1. Suboxone Cheryl Marks, MS, RN-BC, FNP-BC Nurse Practitioner / Coordinator of Inpatient Pain Management Newton-Wellesley Hospital

2. Addiction Human weakness—a defect in character Result of poor choices Lack of willpower or moral strength

3. Addiction A primary, chronic, neurobiological disease with genetic, psychosocial and environmental factors influencing its development and manifestations. Definition accepted by APS, ASMPN, ASAM

5. Brain-imaging studies from drug-addicted individuals show physical changes in areas of the brain that are critical for judgment, decision making, learning and memory, and behavior control. National Institute on Drug Abuse

6. The 5 C’s of Addiction Loss of control Loss of control Compulsive use Compulsive use Continued use despite negative consequence Continued use despite negative consequence Craving Craving Chronicity Chronicity Management of Chemical Dependence in Pregnancy Clinical Obstetrics and Gynecology 2008

8. Additional Risk Factors Partner with history of or active addiction Peer group Depression / mental illness History of trauma / sexual abuse Homeless Domestic violence

9. Fears of Patients with Addiction I won’t be believed I will be ignored and judged I won’t be cared for like other patients

10. Addiction is a Disease of Guilt and Shame

11. Addiction vs Dependence Physical dependence may occur with the chronic use of any substance. It occurs because the body naturally adapts to chronic exposure to a substance (e.g., caffeine or a prescription drug), and withdrawal will occur if stopped abruptly. National Institute on Drug Abuse

12. Tolerance Require more medication for pain relief

13. Figure 5.2 Past Year Initiates of Specific Illicit Drugs among Persons Aged 12 or Older: 2012 Fig7-2 copy

15. An epidemic of chronic pain The crackdown on prescription drug abuse is treating the wrong problem. By Judy Foreman December 08, 2013

16. Prescription drug abuse a target for Massachusetts lawmakers

17. Chronic Pain100 million Americans Institute of Medicine of The National Academies 2013

19. In trying to adequately treat pain, have we inadvertently contributed to this problem of opioid diversion and addiction?

20. Methadone Methadone Maintenance –Addiction Prescribed since 1970s Prescribed since 1970s Recommended for addiction treatment in pregnancy

21. Methadone Full opioid agonist Long half-life with stable levels Once daily dosing

22. +s / -s of Methadone +s / -s of Methadone Works extremely well for maintenance of addiction Must go to a Methadone clinic for treatment –daily dosing Stigma

24. October 2002 FDA approved use of Buprenorphine, a schedule III partial mu receptor agonist for treatment of opioid addiction

25. +s / -s Buprenorphine +s / -s Buprenorphine Buprenorphine—any MD can obtain license to prescribe Protects privacy –can get a month of medication at a time Most visits to MD are pay out of pocket

26. Buprenorphine (partial agonist) High affinity for the opioid receptor with low intrinsic activity – Binds tightly to the mu receptor – Makes acute pain management challenging

27. Buprenorphine Opioid Empty Receptor Withdrawal Pain Opioid Receptor in the brain

29. Imperfect Fit – Limited Euphoric Opioid Effect Courtesy of NAABT, Inc. (naabt.org)

30. )

33. Trade names of drugs containing Buprenorphine and Naloxone Suboxone 2mg/0.5 mg 8mg/2 mg Usual range 8mg/2 mg per day – 32mg/8 mg per day Usually BID dosing Usually BID dosing Stopped making tablet March 2013—now distributed as a film

34. Buprenorphine without Naloxone =Subutex Will see used in pregnancy Dosing: 2 mg 8 mg Dosing: 2 mg 8 mg

35. Trade Names of preparations containing buprenorphine and naloxone Zubsolv --new formulation approved by FDA 5.7mg/1.14 mg SL tablet 5.7mg/1.14 mg SL tablet Zubsolv provides equivalent buprenorphine to one Suboxone 8mg/2 mg. Zubsolv once daily / menthol taste

36. Sublingual is the only route approved for addiction maintenance

40. 32 yr old man who is admitted to the through the Emergency Department with severe abdominal pain requires emergent OR for exploratory laporotomy— on Methadone 60 mg per day for treatment of addiction. What to do for pain relief?

41. Continue Methadone maintenance dose for while in hospital Use additional opioid for pain control (will need higher doses— try to avoid drug of choice) – THINK MULTIMODAL: Consider IV Acetaminophen / IV Toradol / Gabapentin or Lyrica Treatment of Acute Pain on Methadone

42. 32 yr old man admitted to through the Emergency Department with severe abdominal pain requires emergent surgery for exploratory laporotomy. He takes Suboxone 16 mg per day. What to do for pain relief?

43. Treatment of Acute Pain on Suboxone Suboxone Challenging given high affinity for mu receptor

44. Imperfect Fit – Limited Euphoric Opioid Effect Courtesy of NAABT, Inc. (naabt.org)

45. Receptor needs to clear in order for full agonists to be effective Lower the dose, faster the clearance. For 8 mg dose, recommend stopping at least 24 hrs For higher doses, stopping 72 hrs prior to surgery

46. IV Fentanyl can override receptor –careful titration Maximize nonopioids /IV Acetaminophen or round the clock oral Acetaminophen / IV Toradol / Pregabalin

47. When is it best to know when your patient is taking Suboxone?

48. Before he is wheeled into the OR…… Before he is wheeled into the OR……

49. Screening Part of preoperative assessment Face to face screening may not be as accurate Self administered tools may be more likely to elicit honest answers

50. Ask about abuse of prescribed medications and illicit substances “This information is important so that I can take the best care possible of you possible and make sure that your pain is well controlled”

51. Patient on Suboxone Contact Suboxone Prescriber Prior to Surgery Communication is Key to a successful outcome!

52. When to Stop Suboxone Prior to Surgery? 24-72 hrs prior, dependent upon daily total dose 24-72 hrs prior, dependent upon daily total dose Postoperatively 15 mg MS Contin BID for baseline control Postoperatively 15 mg MS Contin BID for baseline control PCA without basal if NPO PCA without basal if NPO Oral short acting if not NPO Oral short acting if not NPO Consider regional anesthesia Consider regional anesthesia Maximize adjuvants— Acetaminophen / NSAIDS / Pregabalin Maximize adjuvants— Acetaminophen / NSAIDS / Pregabalin

53. For minor surgery or surgery without expected need for opioid analgesia Suboxone is taken AM of surgery Suboxone is taken AM of surgery If pain control needed, split Suboxone dose TID If pain control needed, split Suboxone dose TID Regional anesthesia Regional anesthesia Maximize NSAIDS / Tylenol / Consider Tramadol Maximize NSAIDS / Tylenol / Consider Tramadol

54. What about withdrawal? Given partial agonist activity, withdrawal symptoms are reported to be minimal compared to full opioid agonist

55. Illicit Drug Use in Pregnancy Ages 15-44 –combined 2011-2012 Results not significantly different from 2009-2010 Breakdown by age: 15-17 18.3% 18-25 9% 26-44 3.4% http://www.samhsa.gov/data/http://www.samhsa.gov/data/

56. Treatment of Addiction During Pregnancy Lowers maternal morbidity/mortality Prevents up and down cycling that fetus experiences with drug use and withdrawal

57. Buprenorphine without Naloxone =Subutex Will see used in pregnancy Dosing: 2 mg 8 mg Dosing: 2 mg 8 mg

58. Unlike our patients coming for elective surgery, we DO NOT want our pregnant patients stopping Suboxone prior to delivery

59. Epidurals Consider for both vaginal and csection deliveries with women on Subutex

60. Vivitrol IM preparation of Naltrexone –opioid antagonist Once monthly –used for opioid addiction “wears off” by day 25

61. Butrans Patch Buprenorphine patch Used for management of pain Discontinue use prior to surgery

62. Summary Disease of Addiction is growing problem in society Disease of Addiction is growing problem in society See more people in recovery on some preparation of Buprenorphine Those needing immediate pain control on Suboxone: IV Fentanyl go to drug

63. Summary Preoperative Screening and Communication with Community Providers is Key

64. ??????????? Contact Information: Cheryl Marks, NP cmarks1@partners.org Newton-Wellesley Hospital 617-243-6573