Overview
This episode of the Curbsiders Addiction Medicine miniseries features Dr. Will Becker discussing the use of buprenorphine for chronic pain, with a focus on assessment strategies, switching methods from traditional opioids, and practical clinical considerations.
Podcast and CME Information
- Curbsiders offers ad-free episodes and bonus content via Patreon, with a discounted annual rate.
- Free CME credits are available through VCU Health CE for listeners at curbsiders.vcuhealth.org.
- The American College of Academic Addiction Medicine (ACAAM) supports the series and offers various self-study and board prep products.
Case Introduction: Chronic Pain Management
- Case: 72-year-old veteran with chronic back pain on long-term, high-dose oxycodone.
- Patient reports increased sensitivity to pain, reduced effectiveness of opioids, and occasional early medication runs.
Approaching Chronic Pain Assessment
- Allocate 30–40 minutes for comprehensive pain assessment.
- Focus on understanding the patient’s pain experience and overall functional status, not just opioid efficacy.
- Use open-ended questions about daily activities and functional limitations rather than numeric pain scales.
- Evaluate changes in pain and function over 6–12 months to assess benefit versus harm of opioids.
Considering Changes in Opioid Regimen
- Engage patient buy-in by emphasizing potential for improved function and quality of life over mere safety.
- Discuss changes to the opioid regimen and non-opioid treatments as separate but complementary options.
Use of Buprenorphine for Chronic Pain
- Buprenorphine shows promising observational evidence for improving pain, function, and quality of life, though robust RCTs are pending.
- It is a partial agonist with high receptor affinity, less risk of respiratory depression, and potentially fewer side effects.
- Developed originally as a pain medication and effective for analgesia at lower doses.
Assessing for Opioid Use Disorder (OUD)
- Physical dependence (e.g., tolerance, withdrawal) is expected with long-term opioid therapy and does not equate to OUD.
- OUD diagnosis requires evidence of compulsive use or loss of control, not just difficulty tapering.
Buprenorphine Initiation and Formulations
- FDA-approved formulations for pain: transdermal patch and buccal film; sublingual form for OUD but used off-label for pain.
- Dose and formulation selection depend on current opioid requirements; high MME needs sublingual preparations.
- Insurance coverage for off-label use may be challenging.
Switching to Buprenorphine: Methods
- Traditional method: stop full agonist opioids, wait for withdrawal, then start buprenorphine.
- Overlap/microdosing method: introduce low-dose buprenorphine while maintaining full agonist, titrate over 4–5 days before discontinuing the full agonist.
- Overlap approach is preferred for tolerability and patient acceptance.
Use of Full Agonists with Buprenorphine
- Adding a full agonist may be appropriate for chronic pain patients without OUD if buprenorphine alone is insufficient.
- For acute pain (e.g., surgery), full agonists can be temporarily added to ongoing buprenorphine; limit the duration to 3–5 days.
- Oxycodone, hydrocodone, and hydromorphone are commonly considered, with selection based on patient preference, medical contraindications, and insurance approval.
Key Clinical Takeaways
- Prioritize functional assessment and long-term perspective in pain management.
- Frame buprenorphine as a means to improved function and well-being, not just a safer option.
- Overlap initiation of buprenorphine is well tolerated and now preferred.
- Maintain transparency, flexibility, and provide patient options to enhance engagement.
Recommendations / Advice
- Ensure thorough assessment focused on function before changing opioid regimens.
- Consider overlap initiation for buprenorphine to improve patient experience.
- Always check insurance coverage for chosen formulations.
Questions / Follow-Ups
- Monitor for expanded FDA approval for high-dose buprenorphine for pain.
- Stay updated on insurance policies regarding buprenorphine formulations.
Podcast Credits and Acknowledgments
- Special thanks to ACAAM, episode editors, and production team.
- Feedback and CME access via curbsiders.vcuhealth.org and curbsiders.com/addiction.