From the Guidelines
When a patient on home suboxone requires opioid pain control in the hospital, temporarily discontinue the suboxone and initiate appropriate short-acting opioid analgesics at higher doses to overcome buprenorphine's high receptor affinity. This approach is supported by the most recent and highest quality study, which emphasizes the importance of individualizing treatment to the patient's specific circumstances and considering the prescribed daily dose of buprenorphine, indication for treatment, risk of relapse, and expected level of postsurgical pain 1.
Key Considerations
- Document the temporary discontinuation in the patient's chart and consult with pain management specialists if available.
- For mild to moderate pain, consider non-opioid adjuncts like acetaminophen, NSAIDs, or gabapentinoids.
- For severe pain, use short-acting opioids like morphine, hydromorphone, or fentanyl, typically at 2-3 times the usual doses with careful titration and monitoring.
- Once acute pain is controlled and opioid analgesics are no longer needed, coordinate with the patient's suboxone prescriber to resume their maintenance therapy, typically waiting 12-24 hours after the last opioid dose to avoid precipitated withdrawal.
Rationale
The high affinity of buprenorphine for opioid receptors can block other opioids from providing adequate pain relief, making it necessary to temporarily discontinue suboxone and use higher doses of short-acting opioids 1. However, the most recent and highest quality study 1 provides the most relevant guidance on this issue, emphasizing the importance of individualized treatment and careful consideration of the patient's specific circumstances.
Additional Guidance
- Be aware of potential drug-drug interactions, such as those involving QT-prolonging agents, and take steps to minimize risks.
- Consider the use of multimodal analgesia and adjuvant analgesics to enhance pain relief and reduce opioid requirements.
- Ensure that the patient's suboxone prescriber is informed of the temporary discontinuation and plans for resuming maintenance therapy.
From the FDA Drug Label
Buprenorphine hydrochloride injection is indicated for the management of pain severe enough to require an opioid analgesic and for which alternate treatments are inadequate The FDA drug label does not answer the question.
From the Research
Managing a Patient's Home Suboxone Medication in the Hospital
When a patient on home suboxone medication requires opioid pain control in the hospital, several factors should be considered:
- The patient's baseline pain sensitivity and potential need for higher opioid doses to achieve pain relief 2
- The benefits and harms of continuing or interrupting the patient's suboxone medication during acute pain episodes 2, 3
Continuation of Buprenorphine
Research suggests that continuing buprenorphine in patients with opioid use disorder (OUD) during acute pain episodes may reduce the need for additional opioids and minimize the risk of disengagement in care 2, 3
- A systematic review found that patients on buprenorphine opioid agonist therapy (BOAT) may have pain that is more difficult to treat than those not on OAT, but continuing BOAT in the perioperative period may be beneficial 3
- Another study recommended continuing BOAT in the perioperative period when possible and incorporating an interdisciplinary approach with multimodal analgesia 3
Buprenorphine's Pharmacological Properties
Buprenorphine has unique pharmacodynamic and pharmacokinetic properties that make it a preferable option for chronic pain management:
- It acts as a partial agonist with high binding affinity for the μ-opioid receptor, an antagonist with high binding affinity for the δ- and κ-opioid receptors, and an agonist with low binding affinity for the opioid receptor-like 1 receptor 4
- Buprenorphine may have a unique role in mediating analgesic signaling at spinal opioid receptors while having less of an effect on brain receptors, potentially limiting classic opioid-related adverse events 4
Current Evidence-Based Practice
Recent studies have demonstrated that buprenorphine is an effective analgesic agent in both adult and pediatric surgical patients, and can be used to treat chronic pain, particularly in cancer pain and neuropathic pain 5, 6
- Buprenorphine has been recommended as a first-line opioid for chronic pain, especially in the elderly, due to its favorable pharmacological properties and lower risk of misuse and euphoria 6