What are the pain management options for a patient on Suboxone (buprenorphine/naloxone) and Nortriptyline (nortriptyline) with recent positive Urine Drug Screen (UDS)/Urine Drug Test (UDT) results for hydrocodone, codeine, and morphine?

Pain Management Options for Patients on Suboxone and Nortriptyline with Positive UDS Results

For patients on Suboxone (buprenorphine/naloxone) and nortriptyline with positive UDS for hydrocodone, codeine, and morphine, the most appropriate pain management approach is to first verify the UDS results with confirmatory testing while maintaining the current buprenorphine therapy, then implement a multimodal pain management strategy that includes increasing the buprenorphine dose in divided intervals and adding non-opioid adjuvants. 1, 2

Initial Assessment of Positive UDS Results

• Before making treatment decisions, order confirmatory testing using gas chromatography/mass spectrometry (GC/MS) to verify the unexpected positive results for hydrocodone, codeine, and morphine 1, 3
• Discuss the unexpected results with the patient in a non-judgmental manner to understand potential explanations, as immunoassay screens can have false positives due to cross-reactivity with other medications 1, 3
• Check the prescription drug monitoring program (PDMP) to verify if these medications were legitimately prescribed by other providers 1
• Document the assessment, discussion with patient, and plan clearly in the medical record 1

Pain Management Strategies for Patients on Buprenorphine

First-Line Approach:

• Continue the usual dose of buprenorphine/naloxone maintenance therapy rather than discontinuing it, as this provides a baseline level of analgesia 2
• Increase the buprenorphine dosage in divided doses (every 6-8 hours) as an initial step in managing chronic pain - dosing ranges of 4-16 mg divided into 8-hour doses have shown benefit 2
• Consider switching from buprenorphine/naloxone to buprenorphine transdermal formulation alone for improved pain control 2

Adjunctive Non-Opioid Medications:

• Add adjuvant therapy appropriate to the pain syndrome, including:
  • Gabapentin or pregabalin for neuropathic pain 2
  • NSAIDs for musculoskeletal pain 2
  • Topical agents (lidocaine, capsaicin) for localized pain 2
  • Continue nortriptyline as it provides adjunctive pain relief for neuropathic conditions 2

For Inadequate Pain Control:

• If maximal dose of buprenorphine is reached with inadequate pain control, consider adding a potent opioid such as fentanyl or hydromorphone under close monitoring 2
• Higher doses of additional opioids may be needed due to buprenorphine's high binding affinity for the μ-opioid receptor 2
• For patients with persistent inadequate analgesia despite these strategies, consider transitioning from buprenorphine to methadone maintenance 2

Monitoring and Follow-Up

• Implement more frequent follow-up visits and random UDS monitoring 1
• Consider implementing or revising a pain treatment agreement that clearly outlines expectations regarding medication use and monitoring 1
• Apply UDS monitoring policies uniformly to all patients receiving controlled substances to prevent bias and reduce stigmatization 2, 1
• Screen for depression and other mental health conditions that may impact pain management 2

Important Considerations and Pitfalls

• Do not dismiss patients from care based solely on UDS results, as this could have adverse consequences for patient safety 1
• Be aware that standard UDS may have limitations - many benzodiazepines and other medications may not be reliably detected, and false positives can occur 3
• Recognize that patients on buprenorphine may require higher doses of opioid analgesics due to cross-tolerance and increased pain sensitivity 2, 4
• Avoid using mixed agonist-antagonist opioids (pentazocine, nalbuphine, butorphanol) as they may precipitate withdrawal in patients on buprenorphine 2
• Tramadol may represent an effective treatment option for pain in patients on buprenorphine treatment, showing additive analgesic effects in some case reports 5

Special Considerations for Acute Pain

• For acute pain exacerbations or "breakthrough pain," use small amounts of short-acting opioid analgesics in patients at low risk for opioid misuse 2
• For severe acute pain requiring hospitalization, options include:
  • Continuing buprenorphine maintenance therapy and titrating short-acting opioid analgesics for pain of short duration 2
  • Dividing buprenorphine dose to every 6-8 hours for better pain control 2
  • In inpatient settings, discontinuing buprenorphine therapy and treating with methadone at 20-40 mg plus short-acting opioid analgesics 2