Development of a standardized protocol for buprenorphine induction in a chronic pain clinic

Jaycee A. Blair; Savannah G. Hansen

doi:10.5055/jom.0916

Authors

Jaycee A. Blair, PharmD, MBA https://orcid.org/0000-0003-2670-093X
Savannah G. Hansen, PharmD, BCPS

DOI:

https://doi.org/10.5055/jom.0916

Keywords:

buprenorphine, chronic pain, induction, protocol

Abstract

Objective: Create a standardized protocol document on how to convert patients from full opioid agonist to buprenorphine. Providing patients with the best possible chance of a seamless conversion resulting in decreased risk of failure of therapy with buprenorphine.

Methods: A 10-question survey was distributed to better understand the different aspects the providers consider when converting a patient from full opioid agonist to buprenorphine. A medication use evaluation was completed utilizing a retrospective qualitative design to identify all patients who had a new prescription for any buprenorphine product from a chronic pain provider to establish patterns of current practice. This information, in conjunction with guidance from current literature and medication package inserts, was used to create a protocol for buprenorphine induction. Providers were educated on buprenorphine prior to guidance document implementation.

Results: A five-page guidance document on how to convert patients from full opioid agonist to buprenorphine was created for providers within the chronic pain clinic. The document includes recommendations on which patients are candidates for buprenorphine versus those who are not. The document also provides a three-step process to successfully perform a conversion including which buprenorphine product and induction technique to utilize. Definitions of each induction technique along with examples are provided within the document. Recommendation for converting between buprenorphine patch and films are also listed within the document.

Discussion: The five-page guidance document was successfully implemented in June 2024, supplying pain providers with all the knowledge necessary to convert patients comfortably, thus providing patients with the best possible chance of a seamless conversion and decreasing risk of failure of conversion to buprenorphine due to inadequate induction technique.

Author Biographies

Jaycee A. Blair, PharmD, MBA

PGY1 Pharmacy Resident, VA Salt Lake City Health Care System, Salt Lake City, Utah

Savannah G. Hansen, PharmD, BCPS

Outpatient Chronic Pain Clinical Pharmacist Practitioner, VA Salt Lake City Health Care System, Salt Lake City, Utah

References

Dalal S, Chitneni A, Berger AA, et al.: Buprenorphine for chronic pain: A safer alternative to traditional opioids. Health Psychol Res. 2021; 9(1): 27241. DOI: 10.52965/001c.27241.

Pergolizzi J, Böger RH, Budd K, et al.: Opioids and the management of chronic severe pain in the elderly: Consensus statement of an international expert panel with focus on the six clinically most often used World Health Organization step III opioids (buprenorphine, fentanyl, hydromorphone, methadone, morphine, oxycodone). Pain Pract. 2008; 8(4): 287-313. DOI: 10.1111/j.1533-2500.2008.00204.

Center for Medicare and Medicaid Services: CMS roadmap strategy to fight the opioid crisis. 2020. Available at https://www.cms.gov/sites/default/files/2021-05/CMS_OpioidFactSheet_2020.pdf. Accessed September 10, 2024.

Webster L, Gudin J, Raffa RB, et al.: Understanding buprenorphine for use in chronic pain: Expert opinion. Pain Med. 2020; 21(4): 714-723.

Gudin J, Fudin J: A narrative pharmacological review of buprenorphine: A unique opioid for the treatment of chronic pain. Pain Ther. 2020; 9(1): 41-54. DOI: 10.1007/s40122-019-00143-6.

Silverman SM: Opioid induced hyperalgesia: Clinical implications for the pain practitioner. Pain Phys. 2009; 12(3): 679-684.

Spreen LA, Dittmar EN, Quirk KC, et al.: Buprenorphine initiation strategies for opioid use disorder and pain management: A systematic review. Pharmacotherapy. 2022; 42(5): 411-427. DOI: 10.1002/phar.2676.

SAMHSA: Buprenorphine quick start guide. Available at https://www.samhsa.gov/sites/default/files/quick-start-guide.pdf. Accessed May 20, 2024.

Davis MP, Davies A, McPherson ML, et al.: Opioid analgesic dose and route conversion ratio studies: A scoping review to inform an eDelphi guideline. Support Care Cancer. 2024; 32: 542. DOI: 10.1007/s00520-024-08710-0.

Purdue Pharma L.P.: Butrans [package insert]. Stamford, CT. 2014. Available at https://www.accessdata.fda.gov/drugsatfda_docs/label/2014/021306s015s019lbl.pdf. Accessed May 20, 2024.

Endo Pharmaceuticals Inc.: Belbuca [package insert]. Malver. 2015. Available at https://www.accessdata.fda.gov/drugsatfda_docs/label/2015/207932s000lbl.pdf. Accessed May 20, 2024.

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. DOI: 10.2147/SAR.S109919.

Patel P, Dunham K, Lee K: Buprenorphine/naloxone microdosing: The Bernese method. Canadian Mental Health Association. 2019. Available at https://www.schulich.uwo.ca/familymedicine/citywide/docs/Final%20Microdosing%20Summary%20RAAM%20%20TVFHT%20September%202019.pdf. Accessed May 20, 2024.

Becker WC, Frank JW, Edens EL: Switching from high-dose, long-term opioids to buprenorphine: A case series. Ann Intern Med. 2020; 173(1): 70-71. DOI: 10.7326/L19-0725.

Potru S, Viscusi E: How I do it: Buprenorphine conversions/ inductions in the pain clinic and postoperative settings. ASRA News. 2021; 46. DOI: 10.52211/asra050121.033.

Oregon Pain Guidance: Opioid conversion calculator. Available at https://www.oregonpainguidance.org/opioidmedcalculator/. Accessed September 10, 2024.

Priestley T, Chappa A, Mould D, et al.: Converting from transdermal to buccal formulations of buprenorphine: A pharmacokinetic meta-model simulation in healthy volunteers. Pain Med. 2018; 19(10): 1988-1996. DOI: 10.1093/pm/pnx235.