Accurate Education - Buprenorphine Tx and Emergency Pain, Surgery

“Everything will be okay in the end. If it’s not okay, it’s not the end.”
– John Lennon

Buprenorphine

Emergency Pain Management

Surgery Pain Management

It is recommended to first read the following sections to become familiarized with some of the terms and concepts related here:

Buprenorphine for Pain

Buprenorphine for SUD

Key to Links:

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Emergency Pain Management and Buprenorphine

In the event of an emergency pain condition, patients who are taking buprenorphine may face difficulties in their management due to a lack of understanding of how buprenorphine works in pain. Aside from the unfortunate prejudice and disrespect directed at both pain and addiction patients, there is also a common misunderstanding of both the medical and legal implications of buprenorphine treatment.

Buprenorphine is a medication used for the management of both pain and addiction (Substance Use Disorder or SUD). But the laws governing the prescribing of buprenorphine are different depending on the condition treated. In an emergency setting, many patients as well as medical personnel, including physicians, are ignorant of the laws governing the prescribing of buprenorphine. (See below for the emergency management of opioid addiction with buprenorphine).

Prescribing Buprenorphine for Pain

Physicians do NOT need a special license to prescribe buprenorphine for pain, regardless of the buprenorphine product. Buprenorphine-only products (Butrans and Belbuca) are FDA-approved only for treating pain and cannot be prescribed for addiction. The combination products containing buprenorphine and naloxone (Suboxone, Zubsolv, Bunavail) are FDA-approved only for treating addiction and they require a special license to prescribe. But the combination products can also be prescribed “off-label” for treating pain without requiring a special license. Therefore, regardless of whether a physician is treating acute or chronic pain with buprenorphine, they do not need a special license.

Emergency and Surgical Pain Management

When Already Taking Buprenorphine

Urgent and Emergency Pain Management

Mild-Moderate Pain

When taking buprenorphine, a person may experience an acute episode of pain not adequately controlled at the current buprenorphine dose such as may occur with dental pain or a minor injury. The usual first alternative is to try non-opioid medications such as tylenol or an NSAID such as ibuprofen (Motrin) or naproxen (Aleve). When this is not effective, if a patient is taking a low daily dose of buprenorphine (e.g., < 8 mg per day) the buprenorphine dose can sometimes be increased and given at 6-hour intervals to control pain. Before increasing one’s buprenorphine dose, one should consult their prescribing physician for guidance. It may be possible to manage the pain by increasing the buprenorphine dose up to 32 mg/day. Higher doses are not recommended at this time.

Severe Pain

When the efforts above do not work to control severe acute pain, it will be necessary to consult a physician for opioid management, preferably one’s pain management specialist or an emergency physician knowledgable about treating acute pain in buprenorphine management.

Adding a Second Opioid

When a person takes buprenorphine regularly, it may interfere with the actions of a second opioid pain medication. This property of buprenorphine may complicate the management of emergency pain, such as associated with an acute trauma like a broken leg, or post-operative pain after surgery. It is important to know how to address the management of emergency pain or plan for the surgery when taking buprenorphine chronically.

Because buprenorphine binds strongly to the opioid receptors (mu-receptors) in the nervous system that control pain, taking a second opioid for pain while currently taking buprenorphine may potentially result in an inadequate pain relief response because the second opioid can be blocked by the buprenorphine.

The extent to which the second opioid is blocked and the subsequent effectiveness of the second opioid depends on multiple variables:

Receptor Occupancy and Buprenorphine Dosing

The most important variable is how many of the total number of mu-opioid receptors are occupied by buprenorphine and how many receptors are unoccupied. If a significant number of receptors are free and available to the second opioid, the response to the second opioid will be significant. Experimental studies indicate that when buprenorphine doses are less than 1-4 mg/day (as in the case of Butrans and Belbuca or low dose Suboxone 1-2 mg twice a day), it is likely that at least 50% of receptors are available. In this circumstance, adding a second opioid will likely provide full analgesic benefit with little significant blockade by the buprenorphine.

At buprenorphine doses > 16mg/day (or > 8mg twice/day), it is estimated that 80% or more of the receptors will be occupied by the buprenorphine and the analgesic benefit of usual opioids at usual doses will be significantly blocked. While these estimates only represent approximations that will vary amongst individuals, the concept remains that the analgesic benefits of a second opioid will be additive to that of buprenorphine, depending on how much buprenorphine a person is taking.

Opioid Affinity for the Mu-Opioid Receptor

As described above, buprenorphine has a high affinity, or attraction, for binding to the receptors that control pain. A descriptive analogy would be magnetic attraction – the stronger the magnet, the tighter the binding. But although buprenorphine has stronger binding affinity than many other opioids including hydrocodone, oxycodone and morphine, some opioids have yet stronger binding affinities then buprenorphine and when added as a second opioid for pain, they may displace buprenorphine and offer even greater – or less – additive benefit, depending on the relative potency of the second opioid compared to buprenorphine.

Fentanyl, for example has a greater affinity and a higher potency than buprenorphine and therefore would likely be the best choice for an additional opioid for severe, emergency pain control. In fact, some studies have demonstrated that rotating buprenorphine to or from fentanyl at equipotent doses can be accomplished with no adverse effects including withdrawal, and no loss of analgesic benefit. Hydromorphone (Dilaudid) on the other hand, has a greater affinity but weaker potency than buprenorphine and might therefore, depending on the dose, offer less additive benefit if it were to displace the more potent buprenorphine. Unfortunately, no studies have been performed to assess and compare all these variables and these treatment predictions remain speculative.

Other Characteristics of the Second Opioid

While activity at the mu-opioid receptor is the most important variable in the analgesic benefit of an opioid, a number of opioids reduce pain by additional mechanisms and might therefore offer additive analgesic benefits beyond concerns regarding buprenorphine receptor occupancy. Opioids including tramadol, tapentadol, methadone and levorphanol provide benefits for pain unrelated to the mu-opioid receptor and may be useful as additive analgesic agents in combination with buprenorphine.

Individual Variability in Buprenorphine Metabolism

Different people eliminate buprenorphine from their system at markedly different rates. The elimination half-life of buprenorphine (the time required to eliminate half of the amount of buprenorphine in one’s system) in humans varies nearly 3-fold, from 24– 69 hours. Therefore, once the dosing of buprenorphine is discontinued, the rate at which receptor occupancy drops may take 3x as long for some people than others. This will affect the transition of analgesic benefit from buprenorphine to another opioid if buprenorphine is stopped. It also affects how quickly and severely one may experience withdrawal symptoms from buprenorphine in the absence of a replacement opioid.

Planning for Surgical Pain Management

When planning for an upcoming surgery or procedure expected to precipitate additional pain, a patient has a few options available. Unfortunately, it is difficult to predict a patient’s level of post-operative pain or their response to pain medications.

There are 3 basic options:

1. Continue buprenorphine at usual or increased doses up to and after the surgical procedure.

Current research has concluded that there is no need to discontinue buprenorphine prior to a surgical procedure. Usual opioids used for peri-operative pain management may simply be added to the buprenorphine regimen to control additional pain. It was previously believed that the buprenorphine would interfere, reduce or block the pain benefit of the additional opioid. However, this has since been determined to not be of concern as morphine, fentanyl or other opioids can be used even with current use of buprenorphine.

2. Continue buprenorphine at usual doses up until the time of surgery, then discontinue buprenorphine. Treat post-operative pain with other opioids. Resume buprenorphine when able.

Inexperience or uncertainty regarding the use of buprenorphine for pain may lead a physician or surgeon to discontinue buprenorphine in favor of more familiar opioids. There may be a potential for caution in the way that one resumes buprenorphine in the post-operative period.

3. Discontinue buprenorphine 1-5 days prior to surgery, introduce other opioids before and/or after surgery for post-operative pain. Resume buprenorphine when able.

This is probably not necessary but may be an option if adequate pain control from buprenorphine with or without a second opioid may be suspected to be inadequate.

The following guidelines have also previosly been recommended as options to consider when planning for surgery if taking buprenorphine. It is best to discuss specific concerns with one’s buprenophine prescriber and one’s surgeon for the best outcome. There are many proposed guidelines that have been advised by different authorities but none of them are “fit one, fit all.”

If an upcoming surgery or surgical procedure is expected to produce moderate to severe pain, one should consider:

Take last buprenorphine dose on the morning of the day prior to the procedure
Hold buprenorphine dose on day of surgery
Before the procedure: a single dose of extended release (ER) or long-acting (LA) opioid (e.g., morphine ER) on the day of procedure
After the procedure: Opioid analgesics should be started using standard dosing protocols but pain management should be carefully monitored since many buprenorphine patients often have decreased pain tolerance and cross-tolerance to opioid analgesics resulting in the need for higher opioid doses and shorter dosing intervals
Because of its high affinity at the opioid receptor Fentanyl should be the opioid of choice for analgesia during surgery and in post-operative care settings
Continue to hold buprenorphine
Patients can be placed on an opioid to address the patient’s baseline opioid requirements and for sustained pain control
If patient also requires intravenous analgesia for breakthrough pain control use Patient Controlled Analgesia pumps (fentanyl, dilaudid or morphine) with NO basal dose. Continue ER/LA opioid
If patient does not require intravenous analgesia for breakthrough pain control use immdiate release (IR)/short-acting (SA) opioids e.g.,hydrocodone, oxycodone, morphine. Continue ER/LA opioid.
Continue to hold buprenorphine
All patients should be continued on ER/LA opioid
Treat patient’s breakthrough pain with IR/SA opioids e.g., hydrocodone, oxycodone, morphine.
Schedule patient to see their buprenorphine provider within 1 week to consider restarting buprenorphine maintenance.

One last caveat:

Recent studies indicate that the pre-operative use of gabapentin (Neurontin) or pregabalin (Lyrica) in the 24 hours preceding surgery results in significant reductions in post-operative pain. (See: gabapentin and Lyrica).

Buprenorphine – Possible Future Use in Acute Pain Management

The use of buprenorphine in the management of acute pain is being explored and is expected to be employed in the future in a variety of settings. A 2011 study evaluated the use of a 0.4 mg sublingual dose of buprenorphine in the emergency room management of extremity fractures and found it as effective as a 5 mg dose of intravenous morphine.

A 2013 study looked at the use of buprenorphine as a local anesthetic in minor oral surgery in combination with the local anesthetic, lidocaine. It was reported that the “addition of small amounts of buprenorphine to 30 ml lidocaine with adrenaline (1:80000) for minor oral surgery resulted in significant improvement in postoperative analgesia up to 36 hours and markedly reduced the need for excessive analgesic intake.”

Emergency Addiction Management

When Taking Buprenorphine

Prescribing Buprenorphine for Opioid Addiction (SUD)

When prescribing buprenorphine for opioid SUD, a physician requires a special license, granted only after receiving proper training and passing a certification exam. Buprenorphine can only be prescribed for SUD in combination with naloxone, the exception being the use of buprenorphine monotherapy with Subutex during pregnancy. It is against regulations for a physician to prescribe buprenorphine products FDA-approved for pain to patients for opioid SUD.

The Emergency Exception: The 3-Day Rule

In the event of an emergency condition in which a patient is in need of their buprenorphine/naloxone medication to avoid opioid withdrawal, a physician “may administer (but not prescribe) narcotic drugs to a person for the purpose of relieving acute withdrawal symptoms when necessary while arrangements are being made for referral for treatment. Not more than one day’s medication may be administered to the person or for the person’s use at one time. Such emergency treatment may be carried out for not more than three days and may not be renewed or extended.”

Thus, in an emergency situation if an opioid-dependent patient is facing an abrupt onset of opioid withdrawal, emergency or urgent care physicians may administer Suboxone or similar medication to an opioid SUD patient. A copy of the 3-Day Rule can be downloaded here, see below.

References:

Buprenorphine – Overviews

Buprenorphine – Management of Emergency Pain

Buprenorphine – Management of Peri-Operative Pain

Buprenorphine – Emergency Management of Addiction/Withdrawal

Buprenorphine three-day-rule

Emphasis on Education

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Accurate Education – Buprenorphine Tx and Emergency Pain, Surgery