Virginia Research Day 2021

A Case Report of Satisfactory Post Left Knee Replacement Pain Control after Switching from Oxycodone to Buprenorphine Dr. Shuo Qiu 1 , Dr. Sachinder Vasudeva 2 1. Department of Psychiatry and Behavioral Medicine, Carilion Clinic 2. Salem VA Medical Center Introduction Methods Discussion

Our patient endorsed adequate pain control when oxycodone was transitioned to buprenorphine. This begs the question if he could have taken buprenorphine 32 mg daily instead of oxycodone. If so, it would eliminate the need to taper buprenorphine and the risk of opioid withdrawal and relapses. Multiple studies demonstrated adequate pain control when full μ agonists are added on top of buprenorphine. 12,13 However, simply increasing buprenorphine may provide enough pain control without the risk of polypharmacy. There is already ample evidence for using buprenorphine in chronic pain but this case report shows it can also be used for treating acute pain. There are several attractive qualities that warrant considering buprenorphine over full μ opioid agonists. There is a lower risk of respiratory depression compared to other opioids. 14 Due to its partial agonist nature, it is less likely to be abused in patients with a history of substance use disorder. Buprenorphine is also not renally excreted and is safe in patients with renal dysfunction. 15,16 Buprenorphine could serve as an alternative medication before starting full μ opioid agonists, especially in patients with a history of substance use disorder.

Buprenorphine is an opioid partial agonist used to treat opioid use disorder. 1,2 Due to its high affinity to the μ opioid receptor, it is able to displace many opioids (eg. hydrocodone) used for postoperative pain. 1,2 Buprenorphine has intrinsic pain-relieving properties even when only occupying 10% of μ receptors. 3 Progressively greater analgesic property is possible until doses of 24-32 mg where it’s occupying >95% of μ receptors. 3 Studies have shown that buprenorphine can be used to treat chronic pain.4–6 Postoperative pain in patients with opioid use disorder poses a challenge because one must balance between the treatment of pain and the risk of opioid withdrawal. 3,7–9

Discussion The patient was a 65-year-old male with a history of opioid use disorder, chronic knee and hip pain, depression, nicotine use disorder, anxiety, and hepatitis C. He was living at home with his wife and was unemployed. He was getting buprenorphine 16mg daily. His heaviest use of opioids consisted of hydrocodone/acetaminophen unknown dose 10 times a day with an additional unknown dose of methadone. His last use of opioids was 10 years before his surgery. He stopped buprenorphine 48 hours prior to his left total knee replacement surgery. UDS was negative for 1 month prior to surgery. Postoperative pain management included ketorolac 15mg every 6 hours as needed, meloxicam 15mg daily, morphine IV 1-2 mg every 1 hour as needed while in the hospital. On the day of discharge, he complained of 8/10 pain with exertion. He was discharged on postoperative day 3 with oxycodone 5mg every 4 hours as needed for pain level 1-5 and 10 mg for pain level 6-10, with 150 tablets of 5mg tablets given and meloxicam 15mg daily. There was no postoperative complication but the patient experienced significant pain at the incision site after he finished oxycodone. Orthopedics prescribed Aspirin 325mg daily. The patient restarted buprenorphine 32 mg daily using the left-over medication without consulting his buprenorphine provider. He endorsed good pain control on subsequent clinic visits. Buprenorphine dose was gradually decreased to 20mg daily 3 months later. UDS was negative for the next 6 months. Due to its partial agonist activity, buprenorphine has a ceiling for pain relief. Exactly how much pain relief buprenorphine can provide is not currently well studied. No head-to-head studies have been performed to compare buprenorphine with full μ opioid agonists. 5 The patient underwent major surgery and stopped buprenorphine preoperatively. After finishing his oxycodone prescription, this patient complained of significant pain which was relieved when he started taking buprenorphine 32 mg daily. Unbeknownst to him, he took the highest dose of buprenorphine for pain relief. 3 He did not request additional opioid pain medications or seek illicit opioid substances evidenced in his negative urine drug screens. Not only did this patient achieve significant pain control, but he also did not relapse on illicit opioids. Due to buprenorphine’s partial blockade of μ opioid receptors, many providers are concerned about the inability to use full μ opioid agonists. As a result, providers may stop buprenorphine preoperatively, as in the case of this patient. However, tapering buprenorphine preoperatively can precipitate withdrawal symptoms and relapses of opioid use. 3,7,9 Though this patient did not relapse, it is a potential risk and many institutions either continue buprenorphine or reduce rather than stop buprenorphine perioperatively. 9–11

Conclusions

Buprenorphine provides a number of advantages in relieving pain in patients with substance use disorder, but patients should consult with their provider before changing the dose of their buprenorphine, unlike the patient in this case report.

References

Psychopharmacology Institute , psychopharmacologyinstitute.com/section/buprenorphine-for-opioid-use-disorder-mechanism-of-action-2037-4002.

1. Chen KY, Chen L, Mao J: Buprenorphine–Naloxone Therapy in Pain Management. Anesthesiol J Am Soc Anesthesiol . 2014;120(5):1262-1274. doi:10.1097/ALN.0000000000000170 2. Bettinger JJ, PharmD, Fudin J, et al.: Buprenorphine and Surgery: What’s the Protocol? Practical Pain Management. Available at https://www.practicalpainmanagement.com/resource-centers/opioid-monitoring-2nd-ed/buprenorphine-surgery-what-protocol. Accessed July 31, 2020. 3. Anderson TA, Quaye ANA, Ward EN, et al.: To Stop or Not, That Is the QuestionAcute Pain Management for the Patient on Chronic Buprenorphine. Anesthesiol J Am Soc Anesthesiol . 2017;126(6):1180-1186. doi:10.1097/ALN.0000000000001633. 4. Likar R: Transdermal buprenorphine in the management of persistent pain – safety aspects. Ther Clin Risk Manag . 2006;2(1):115-125. 5. Dankiewicz EH: Use of the Low-Dose Buprenorphine Patch: A Response. J Palliat Med . 2014;17(4):379-380. doi:10.1089/jpm.2014.9438. 6. Aiyer R, Gulati A, Gungor S, et al.: Treatment of Chronic Pain With Various Buprenorphine Formulations: A Systematic Review of Clinical Studies. Anesth Analg . 2018;127(2):529–538. doi:10.1213/ANE.0000000000002718. 7. Ward EN, Quaye AN-A, Wilens TE.: Opioid Use Disorders: Perioperative Management of a Special Population. Anesth Analg . 2018;127(2):539-547. doi:10.1213/ANE.0000000000003477. 8. Kunkel FA, Luke C.: Preparing Patients Taking Sublingual Buprenorphine to Treat Addiction for Surgery. Practical Pain Management. Available at: https://www.practicalpainmanagement.com/treatments/pharmacological/preparing-patients-taking-sublingual- buprenorphine-treat-addiction. Accessed July 31, 2020. 9. Lembke A, Ottestad E, Schmiesing C.: Patients Maintained on Buprenorphine for Opioid Use Disorder Should Continue Buprenorphine Through the Perioperative Period. Pain Med . 2019;20(3):425-428. doi:10.1093/pm/pny019. 10. Buresh M, Ratner J, Zgierska A, et al.: Treating Perioperative and Acute Pain in Patients on Buprenorphine: Narrative Literature Review and Practice Recommendations. J Gen Intern Med . Published online August 21, 2020. doi:10.1007/s11606-020-06115-3. 11. Preoperative Opioid Taper Initiative. Available at https://anes-conf.med.umich.edu/opioidtaper/opioidtaper.htm. Accessed July 31, 2020. 12. Kornfeld H, Manfredi L: Effectiveness of full agonist opioids in patients stabilized on buprenorphine undergoing major surgery: a case series. Am J Ther . 2010;17(5):523-528. doi:10.1097/MJT.0b013e3181be0804. 13. Macintyre PE, Russell RA, Usher KAN, et al.: Huxtable CA. Pain relief and opioid requirements in the first 24 hours after surgery in patients taking buprenorphine and methadone opioid substitution therapy. Anaesth Intensive Care . 2013;41(2):222-230. doi:10.1177/0310057X1304100212. 14. Khanna IK, Pillarisetti S: Buprenorphine – an attractive opioid with underutilized potential in treatment of chronic pain. J Pain Res . 2015;8:859-870. doi:10.2147/JPR.S85951. 15. Böger RH: Renal impairment: a challenge for opioid treatment? The role of buprenorphine. Palliat Med . 2006;20 Suppl 1:s17-23. 16. Filitz J, Griessinger N, Sittl R, et al.: Effects of intermittent hemodialysis on buprenorphine and norbuprenorphine plasma concentrations in chronic pain patients treated with transdermal buprenorphine. Eur J Pain . 2006;10(8):743-748. doi:10.1016/j.ejpain.2005.12.001.

Buprenorphine molecular structure “Buprenorphine.” Wikipedia , Wikimedia Foundation, 7 Feb. 2021, en.wikipedia.org/wiki/Buprenorphine.

Heroin molecular structure Heroin Drug Profile , 1 Sept. 2020, www.emcdda.europa.eu/publications/drug-profiles/heroin_en.

Objectives Primary: elucidate the extent of acute pain relief from buprenorphine. Secondary: discuss advantages of using buprenorphine as an analgesic.

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