Pain Management: Patients Maintained on Buprenorphine

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

2. 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 0.3-0.6 mg q 6-8 hours parenteral and 0.2-0.4 mg q 6-8 hours sublingual

4. 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 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

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