What alternative pain management options can be safely given to an elderly male patient with a right hip fracture, chronic pain, and normal vital signs, who is currently taking gabapentin (300 mg tid) and has received Percocet (oxycodone/acetaminophen) 10/325 mg orally with no change in pain, and does not have access to his usual buprenorphine medication?

Pain Management for Elderly Hip Fracture Patient on Buprenorphine Without Access to Usual Medication

Given that buprenorphine is unavailable and Percocet has failed, you should immediately initiate intravenous morphine at higher-than-standard doses (starting at 0.1-0.2 mg/kg IV, titrated to effect) because buprenorphine's high μ-receptor affinity requires full opioid agonists at increased doses to compete for analgesia, and simultaneously optimize his gabapentin dosing to maximize its analgesic contribution. 1

Understanding the Buprenorphine Challenge

The core problem is that buprenorphine binds with extremely high affinity to the μ-opioid receptor, creating competition with full agonist opioids like oxycodone (Percocet). 1 This explains why standard-dose Percocet provided no pain relief—the buprenorphine is blocking the oxycodone from accessing the receptor. 1

Four evidence-based approaches exist for managing acute pain in patients on buprenorphine maintenance therapy: 1

Option 1: Continue Buprenorphine + Titrate Full Agonist (NOT APPLICABLE - No Buprenorphine Available)

• This approach requires continuing the patient's usual buprenorphine dose while adding short-acting opioids at higher-than-normal doses. 1
• Since buprenorphine is unavailable, this option cannot be used. 1

Option 2: Convert to Methadone + Full Agonist Opioids (RECOMMENDED APPROACH)

This is your best option for this hospitalized patient with severe acute pain. 1

• Immediately convert the patient to methadone 30-40 mg/day (divided into 2-4 doses) to prevent opioid withdrawal and manage baseline opioid requirements. 1
• Methadone binds less tightly to the μ-receptor than buprenorphine, allowing full agonist analgesics to work as expected. 1
• If withdrawal symptoms persist, increase methadone by 5-10 mg increments. 1
• Add IV morphine for acute fracture pain, starting at 0.1-0.2 mg/kg every 4 hours, titrated to effect. 2
• In elderly patients, start at the lower end (0.1 mg/kg) and titrate slowly while monitoring for respiratory depression. 2

Option 3: Discontinue Buprenorphine + Full Agonist Monotherapy

• Stop buprenorphine entirely and treat with scheduled full opioid agonists (sustained-release and immediate-release morphine). 1
• This approach requires careful titration to avoid withdrawal while achieving analgesia. 1
• Critical caveat: When buprenorphine is abruptly discontinued, increased sensitivity to full agonists regarding sedation and respiratory depression can occur. 1

Specific Medication Recommendations

Intravenous Morphine (Primary Analgesic)

Start with IV morphine 0.1 mg/kg (approximately 6-8 mg for average elderly male) administered slowly every 4 hours. 2

• The FDA label specifies starting doses of 0.1-0.2 mg/kg for adults, with lower doses recommended in elderly patients. 2
• Administer slowly to avoid chest wall rigidity. 2
• Expect to need higher doses than typical due to opioid tolerance from chronic buprenorphine use. 1
• Monitor closely for respiratory depression, sedation, and hypotension. 2
• Have naloxone immediately available at bedside. 1

Optimize Gabapentin Dosing

His current gabapentin 300 mg TID (900 mg/day total) is at the minimum effective dose—increase to 600 mg TID (1800 mg/day) over 3-7 days. 3, 4

• The American Academy of Neurology recommends target doses of 1800-3600 mg/day for neuropathic pain conditions. 3, 4
• In elderly patients, titrate slowly by 300 mg increments every 3-7 days. 3, 4
• Critical: Check renal function before increasing dose. 4 Elderly patients invariably have reduced creatinine clearance requiring dose adjustment. 4
• For severe renal impairment (CrCl 15-29 mL/min), maximum dose is 200-700 mg/day as single daily dose. 4
• Gabapentin can serve as a coanalgesic to reduce opioid requirements. 3

Intravenous Acetaminophen

Add scheduled IV acetaminophen 1000 mg every 6 hours as part of multimodal analgesia. 1

• The 2023 WSES guidelines strongly recommend regular IV acetaminophen as first-line treatment in elderly trauma patients. 1
• This is effective and safe in elderly hip fracture patients. 1
• Provides opioid-sparing effects without the risks of NSAIDs in elderly patients. 1

Avoid NSAIDs in This Elderly Patient

Do NOT add NSAIDs given the risks in elderly trauma patients. 1

• NSAIDs are not recommended in perioperative pain management of elderly hip fracture patients due to acute kidney injury and gastrointestinal complications. 1
• If NSAIDs must be used, co-prescribe a proton pump inhibitor and monitor for drug interactions with ACE inhibitors, diuretics, or antiplatelets. 1

Regional Anesthesia Considerations

Strongly consider peripheral nerve block (fascia iliaca or femoral nerve block) for superior analgesia with reduced opioid requirements. 1

• The 2023 WSES guidelines provide a strong recommendation (1A evidence) for peripheral nerve blocks in elderly hip fracture patients at presentation. 1
• This reduces both preoperative and postoperative opioid consumption. 1
• Epidural or spinal analgesia can be considered for postoperative pain if skills are available. 1
• Critical warning: Carefully evaluate anticoagulation status before neuraxial or plexus blocks to avoid bleeding complications. 1

Critical Monitoring Requirements

This patient requires intensive monitoring due to high-risk factors: 1

• Naloxone must be immediately available at bedside. 1
• Monitor level of consciousness and respiration frequently due to variable rates of buprenorphine dissociation from μ-receptor. 1
• Elderly patients have increased sensitivity to opioids and higher risk of respiratory depression. 2, 5
• Watch for oversedation, respiratory depression, and delirium. 1

Plan for Resuming Buprenorphine

When acute pain resolves, discontinue methadone and full agonist opioids, then restart buprenorphine using an induction protocol. 1

• Critical pitfall: Buprenorphine can precipitate opioid withdrawal when restarted. 1
• The patient must be in mild opioid withdrawal before restarting buprenorphine therapy. 1
• Coordinate with the patient's buprenorphine prescriber or addiction treatment program. 1

Common Pitfalls to Avoid

• Never assume standard opioid doses will work—patients on buprenorphine maintenance require higher doses at shorter intervals due to tolerance and receptor competition. 1
• Never abruptly discontinue buprenorphine without a plan—this creates risk of both withdrawal and increased sensitivity to full agonists causing respiratory depression. 1
• Never use mixed agonist-antagonist opioids (like nalbuphine or butorphanol)—these will precipitate acute withdrawal. 1
• Never write PRN-only orders—use continuous scheduled dosing for adequate pain control. 1
• Never forget to notify the addiction treatment program about hospitalization, medications given, and discharge plans. 1

Summary Algorithm

1. Immediately: Start methadone 30-40 mg/day divided into 2-4 doses to prevent withdrawal 1
2. Simultaneously: Initiate IV morphine 0.1 mg/kg every 4 hours, titrated to effect 2
3. Add: IV acetaminophen 1000 mg every 6 hours 1
4. Optimize: Increase gabapentin to 600 mg TID over 3-7 days (after checking renal function) 3, 4
5. Consider: Peripheral nerve block for superior analgesia 1
6. Monitor: Intensive respiratory and sedation monitoring with naloxone at bedside 1
7. Plan: Coordinate with buprenorphine prescriber for eventual reinduction after surgery 1