From the Guidelines
For a patient potentially addicted to hydromorphone, the recommended management involves transitioning to buprenorphine for longer-term pain management with reduced addiction potential, as it has been shown to be beneficial in patients with chronic noncancer pain 1. When managing a patient who may be addicted to hydromorphone, it is crucial to consider the risks and benefits of different opioid medications.
- Buprenorphine has been recommended as an initial step in the management of chronic pain, with dosing ranges of 4–16 mg divided into 8-hour doses showing benefit in patients with chronic noncancer pain 1.
- The use of buprenorphine offers several advantages, including its partial opioid agonist properties with a ceiling effect that limits respiratory depression and euphoria while providing effective analgesia.
- Before initiating treatment, patients should undergo comprehensive assessment including substance use history, pain evaluation, and screening for comorbid mental health conditions.
- Adjunctive non-opioid pain management strategies should be incorporated, including NSAIDs, acetaminophen, gabapentinoids, physical therapy, and cognitive behavioral therapy.
- For patients with severe addiction, referral to addiction specialists and consideration of a structured program with psychosocial support may be necessary.
- If a maximal dose of buprenorphine is reached, an additional long-acting potent opioid such as fentanyl, morphine, or hydromorphone should be tried, but with close monitoring due to the potential for increased addiction risk 1. The goal of transitioning to buprenorphine is to provide effective pain management while reducing the risks associated with full opioid agonists and minimizing the potential for addiction.
- It is essential to carefully monitor the patient during the transition period, as buprenorphine can precipitate withdrawal if started too early.
- A closely monitored trial of higher doses of an additional opioid may be necessary if usual doses are ineffective for improving chronic pain 1. By prioritizing the use of buprenorphine and incorporating adjunctive non-opioid pain management strategies, healthcare providers can effectively manage chronic pain in patients potentially addicted to hydromorphone while minimizing the risks associated with opioid use.
From the Research
Recommended Management for Opioid Use Disorder
The recommended management for a patient who may be addicted to hydromorphone involves transitioning to a different opioid with longer pain management efficacy and reduced addiction potential.
- Buprenorphine and methadone are two commonly used opioids for the treatment of opioid use disorder (OUD) 2, 3.
- Methadone has higher treatment retention rates than buprenorphine, while buprenorphine has a lower risk of overdose 2, 3.
- Buprenorphine is recommended for socially stable prescription oral opioid users, particularly if their work or family commitments make it difficult for them to attend the pharmacy daily 2.
- Methadone is preferred over buprenorphine for patients at higher risk of treatment dropout, such as injection opioid users 2.
Transitioning to Buprenorphine
Transitioning to buprenorphine without prerequisite opioid withdrawal is a viable option for patients with OUD 4.
- Sublingual buprenorphine is the most common initial formulation, comprising 55% of cases 4.
- Approximately half of patients experienced any level of withdrawal during buprenorphine initiation, while 7% reported clinically significant withdrawal 4.
- 81% of patients transitioned to buprenorphine successfully 4.
Guidelines for OUD Management
Existing guidelines recommend the use of methadone or buprenorphine to treat OUD and opioid withdrawal 5.
- Guidelines also recommend the use of multimodal, nonopioid therapy, and when needed, short-acting opioid analgesics in addition to buprenorphine or methadone, for acute pain management 5.
- Ensuring linkage to ongoing methadone or buprenorphine treatment and referring patients to psychosocial treatment are also recommended 5.