Outpatient cross-titration to buprenorphine for chronic pain: A retrospective analysis

Satoru Ito; Mackenzie Welsh; Christina Bockman; Rebecca Dale; David Pilkington; Katherin Peperzak

doi:10.5055/jom.0839

Authors

Satoru Ito, PharmD, BCPS
Mackenzie Welsh, PharmD
Christina Bockman, PharmD
Rebecca Dale, DO
David Pilkington, DO
Katherin Peperzak, MD

DOI:

https://doi.org/10.5055/jom.0839

Keywords:

buprenorphine, buprenorphine, naloxone drug, combination, chronic pain, analgesics, opioid, buprenorphine cross-titration

Abstract

Objective: To determine the effectiveness and safety of the University of Washington's buprenorphine cross-titration protocol for chronic pain in the outpatient setting.

Methods: Retrospective chart review was performed on 150 patients transitioned from full μ-opioid agonist therapy to buprenorphine using the University of Washington Medical Center Pain Clinic's cross-titration protocol between September 1, 2020, and December 31, 2021, in an outpatient setting. Primary outcome was to determine the percentage of patients who completed the cross-titration and continued buprenorphine without full μ-opioid agonists 4 weeks after completion. Secondary outcomes included final buprenorphine dose, days needed to complete cross-titration, deviation rates from the protocol, and opioid-related adverse events.

Results: Fifteen of 31 (48.4 percent) included patients successfully converted to buprenorphine. Median duration of successful cross-titration was 29 days (interquartile range 19-57). Average end-titration dose for patients on buprenorphine/naloxone sublingual films was 7.9 ± 5.7 mg/day, while for buprenorphine transdermal (TD) patches, it was 11.9 ± 4.8 mcg/h. Morphine equivalent daily dose (MEDD) prior to induction varied widely. All patients transitioned to TD buprenorphine were taking ≤30 mg MEDD. Patients previously taking >120 mg MEDD stabilized on 8-16 mg/day buprenorphine. Most common reasons for cross-titration failure were inadequate pain control and intolerable adverse effects.

Discussion: The University of Washington's buprenorphine cross-titration protocol for chronic pain was successful in about half of included patients undergoing conversion from chronic full μ-opioid agonist therapy and generally well tolerated. Clinical responses were widely variable, and many required slower taper and higher end-titration buprenorphine dose than anticipated. Although protocols provide structure for cross-titration, each course should be monitored closely and individualized.

Author Biographies

Satoru Ito, PharmD, BCPS

Department of Pharmacy Services, University of Washington Medicine, Seattle, Washington

Mackenzie Welsh, PharmD

Department of Pharmacy Services, University of Washington Medicine, Seattle, Washington

Christina Bockman, PharmD

Department of Pharmacy Services, University of Washington Medicine, Seattle, Washington

Rebecca Dale, DO

Department of Anesthesia and Pain Medicine, University of Washington Center for Pain Relief, Seattle, Washington

David Pilkington, DO

Department of Rehabilitation Medicine, University of Washington, Seattle, Washington

Katherin Peperzak, MD

Department of Anesthesia and Pain Medicine, University of Washington Center for Pain Relief, Seattle, Washington

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