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

2. 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

3. 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 mg q 6-8 hours parenteral and 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.
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NOTE: Additional information on the treatment of patients who suffer from chronic pain can be found in the Appendix to this section.

4. 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

5. 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

6. 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.

7. 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

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

9. 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

10. 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)

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

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

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

17. 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

18. Cold-pressor Withdrawal Latency

19. Cold-pressor withdrawal latency

20. “In God we trust; for every one else, give us data”. The FDA