From the Guidelines
When treating a patient on daily buprenorphine with IV opioids for acute severe pain, discontinue buprenorphine therapy and treat the patient with full scheduled opioid agonist analgesics by titrating to effect to avoid withdrawal and then to achieve analgesia. This approach is recommended due to the high affinity of buprenorphine for the μ receptor, which can complicate pain treatment with opioids 1. The patient's buprenorphine therapy can be resumed after the acute pain has resolved, using an induction protocol 1.
Some key considerations when treating patients on buprenorphine with IV opioids include:
- Monitoring patients closely for respiratory depression, sedation, and inadequate pain control
- Using higher doses of full opioid agonists to overcome buprenorphine's partial blockade effect
- Considering multimodal analgesia with NSAIDs, acetaminophen, ketamine, regional anesthesia, and non-pharmacological approaches to reduce opioid requirements
- Gradually tapering the full agonist opioids while maintaining the buprenorphine dose to prevent withdrawal and ensure continued opioid use disorder treatment when the acute pain resolves
It is essential to note that clinical experience treating acute pain in patients receiving maintenance therapy with buprenorphine is limited 1. Therefore, consultation with pain specialists or addiction medicine physicians may be necessary for complex cases, especially for patients on higher buprenorphine doses (>16mg daily). Additionally, naloxone should be available, and the level of consciousness and respiration should be frequently monitored due to the highly variable rates of buprenorphine dissociation from the μ receptor 1.
From the FDA Drug Label
DOSAGE AND ADMINISTRATION • Buprenorphine hydrochloride should be prescribed only by healthcare professionals who are knowledgeable about the use of opioids and how to mitigate the associated risks. Use the lowest effective dosage for the shortest duration of time consistent with individual patient treatment goals [see WARNINGS] Because the risk of overdose increases as opioid doses increase, reserve titration to higher doses of buprenorphine hydrochloride for patients in whom lower doses are insufficiently effective and in whom the expected benefits of using a higher dose opioid clearly outweigh the substantial risks. Respiratory depression can occur at any time during opioid therapy, especially when initiating and following dosage increases with buprenorphine hydrochloride Consider this risk when selecting an initial dose and when making dose adjustments [see WARNINGS]. In high-risk patients (e.g., elderly, debilitated, presence of respiratory disease, etc.) and/or in patients where other CNS depressants are present, such as in the immediate postoperative period, the dose should be limited to the minimum required. Extra caution should be exercised with the intravenous route of administration, particularly with the initial dose.
The main risks to consider when treating a patient on daily buprenorphine with IV opiates for acute severe pain are:
- Respiratory depression: can occur at any time during opioid therapy, especially when initiating and following dosage increases.
- Overdose: risk increases as opioid doses increase.
- Addiction, abuse, and misuse: buprenorphine contains a Schedule III controlled substance and exposes users to these risks.
- Concomitant use with benzodiazepines or other CNS depressants: can result in profound sedation, respiratory depression, coma, and death. To mitigate these risks, it is essential to:
- Use the lowest effective dosage for the shortest duration of time.
- Monitor patients closely for signs of respiratory depression and overdose.
- Assess each patient's risk for opioid addiction, abuse, or misuse prior to prescribing buprenorphine.
- Exercise extra caution with the intravenous route of administration, particularly with the initial dose.
- Limit the dose to the minimum required in high-risk patients and/or in patients where other CNS depressants are present 2.
- Be aware of the potential for drug-related mortality when using opioid analgesics and benzodiazepines concomitantly 2.
From the Research
Risks and Cautions
When treating a patient on daily buprenorphine with IV opiates for acute severe pain, several risks and cautions should be considered:
- Precipitated opioid withdrawal: Buprenorphine can precipitate opioid withdrawal in patients physically dependent on full agonist opioids 3, 4.
- Inadequate analgesia: Buprenorphine's partial agonist properties may limit the effectiveness of full agonist opioids for acute pain management 5, 6.
- Iatrogenic harm: Stopping buprenorphine preoperatively or at the onset of acute pain can lead to relapse and difficulties transitioning back to buprenorphine after acute pain has resolved 6.
- Respiratory depression: Combining buprenorphine with full agonist opioids can increase the risk of respiratory depression 5.
Management Strategies
To mitigate these risks, the following management strategies can be employed:
- Continuing buprenorphine in the perioperative or acute pain period for patients with opioid use disorder 6.
- Using a multi-modal analgesic approach, including both opioid and non-opioid analgesic options for breakthrough pain 5, 6.
- Individualized approach founded upon shared decision-making, taking into account patient-specific factors and buprenorphine formulation 7.
- Considering alternative treatments, such as ketamine, for buprenorphine precipitated opioid withdrawal 4.