How to manage acute severe pain in a patient on buprenorphine (partial opioid agonist) therapy?

Managing Acute Severe Pain in Patients on Buprenorphine Therapy

For patients on buprenorphine therapy experiencing acute severe pain, continue the buprenorphine maintenance therapy and aggressively titrate short-acting opioid analgesics at higher doses and shorter intervals to overcome the partial blockade effect. 1

Understanding the Challenge

Buprenorphine presents unique challenges in pain management due to its:

• High binding affinity for μ-opioid receptors (higher than other opioids)
• Partial agonist properties (ceiling effect on analgesia)
• Long half-life and slow dissociation from receptors
• Potential blockade of full opioid agonists 2

Management Algorithm for Acute Severe Pain

Step 1: Maintain Buprenorphine Therapy

• Continue the usual dose of buprenorphine rather than discontinuing it 1, 2
• Verify the maintenance dose with the prescribing physician or clinic 1
• Consider dividing the buprenorphine dose to every 6-8 hours to maximize analgesic effect 1, 2

Step 2: Implement Multimodal Analgesia

• Use non-opioid adjunctive therapies:
  • NSAIDs for pain and discomfort
  • Regional anesthesia techniques when appropriate
  • Gabapentinoids for neuropathic pain
  • Topical agents when applicable 2

Step 3: Add Short-Acting Opioid Analgesics

• Use conventional short-acting opioid analgesics at higher doses and shorter intervals 1
• Expect to need higher doses due to:
  • Cross-tolerance
  • Increased pain sensitivity in opioid-dependent patients
  • Partial blockade from buprenorphine 1
• Use continuous scheduled dosing rather than as-needed orders 1
• Avoid mixed agonist-antagonist opioids (e.g., nalbuphine, butorphanol) as they may precipitate withdrawal 1

Step 4: Alternative Approaches (If Initial Management Fails)

For hospitalized patients with severe pain not responding to the above measures:

1. Consider discontinuing buprenorphine and using full opioid agonists
2. If hospitalized, consider temporarily switching to methadone 20-40 mg with short-acting opioids (have naloxone available)
3. Convert back to buprenorphine therapy when acute pain resolves 1

Special Considerations

• Monitor closely for respiratory depression, sedation, withdrawal symptoms, and pain control 2
• Communicate with the addiction treatment provider about admission, discharge, and medications given 1
• Reassure the patient that their addiction history will not prevent adequate pain management 1
• Discuss the pain management plan with the patient in a nonjudgmental manner to reduce anxiety 1

Common Pitfalls to Avoid

• Discontinuing buprenorphine prematurely: This can lead to withdrawal and increased risk of relapse 3
• Underestimating opioid requirements: Patients on buprenorphine often need higher doses of opioid analgesics 1, 4
• Using PRN dosing: Scheduled dosing is more effective than as-needed orders 1
• Inadequate communication: Failure to coordinate with addiction treatment providers can lead to gaps in care 1
• Stigmatizing attitudes: These can impair effective pain management and patient trust 1

Recent evidence from a 2023 study shows that continuation of outpatient buprenorphine therapy in trauma patients is associated with decreased daily opioid requirements while maintaining similar analgesic efficacy compared to discontinuation 4, supporting the recommendation to maintain buprenorphine therapy during acute pain episodes.