1. Acute Pain Management for Patients Receiving Buprenorphine Therapy
Relatively Painless:
Acute Pain Management for Patients Receiving Buprenorphine Therapy
Kimmy Nguyen, PharmD
PGY-1 Pharmacy Practice Resident
Corporal Michael J. Crescenz VA Medical Center
May 2017

2. Financial Disclosures
I have not received any commercial or financial support for this program. I will not discuss off-label or investigational use of medications.

3. Objectives
Identify treatment options for acute pain management in the post-operative setting for patients receiving buprenorphine therapy for opioid use disorder (OUD)
Describe re-induction protocol when restarting buprenorphine therapy

4. Case Vignette
LC is a 46-year-old male with a PMH of depression, anxiety, alcohol/benzodiazepine/opioid use disorder and squamous cell carcinoma of the left temporal bone scheduled for a left ear mastoidectomy. He recently underwent opioid detox and was started on Suboxone® (buprenorphine 4 mg/naloxone 1 mg) once daily. What should be done with the buprenorphine/naloxone to ensure adequate pain management during and after the procedure?

5. Opioid Use Disorder (OUD)
DSM-5 Diagnostic Criteria
Cravings
Tolerance
Withdrawal
Continued use despite adverse consequences
Persistent or unsuccessful efforts to cut down on use
Large amount of time spent obtaining, using, or recovering
Opioids taken in larger amounts or for longer than intended .
Category
Criteria
Timeframe
Mild
2 – 3
Within a
12-month period
Moderate
4 – 5
Severe ≥6
American Psychiatric Association. DSM
Kasper D, et. al. Harrison’s Principles of Internal Medicine, 19e
Diagnostic and Statistical Manual of Mental Disorders

6. Opioid Statistics (2015)
33,091 opioid-related deaths/year  91 deaths/day
3,264 deaths in Pennsylvania
Prescription opioids: >15,000 deaths
Heroin: Approximately 13,000 deaths
Top 5 states with the highest rates of overdose deaths: 1 WV
41.5 per 100,000 2 NH
34.3 per 100,000 3 KY
29.9 per 100,000 4 OH
29.9 per 100,000 5 RI
28.2 per 100,000
Centers for Disease Control and Prevention. MMWR MorbMortal WklyRep. 2016:65(50-51);

7. Treatment of OUD Opioid Agonist Opioid Antagonist
Buprenorphine
Methadone
Opioid Antagonist
Naltrexone
Psychosocial Treatment
American Psychiatric Association. DSM
Kasper D, et. al. Harrison’s Principles of Internal Medicine, 19e

8. Common Misconception = FALSE Maintenance opioid agonists
provide adequate analgesia
Analgesic action: 4-8 hours
Suppression of opioid withdrawal: hours
= FALSE
Alford DP, et. al. Ann Intern Med. 2006;144:
Suboxone®. Prescribing information. Indivior Inc

9. Buprenorphine/Naloxone
Buprenorphine – partial agonist at the mu-opioid receptor and antagonist at the kappa-opioid receptor
Naloxone – antagonist at mu-opioid receptors
Produces opioid withdrawal signs/symptoms in individuals with physical dependence
Suboxone®. Prescribing information. Indivior Inc

10. Opioid Receptor
Full
Opioid
Agonist
Analgesia
Opioid Receptor
Euphoria

11. Withdrawal
Full
Opioid
Agonist
Opioid Receptor
Withdrawal

12. Buprenorphine Buprenorphine Opioid Receptor Full Opioid Agonist Full

13. Case Vignette
LC is a 46-year-old male with a PMH of depression, anxiety, alcohol/benzodiazepine/opioid use disorder and squamous cell carcinoma of the left temporal bone scheduled for a left ear mastoidectomy. He recently underwent opioid detox and was started on Suboxone® (buprenorphine 4 mg/naloxone 1 mg) once daily. Suboxone® was held prior to surgery. After the procedure, the patient was on hydromorphone 8 mg q3h with plans to re-initiate Suboxone® at the same time.

14. The Concern Buprenorphine Opioid Receptor Withdrawal Analgesia Full
Agonist
Opioid Receptor
Analgesia
Withdrawal

15. General Recommendations
Multimodal analgesia
Nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen (APAP)
Analgesic dosing as continuous or scheduled rather than “as needed”
Re-emergence of pain  Unnecessary suffering
Naloxone and respiratory support available as rescue measures
Alford DP, et. al. Ann Intern Med. 2006;144:
Kasper D, et. al. Harrison’s Principles of Internal Medicine, 19e

16. Management Strategies
Buprenorphine + Short-acting opioids
Overcome buprenorphine antagonism at receptor
Buprenorphine alone
Maximum 32 mg/day dosed every 6-8 hours
Switch to methadone + Short-acting opioids
Convert back to buprenorphine or stay on methadone
Mitra S and Sinatra RS. Anesthesiology.2004;101(1):
Alford DP, et. al. Ann Intern Med. 2006;144:
Johnson RE, et. al. J Pain Symptom Manage. 2005;29(3):
Suboxone®. Prescribing information. Indivior Inc

17. Stopping Buprenorphine
Stop buprenorphine
Use opioid analgesics for pain
Higher doses initially to overcome receptor blockade
Restart buprenorphine with guidance from provider trained in buprenorphine therapy for OUD
Alford DP, et. al. Ann Intern Med. 2006;144:
Suboxone®. Prescribing information. Indivior Inc

18. Stop and Restart Method
Stop buprenorphine hours prior to surgery
Give short-acting opioids during and/or after surgery
Re-initiate buprenorphine therapy when pain management allows
Re-start once opioid-free for at least 6 hours
Observable, objective signs of opioid withdrawal
Clinical Opiate Withdrawal Scale (COWS)
Kampman K and Jarvis M. ASAM. 2015;9(5):

19. Restarting Buprenorphine
Day 1: Start with…
buprenorphine 2 mg/naloxone 0.5 mg (2:0.5) OR
buprenorphine 4 mg/naloxone 1 mg (4:1)
Titrate dose based on control of acute withdrawal symptoms every 2-4 hours up to a total dose of 8:2
Day 2: Titrate up to buprenorphine 16 mg/naloxone 4 mg (16:4) once daily
Alford DP, et. al. Ann Intern Med. 2006;144:
Kampman K and Jarvis M. ASAM. 2015;9(5):
Suboxone®. Prescribing information. Indivior Inc

20. Case Vignette
LC is a 46-year-old male with a PMH of depression, anxiety, alcohol/benzodiazepine/opioid use disorder and squamous cell carcinoma of the left temporal bone scheduled for a left ear mastoidectomy. He recently underwent opioid detox and was started on Suboxone® (buprenorphine 4 mg/naloxone 1 mg) once daily. What should be done with the buprenorphine/naloxone to ensure adequate pain management during and after the procedure?

21. When should buprenorphine/naloxone be stopped
Question 1
When should buprenorphine/naloxone be stopped
prior to surgery?
6-12 hours prior to procedure
24-36 hours prior to procedure
48-72 hours prior to procedure
One week prior to procedure

22. Question 2
Which of the following should be done upon buprenorphine/naloxone re-initiation?
Re-start once opioid-free for at least 72 hours
Titrate dose rapidly up to buprenorphine 16 mg/naloxone 4 mg (16:4) once daily on day 1
Re-start in presence of observable signs of withdrawal
Have naltrexone available as a rescue measure

23. Conclusion
Buprenorphine binds with high affinity to displace and prevent other opioids from binding to the receptor
Strategies for acute pain management in the post-operative setting are based on expert opinion rather than high-quality evidence
Naloxone and respiratory support should be available as rescue measures
Consult with provider trained in buprenorphine therapy for OUD

24. Questions

25. References
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, Arlington, VA 2013. 
Kasper D, et. al. Chapter 468e: Opioid-Related Disorders. Harrison’s Principles of Internal Medicine 19th edition
Centers for Disease Control and Prevention. MMWR MorbMortal WklyRep. 2016:65(50-51);
Alford DP, Compton P, Samet JH. Acute pain management for patients receiving maintenance methadone or buprenorphine therapy. Ann Intern Med. 2006;144:
Suboxone® (buprenorphine/naloxone) [prescribing information]. Richmond, VA: Indivior Inc.; Dec 2016.
Mitra S and Sinatra RS. Perioperative management of acute pain in the opioid-dependent patient. Anesthesiology. 2004;101(1):
Johnson RE, Fudala PJ, Payne R. Buprenorphine: considerations for pain management. J Pain Symptom Manage. 2005;29(3):
Kampman K and Jarvis M. American Society of Addiction Medicine (ASAM) national practice guideline for the use of medications in the treatment of addiction involving opioid use. ASAM. 2015;9(5):