P0566 - Transdermal Buprenorphine in Children with Complex Chronic Conditions: A Case Series

Introduction:
Although the incidence of severe chronic abdominal pain is unknown in children with complex chronic conditions (CCC), it can be a distressing and challenging symptom to treat when present. Severe chronic abdominal pain in children with CCC can result from multiple different causes, including but not limited to severe dysmotility, intestinal pseudo-obstruction, and chronic pancreatitis. Although primary pediatricians and/or primary subspecialists often manage this chronic pain, our palliative care team is often consulted for additional pain management support when these children’s pain leads to prolonged hospitalizations and opioid use.

Despite the negative effect of opioids on gastrointestinal activity, at times they may seem unavoidable in this population due to the severity of abdominal pain. In addition, nausea, vomiting, and intolerance of enteral nutrition can limit available routes for medication delivery, leading to treatment with intravenous opioid treatment during hospitalizations. Despite the Centers for Disease Control and Prevention’s recommendations to use non opioids for chronic pain, transdermal buprenorphine may be a treatment option for severe, refractory chronic abdominal pain in children with CCC to minimize pure opioid agonist exposure and decrease frequency and duration of inpatient admissions for pain.

Case Series:
We describe our experience using transdermal buprenorphine in five children with CCC who presented to our palliative care consult service during an acute exacerbation of chronic pain requiring hospitalization and intravenous opioids. After initiation of the buprenorphine patch during their inpatient stay, all five patients achieved improvement in acute pain and discontinuation of intravenous opioids. In addition, all five patients demonstrated decreased number of future acute pain exacerbations requiring hospitalization and decreased chronic pure opioid agonist use. Transdermal buprenorphine was well tolerated in all five patients without side effects. Three patients demonstrated prolonged duration of effect without the need for buprenorphine dose titrations over time.

Discussion:
Buprenorphine, a potent, semi synthetic mixed agonist/antagonist opioid, was developed in the 1960’s and currently remains FDA approved for pain management. In addition to its use in opioid dependency disorder, there is reported safety and efficacy in the treatment of chronic cancer and non-cancer pain in adults. Literature examining the safety and efficacy of buprenorphine use in children is primarily limited to case reports. Although more study is warranted, transdermal buprenorphine is a promising, well tolerated treatment option when treating intractable chronic abdominal pain in children with CCC.