawal latency

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