Facilitating discontinuation of intravenous opioids by concurrent use of sublingual buprenorphine with rapid microdosing induction: A pain management case study

Arjun Tara, DO; Gregory Acampora, MD; Jingping Wang, MD, PhD; Karina De Sousa, BS; Yi Zhang, MD, PhD

doi:10.5055/jom.2021.0652

Authors

Arjun Tara, DO https://orcid.org/0000-0002-2563-0063
Gregory Acampora, MD
Jingping Wang, MD, PhD
Karina De Sousa, BS
Yi Zhang, MD, PhD

DOI:

https://doi.org/10.5055/jom.2021.0652

Keywords:

buprenorphine, sublingual buprenorphine, acute pain management, perioperative pain management, microdosing induction

Abstract

We report a case in which sublingual buprenorphine was used to help transition a patient off intravenous (IV) opioid analgesics medications post-multiple abdominal procedures. Intravenous opioids are commonly used in inpatient surgical pain management for patients with severe pain who are unable to take oral medications. Typically, a short course of IV analgesics is used, followed by transition to oral analgesic regimen. However, in patients with poor gastrointestinal absorption, pain control can be challenging. We present this case to highlight how sublingual buprenorphine can be a useful agent for acute pain management, especially when conventional strategies provide suboptimal responses.

Author Biographies

Arjun Tara, DO

Clinical Fellow, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts

Gregory Acampora, MD

Assistant Professor, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts

Jingping Wang, MD, PhD

Associate Professor, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts

Karina De Sousa, BS

Clinical Research Coordinator, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts

Yi Zhang, MD, PhD

Assistant Professor, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts

References

Grond S, Radbruch L, Lehmann KA: Clinical pharmacokinetics of transdermal opioids: Focus on transdermal fentanyl. Clin Pharmacokinet. 2000; 38(1): 59-89.

Blick SK, Wagstaff AJ: Fentanyl buccal tablet: In breakthrough pain in opioid-tolerant patients with cancer. Drugs. 2006; 66(18): 2387-2393. (Discussion 94-5).

Taylor DR: Fentanyl buccal tablet: Rapid relief from breakthrough

pain. Expert Opin Pharmacother. 2007; 8(17): 3043-3051.

Mendelson J, Upton RA, Everhart ET, et al.: Bioavailability of sublingual buprenorphine. J Clin Pharmacol. 1997; 37(1): 31-37.

Bullingham RE, McQuay HJ, Moore A, et al.: Buprenorphine kinetics. Clin Pharmacol Ther. 1980; 28: 667-672.

Elkader A, Sproule B: Buprenorphine: Clinical pharmacokinetics in the treatment of opioid dependence. Clin Pharmacokinet. 2005; 44: 661-680.

Mozafari J, Masoumi K, Forouzan A, et al.: Sublingual buprenorphine efficacy in renal colic pain relief: A randomized placebo-controlled clinical trial. Pain Ther. 2017; 6(2): 227-234.

James IG, O'Brien CM, McDonald CJ: A randomized, double-blind, double-dummy comparison of the efficacy and tolerability of low-dose transdermal buprenorphine (BuTrans seven-day patches) with buprenorphine sublingual tablets (temgesic) in patients with osteoarthritis pain. J Pain Symptom Manag. 2010; 40(2): 266-278.

Neumann A, Blondell R, Jaanimägi U, et al.: A preliminary study comparing methadone and buprenorphine in patients with chronic pain and coexistent opioid addiction. J Addict Dis. 2013; 32: 68-78.

Walsh SL, Preston KL, Stitzer ML, et al.: Clinical pharmacology of buprenorphine: Ceiling effects at high doses. Clin Pharmacol Ther. 1994; 55(5): 569-580.

Welsh C, Valadez-Meltzer A: Buprenorphine: A (relatively) new treatment for opioid dependence. Psychiatry (Edgmont). 2005; 2(12): 29-39.

Anderson TA, Quaye ANA, Ward EN, et al.: To stop or not, that is the question: Acute pain management for the patient on chronic buprenorphine. Anesthesiology. 2017; 126(6): 1180-1186.

Jonan AB, Kaye AD, Urman RD: Buprenorphine formulations: Clinical best practice strategies recommendations for perioperative management of patients undergoing surgical or interventional pain procedures. Pain Phys. 2018; 1(1): E1-E12.

Kögel B, Christoph T, Strassburger W, et al.: Interaction of mu-opioid receptor agonists and antagonists with the analgesic effect of buprenorphine in mice. Eur J Pain. 2005; 9(5): 599-611.

Mercadante S, Villari P, Ferrera P, et al.: Safety and effectiveness of intravenous morphine for episodic breakthrough pain in patients receiving transdermal buprenorphine. J Pain Symptom Manag. 2006; 32(2): 175-179.

Beltrutti D, Niv D: Pain relief after simultaneous administration of intravenous buprenorphine and intrathecal morphine in terminally ill patients; a report of two cases. The Pain Clinic. 2000; 12: 121-123.

Beltrutti D, Niv D, Ben-Abraham R, et al.: Late antinociception and lower untoward effects of concomitant intrathecal morphine and intravenous buprenorphine in humans. J Clin Anesth. 2002; 14(6): 441-446.

Webster L, Gruener D, Kirby T, et al.: Evaluation of the tolerability of switching patients on chronic full mu-opioid agonist therapy to buccal buprenorphine. Pain Med. 2016; 17: 899-907.

Greenwald M, Johanson CE, Bueller J, et al.: Buprenorphine duration of action: Mu-opioid receptor availability and pharmacokinetic and behavioral indices. Biol Psychiatr. 2007; 61(1): 101-110.

Greenwald MK, Comer SD, Fiellin DA: Buprenorphine maintenance and mu-opioid receptor availability in the treatment of opioid use disorder: Implications for clinical use and policy. Drug Alcohol Depend. 2014; 144: 1-11.

Quaye AN, Zhang Y: Perioperative management of buprenorphine: Solving the conundrum. Pain Med. 2019; 20(7): 1395-1408.

Lembke A, Ottestad E, Schmiesing C: Patients maintained on buprenorphine for opioid use disorder should continue buprenorphine through the perioperative period. Pain Med. 2019; 20(3): 425-428.

Warner NS, Warner MA, Cunningham JL, et al.: A practical approach for the management of the mixed opioid agonistantagonist buprenorphine during acute pain and surgery. Mayo Clin Proc. 2020; 95(6): 1253-1267.

Quaye A, Potter K, Roth S, et al.: Perioperative continuation of buprenorphine at low-moderate doses was associated with lower postoperative pain scores and decreased outpatient opioid dispensing compared with buprenorphine discontinuation. Pain Med. 2020; 21(9): 1955-1960. DOI: 10.1093/pm/pnaa020.

Hämmig R, Kemter A, Strasser J, et al.: Use of microdoses for induction of buprenorphine treatment with overlapping full opioid agonist use: The Bernese method. Subst Abuse Rehabil. 2016; 7: 99-105.

Terasaki D, Smith C, Calcaterra SL: Transitioning hospitalized patients with opioid use disorder from methadone to buprenorphine without a period of opioid abstinence using a microdosing protocol. Pharmacotherapy. 2019; 39(10): 1023-1029.

Klaire S, Zivanovic R, Barbic SP, et al.: Rapid micro-induction of buprenorphine/naloxone for opioid use disorder in an inpatient setting: A case series. Am J Addict. 2019; 28(4): 262-265.

Lee DS, Hann JE, Klaire SS, et al.: Rapid induction of buprenorphine/naloxone for chronic pain using a microdosing regimen: A case report. AA Pract. 2020; 14(2): 44-47.

Administration SAaMHS: Medication assisted treatment for opioid use disorders. 2016. Available at https://www.federalregister.gov/documents/2016/07/08/2016-16120/medication-assisted-treatment-for-opioid-use-disorders. Accessed December 27, 2020.