Can I administer a one-time evening dose of Suboxone (buprenorphine) to a patient with headache and abdominal pain who declined their morning dose and is being treated for ethanol (ETOH) abuse?

Managing Acute Pain in a Patient on Suboxone for Alcohol Abuse

Yes, you should administer the one-time evening dose of Suboxone to the patient experiencing headache and abdominal pain who declined their morning dose. 1

Rationale for Administering the Missed Dose

When patients on opioid agonist therapy (OAT) like Suboxone (buprenorphine) experience acute pain:

1. Maintaining baseline OAT is critical - Continuing the usual dose of OAT is essential to prevent withdrawal and maintain stability 1
2. Missed doses should be replaced - The patient declined their morning dose but now needs it for pain management
3. Pain management is a priority - Headache and abdominal pain should be addressed promptly to prevent worsening symptoms

Pharmacological Considerations

• Buprenorphine has analgesic properties that can help manage the patient's current pain symptoms 2
• For patients with acute pain who are on buprenorphine maintenance:
  • The American College of Physicians recommends maintaining buprenorphine dosing 2
  • Dividing the daily dose can take advantage of buprenorphine's analgesic properties 1

Implementation Plan

1. Administer the missed dose - Provide the scheduled Suboxone dose that was declined in the morning
2. Monitor response - Assess if the dose adequately addresses the headache and abdominal pain
3. Consider additional interventions if pain persists:
   • Non-opioid analgesics (NSAIDs, acetaminophen) may be added for multimodal pain management 1
   • For severe pain, short-acting opioid analgesics can be titrated alongside buprenorphine maintenance therapy 1

Special Considerations for This Patient

• Alcohol abuse history - The patient is admitted for alcohol abuse, not opioid use disorder, which is important to note
• Headache and abdominal pain - These symptoms could be related to alcohol withdrawal or other causes
• No other pain medications ordered - Suboxone may be the only available option for pain management at this time

Potential Pitfalls to Avoid

• Do not withhold the scheduled dose - Withholding buprenorphine can lead to withdrawal symptoms and worsen pain 1
• Avoid assuming drug-seeking behavior - Pain complaints in patients with substance use disorders are often undertreated due to stigma 1
• Do not add benzodiazepines - These can increase risk of respiratory depression when combined with buprenorphine 2

Documentation and Communication

• Document the administration of the one-time evening dose
• Communicate with Dr. Patel about the patient's pain and the administered dose
• Consider consulting addiction medicine specialists for ongoing management if pain persists

By providing the missed Suboxone dose, you will help manage the patient's pain while maintaining their addiction treatment regimen, which aligns with best practices for pain management in patients receiving OAT.