(74) Multimodal Pain Management in a Patient Taking Extended-Release Buprenorphine

Abstract body:

Introduction:
Buprenorphine is a high-affinity, long-acting partial agonist of the mu-opioid receptor that has been shown to reduce mortality in individuals with opioid use disorder (OUD) (Sordo et al., 2017). In the treatment of acute pain, buprenorphine can limit the analgesic effect of full mu-opioid receptor agonists. Extended-release buprenorphine (XR buprenorphine) is a long-acting subcutaneous formulation that is dosed at 300 mg monthly for the first two months followed by 100 mg monthly thereafter, resulting in steady-state concentrations similar to 24 mg of sublingual (SL) buprenorphine (Nasser et al., 2016). While numerous studies address acute pain management in individuals taking SL buprenorphine (Buresh et al., 2020), very few address pain management in patients taking XR buprenorphine. We present a case of acute and subacute pain management in a woman with OUD stabilized on XR buprenorphine who required an extensive spinal surgery for treatment of scoliosis.

Case Description:
A 40-year-old (she/her) with scoliosis and OUD in remission on maintenance therapy with XR buprenorphine experienced a subacute back pain exacerbation secondary to rapidly progressive scoliosis. After a failure of conservative treatment, a T4 to sacral posterior spinal fusion was recommended by orthopedic surgery.

Initially, the patient continued XR buprenorphine 100 mg with an additional regimen of acetaminophen, meloxicam, gabapentin, cyclobenzaprine, and topical diclofenac. For severe breakthrough pain, oxycodone 10 mg was trialed but later switched higher potency hydromorphone with a maximum dose of 8 mg every 8 hours. Despite some improvement, she still reported significant pain interfering with function, so at the date of her next XR buprenorphine injection, she was transitioned back to SL buprenorphine 8 mg daily with ongoing hydromorphone and non-opioid pharmacotherapies. During this time, visit frequency was increased to every 1-2 weeks and opioids were refilled at 1-week intervals.

During an 8-day hospitalization for surgery, the patient continued acetaminophen, gabapentin, cyclobenzaprine, and SL buprenorphine. Intravenous ketamine, hydromorphone patient-controlled analgesia, and oral oxycodone were added in consultation with the acute pain consultation service. SL buprenorphine was later discontinued due post-operative encephalopathy resulting in inconsistent dosing.

After hospitalization, the patient continued her pre-operative regimen without buprenorphine for two months due to ongoing pain during recovery and initiation of physical therapy. Her pain experience and functional status were reviewed every 1-2 weeks. Two months after surgery, the patient was transitioned back to buprenorphine with her consent. She completed a microinduction to SL buprenorphine 8-12 mg daily without complications, then restarted XR buprenorphine after two weeks on the SL formulation. She is in the process of self-tapering hydromorphone.

Discussion: This case illustrates a multimodal, patient-centered pain management strategy for controlling acute and subacute pain in a patient with OUD stabilized on XR buprenorphine. Several strategies were considered: increasing XR buprenorphine dose to 300 mg, switching to SL buprenorphine in order to split or reduce the dose, or continuing XR buprenorphine 100 mg with other pharmacotherapies. In this case, XR buprenorphine was stopped to achieve adequate pain coverage but was restarted successfully after 2 months. Treatment decisions were made in partnership with the patient to optimize autonomy, safety, and function.

References: Buresh, M., Ratner, J., Zgierska, A., Gordin, V., & Alvanzo, A. (2020). Treating Perioperative and Acute Pain in Patients on Buprenorphine: Narrative Literature Review and Practice Recommendations. Journal of General Internal Medicine, 35(12), 3635–3643.

Nasser, A., Greenwald, M., Vince, B., Fudala, P., Twumasi-Ankrah, P., Liu, Y., … Heidbreder, C. (2016). Sustained-Release Buprenorphine (RBP-6000) Blocks the Effects of Opioid Challenge With Hydromorphone in Subjects With Opioid Use Disorder. Journal of Clinical Psychopharmacology, 36(1), 18–26.

Sordo, L., Barrio, G., Bravo, M. J., Indave, B. I., Degenhardt, L., Wiessing, L., … Pastor-Barriuso, R. (2017). Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies. BMJ, 357, j1550.Diversity, Equity, and Inclusion: Individuals with opioid use disorders often experience social stigma and negative healthcare encounters that result in mistrust and underutilization of healthcare services. We attempted to address this issue by developing a collaborative, multimodal approach to pain management that spanned the pre-operative, peri-operative, and post-operative periods without disruptions that could have resulted in loss to follow up or lapses in communication between the patient and the treatment team. Throughout this period, access to care was prioritized through frequent visits (sometimes utilizing virtual platforms) to re-assess treatment goals.