From the Guidelines
When up-titrating OxyNorm (immediate-release oxycodone) for breakthrough pain in palliative care patients already using buprenorphine patches, start with 5-10 mg every 4-6 hours as needed and increase by 5 mg increments if pain control remains inadequate, as this approach is supported by the most recent and highest quality study available 1.
Key Considerations
- The typical effective dose range is 5-20 mg per dose, and buprenorphine patches can be used alongside full opioid agonists like oxycodone without significant antagonistic effects at therapeutic doses, contrary to older beliefs.
- This combination works because buprenorphine at analgesic doses only partially occupies mu-opioid receptors, leaving receptors available for full agonists to bind.
- Monitor patients closely for side effects including sedation, respiratory depression, and constipation, especially during dose adjustments.
- Ensure regular laxative use and consider antiemetics as needed.
- Document breakthrough pain episodes and medication effectiveness to guide further adjustments.
Clinical Evidence
- The 2017 HIVMA of IDSA clinical practice guideline for the management of chronic pain in patients living with HIV recommends increasing the dosage of buprenorphine in divided doses as an initial step in the management of chronic pain, and switching to a long-acting potent opioid such as fentanyl, morphine, or hydromorphone if a maximal dose of buprenorphine is reached 1.
- The guideline also suggests that if usual doses of an additional opioid are ineffective for improving chronic pain, a closely monitored trial of higher doses of an additional opioid may be necessary, as buprenorphine's high binding affinity for the μ-opioid receptor may prevent the lower doses of other opioids from accessing the μ-opioid receptor.
Practical Application
- When managing breakthrough pain in palliative care patients using buprenorphine patches, it is essential to consider the individual patient's response to treatment and adjust the dose of OxyNorm accordingly.
- Regular monitoring of the patient's condition and adjustment of the treatment plan as needed can help optimize pain control and minimize adverse effects.
- The use of adjuvant therapy, such as nonpharmacologic treatments, steroids, nonopioid analgesics, and topical agents, may also be beneficial in managing breakthrough pain in these patients 1.
From the Research
Buprenorphine Titration in Palliative Care
To up-titrate or adjust the dosage of buprenorphine in palliative care patients, especially those taking a buprenorphine patch, several factors and strategies should be considered:
- Microdosing Strategy: The use of microdosing inductions, where buprenorphine is gradually titrated while full agonist opioids are continued, is a viable approach for patients on higher doses of opioids 2.
- Individualized Approach: Microdosing regimens should be individualized based on local guidelines and patient-specific factors, considering the unique pharmacology of buprenorphine and its advantages in palliative care 2, 3.
- Available Formulations: Buprenorphine is available in various formulations, including sublingual tablets, transdermal patches (Butrans®), and buccal films (Belbuca®), each with its own considerations for initiation and conversion strategies 3.
- Initiation and Conversion: When initiating buprenorphine, especially in patients with opioid use disorder, understanding the requirements for an opioid-free interval or withdrawal during the transition is crucial, and microdosing can offer a gradual and safer transition 2.
- Pain Management: Buprenorphine's unique pharmacological properties make it an effective option for managing chronic pain in palliative care, with less concern for respiratory depression and constipation compared to full agonist opioids 3, 4.
Considerations for Palliative Care Patients
Palliative care patients taking buprenorphine patches or other formulations should be monitored closely, considering:
- Drug-Drug Interactions: Understanding potential drug-drug interactions and managing them appropriately is essential for safe buprenorphine use in palliative care 3.
- Ideal Patient Populations: Identifying ideal populations for buprenorphine use within palliative care, such as patients with comorbid substance use disorder or those at risk of opioid misuse, can help in making informed treatment decisions 3, 4.
- Clinical Guidelines: Following clinical guidelines and recommendations for buprenorphine use in palliative care, including those related to dosing and titration, can ensure optimal patient outcomes 5, 6.