Buprenorphine/naloxone induction for treatment of acute on chronic pain using a micro-dosing regimen: A case report

Raman Sandhu, Rebecca Zivanovic, Sukhpreet Klaire, Mohammadali Nikoo, Jennifer Rozylo, Pouya Azar, Raman Sandhu, Rebecca Zivanovic, Sukhpreet Klaire, Mohammadali Nikoo, Jennifer Rozylo, Pouya Azar

Abstract

Background: Due to its unique pharmacologic properties, efficacy as an analgesic, and role as a first-line medication for the treatment of opioid use disorder, sublingual buprenorphine has emerged as a treatment for patients with concurrent chronic pain and opioid use disorders. One challenge to utilizing buprenorphine is that precipitated opioid withdrawal can result if this medication is initiated in the presence of other opiates with lesser binding affinities. Micro-dosing induction regimens utilize a slower titration to avoid the need for a period of abstinence from other opiates and decrease the risk of precipitated withdrawal. Aims: The aim of this article is to present a case where a standardized micro-dosing induction regimen was used to transition a patient from other opiate analgesia to a sublingual formulation of buprenorphine/naloxone. Methods: This case took place on an inpatient neurosurgical unit of a Canadian tertiary-care city hospital. Written informed consent was collected prior to a detailed chart review. Results: Here we present a case of a postoperative neurosurgical inpatient who was referred to our team for pain management in the context of chronic pain and a past history of opioid use disorder. She was successfully transitioned to buprenorphine/naloxone, replacing all other opioid analgesia, without a period of opioid withdrawal using a micro-dosing induction regimen. Conclusions: Sublingual buprenorphine/naloxone can be safe and effective for treatment of chronic pain, particularly for those with past or current opioid use disorder. Micro-dosing provides a preferable induction strategy for patients who are not able to tolerate the requirement for moderate opioid withdrawal prior to initiation with existing regimens.

Keywords: Bernese method; buprenorphine/naloxone; chronic pain; micro-dosing; opioid.

Conflict of interest statement

No potential conflict of interest was reported by the authors.

© 2019 The Author(s). Published with license by Taylor & Francis Group, LLC.

References

    1. Birse TM, Lander J.. Prevalence of chronic pain. Can J Public Health. 1998;89:129–31.
    1. Breivik H, Collett B, Ventafridda V, Cohen R, Gallacher D. Survey of chronic pain in Europe: prevalence, impact on daily life, and treatment. Eur J Pain. 2006;10(4):287–333. doi:10.1016/j.ejpain.2005.06.009.
    1. Schopflocher D, Taenzer P, Jovey R. The prevalence of chronic pain in Canada. Pain Res Manag. 2011;16:445–50.
    1. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain–United States, 2016. JAMA. 2016;315(15):1624–45. doi:10.1001/jama.2016.1464.
    1. Volkow ND, McLellan AT. Opioid abuse in chronic pain–misconceptions and mitigation strategies. N Engl J Med. 2016;374(13):1253–63. doi:10.1056/NEJMra1507771.
    1. Chen KY, Chen L, Mao J. Buprenorphine-naloxone therapy in pain management. Anesthesiology. 2014;120(5):1262–74. doi:10.1097/ALN.0000000000000170.
    1. Cote J, Montgomery L. Sublingual buprenorphine as an analgesic in chronic pain: a systematic review. Pain Med. 2014;15(7):1171–78. doi:10.1111/pme.2014.15.issue-7.
    1. British Columbia Centre on Substance Use . A guideline for the clinical management of opioid use disorder. Victoria, British Columbia: British Columbia Ministry of Health; 2017.
    1. Aiyer R, Gulati A, Gungor S, Bhatia A, Mehta N. Treatment of chronic pain with various buprenorphine formulations: a systematic review of clinical studies. Anesth Analg. 2018;127(2):529–38. doi:10.1213/ANE.0000000000003570.
    1. Fishman MA, Kim PS. Buprenorphine for chronic pain: a systematic review. Current Pain and Headache Reports. 2018;22(83):1–7. doi:10.1007/s11916-018-0732-2.
    1. Daitch D, Daitch J, Novinson D, Frey M, Mitnick C, Pergolizzi J. Conversion from high-dose full-opioid agonists to sublingual buprenorphine reduces pain scores and improves quality of life for chronic pain patients. Pain Med. 2014;15(12):2087–94. doi:10.1111/pme.12520.
    1. Davis MP, Pasternak G, Behm B. Treating chronic pain: an overview of clinical studies centered on the buprenorphine option. Drugs. 2018;78(12):1211–28. doi:10.1007/s40265-018-0953-z.
    1. Lutfy K, Eitan S, Bryant CD, Yang YC, Saliminejad N, Walwyn W, Kieffer BL, Takeshima H, Carroll FI, Maidment NT, et al. Buprenorphine-induced antinociception is mediated by mu-opioid receptors and compromised by concomitant activation of opioid receptor-like receptors. J Neurosci. 2003;23(32):10331–37. doi:10.1523/JNEUROSCI.23-32-10331.2003.
    1. Walsh SL, Preston KL, Stitzer ML, Cone EJ, Bigelow GE. Clinical pharmacology of buprenorphine: ceiling effects at high doses. Clin Pharmacol Ther. 1994;55(5):569–80. doi:10.1038/clpt.1994.71.
    1. Chiang CN, Hawks RL. Pharmacokinetics of the combination tablet of buprenorphine and naloxone. Drug Alcohol Depend. 2003;70(2 Suppl):S39–47. doi:10.1016/S0376-8716(03)00058-9.
    1. Daniulaityte R, Carlson R, Brigham G, Cameron D, Sheth A. “Sub is a weird drug:” A web-based study of lay attitudes about use of buprenorphine to self-treat opioid withdrawal symptoms. Am J Addict. 2015;24(5):403–09. doi:10.1111/ajad.12300.
    1. Hämmig R, Kemter A, Strasser J, von Bardeleben U, Gugger B, Walter M, Dürsteler KM, Vogel M. Use of microdoses for induction of buprenorphine treatment with overlapping full opioid agonist use: the Bernese method. Subst Abuse Rehabil. 2016;7:99–105. doi:10.2147/SAR.S109919.
    1. Kornfeld H, Reetz H. Transdermal buprenorphine, opioid rotation to sublingual buprenorphine, and the avoidance of precipitated withdrawal: a review of the literature and demonstration in three chronic pain patients treated with butrans. Am J Ther. 2015;22(3):199–205. doi:10.1097/MJT.0b013e31828bfb6e.
    1. Poulain P, Denier W, Douma J, Hoerauf K, Samija M, Sopata M, Wolfram G. Efficacy and safety of transdermal buprenorphine: a randomized, placebo-controlled trial in 289 patients with severe cancer pain. J Pain Symptom Manage. 2008;36(2):117–25. doi:10.1016/j.jpainsymman.2007.09.011.
    1. Gordon A, Callaghan D, Spink D, Cloutier C, Dzongowski P, O‘Mahony W, Sinclair D, Rashiq S, Buckley N, Cohen G, et al. Buprenorphine transdermal system in adults with chronic low back pain: a randomized, double-blind, placebo-controlled crossover study, followed by an open-label extension phase. Clin Ther. 2010;32(5):844–60. doi:10.1016/j.clinthera.2010.06.017.
    1. Neumann AM, Blondell RD, Jaanimägi U, Giambrone AK, Homish GG, Lozano JR, Kowalik U, Azadfard M. A preliminary study comparing methadone and buprenorphine in patients with chronic pain and coexistent opioid addiction. J Addict Dis. 2013;32(1):68–78. doi:10.1080/10550887.2012.759872.
    1. White LD, Hodge A, Vlok R, Hurtado G, Eastern K, Melhuish TM. Efficacy and adverse effects of buprenorphine in acute pain management: systematic review and meta-analysis of randomized controlled trials. Br J Anaesth. 2018;120(4):668–78. doi:10.1016/j.bja.2017.11.086.
    1. Anderson T, Quaye A, Ward E, Wilens T, Hillard P. To stop or not, that is the question: acute pain management for the patient on chronic buprenorphine. Anesthesiology. 2017;125:1180–86. doi:10.1097/ALN.0000000000001633.

Source: PubMed

Sponsor e collaboratori

Condizioni mediche

Interventi farmacologici

3
Sottoscrivi