Buprenorphine can be an effective part of a treatment plan for opioid-use disorder, but a quandary sometimes occurs when anesthesia is necessary in a patient taking the drug chronically for OUD. A recent study using VA data advised, however, that buprenorphine can be safely continued in most patients with various sources of pain management, irrespective of the initial diagnosis of chronic pain or OUD.
Click to Enlarge: TDD change from index date to discharge with or without additional pain medications Source: Journal of the American Pharmacists Association
DURHAM, NC — Opioid-use disorder (OUD) has been referred to as a battle that takes more lives every year than the Vietnam or Korean wars.
According to the national Centers for Disease Control, opioid overdoses killed more than 80,000 people in 2021. While OUD can affect anyone, veterans have numerous risk factors—including chronic pain, mental health conditions and trauma—that place them at particular risk. Research indicates that veterans die from opioid-related overdoses at roughly twice the rate of the general population.
To combat this deadly disorder, many clinicians have found it increasingly necessary to consider safe and effective therapies to mitigate its risks for patients. One of these therapies is buprenorphine, a schedule III, partial mu-opioid agonist that is FDA approved for moderate-to-severe acute and chronic pain.
As a partial agonist at the mu-opioid receptor, buprenorphine offers potent analgesia while also providing the benefit of a ceiling effect on respiratory depression. Moreover, it interacts with other opioid receptors, such as the delta-opioid receptor, kappa opioid receptor and opioid receptorlike 1, mitigating adverse effects, influencing mood, benefiting diverse pain conditions and decreasing the risk of tolerance and dependence.
Acute Pain Presents a Prescribing Dilemma
While buprenorphine has shown to be an effective part of a treatment plan for opioid-use disorder, a dilemma arises when a person taking the drug chronically for OUD undergoes an acutely painful event, such as surgery, that requires anesthesia. On the one hand modifying buprenorphine use poses the risk of inadequately managed pain. Discontinuing buprenorphine also has numerous implications, including risk of opioid-induced hyperalgesia that may require intensification of opioid therapy following surgery. Additionally, patients may suffer from worsening pain and withdrawal syndromes when other pain regimens are substituted for nonopioid analgesics.
With minimal information to guide them through this dilemma, researchers turned to VA electronic health records to characterize “what treatment modality is being completed in practice and to determine if it was safe and effective for patients,” said Alexis C. Jones, PharmD, PGY-2 Ambulatory Care Pharmacy Resident at the Durham, NC, VA Health Care System.
The researchers conducted a retrospective cohort study using data collected from electronic health records from Jan. 1, 2012 to Jan. 1, 2022, said Jones. Eligible patients included those who received an outpatient prescription for buprenorphine and presented to the VA emergency department for the treatment of acute pain or presented for a surgical procedure during the time period. Patients were excluded if the buprenorphine prescription was in the buccal or transdermal formulation, prescription was written by a non-VA provider, or the veteran received a full agonist opioid 30 days before the index date. “After the patients were identified, as much information that could be pulled from the corporate data warehouse were pulled into a database and the rest of the information needed was collected via chart review,” she said.1
Continuation of Chronic Buprenorphine Therapy Was Common
A total of 70 of 259 screened patients—78.6% of whom had an OUD diagnosis—met inclusion criteria. While 84.3% presented to the emergency department, 15.7% underwent surgical procedures.
“The primary outcome was to characterize buprenorphine treatment strategies based on the change in total daily dose between the index data and discharge date,” Jones said. The total daily dose of buprenorphine/naloxone from index date to discharge was continued in 90% of cases, increased in 2.9% of cases, decreased in 1.4% of cases and discontinued in 5.7% of cases.
“Based on the outcomes of this review, the continuation of chronic buprenorphine therapy was the most common practice observed,” said Jones, noting that safety concerns, such as representation for acute pain, OUD relapse, overdose or mortality, were not “clinically meaningful.”
“This study suggests that buprenorphine can be safely continued in most patients with various sources of pain, irrespective of the initial diagnosis of chronic pain or OUD,” Jones said.
She said to her knowledge, the review is the first to characterize acute and postsurgical pain management in a veteran population on chronic buprenorphine or buprenorphine/naloxone therapy.
She added, future large, prospective studies are needed to identify the best strategies and clear recommendations on how to most effectively manage acute pain in patients receiving buprenorphine products.
- Jones, A. C., Tillman, F., 3rd, Kahlon, C., Seys, R., & Pepin, M. (2024). Characterizing acute and postsurgical pain management in patients receiving buprenorphine or buprenorphine/naloxone. Journal of the American Pharmacists Association : JAPhA, 102035. Advance online publication. https://doi.org/10.1016/j.japh.2024.02.008