managing acute pain with buprenorphine split dose and short acting opioid

When patients receiving buprenorphine-naloxone treatment for opioid use disorder experience acute, severe pain that does not respond to nonopioid management, one option is to continue the buprenorphine-naloxone but at a split dose to take advantage of the analgesic properties of buprenorphine, and add short-acting opioid analgesics for a short period of time.

When a patient receiving buprenorphine-naloxone maintenance therapy for opioid use disorder (OUD) experiences acute pain, the maintenance medication will provide very little if any analgesia after the first 6 to 8 hours, both because of tolerance and because of the shorter analgesic half-life of buprenorphine (6-8 hours) compared with its duration of action for treating OUD (24-36 hours). Thus, the best course of action in this setting is to:

  • Divide the patient’s total daily buprenorphine dose into a dosing interval of every 6 to 8 hours for better pain coverage.
  • If the pain is mild to moderate, recommend adjunctive nonopioid treatments. If the pain is more severe, such as after major surgery or significant trauma, recommend a multimodal pain-management strategy — with nonopioid medications (nonsteroidal anti-inflammatory drugs and acetaminophen) as well as epidural/spinal analgesia or nerve blocks.
  • In cases of acute, severe pain where the benefits of opioid analgesics exceed the risks, consider prescribing a short duration (1-3 days) of full agonist opioids, to be taken in combination with the buprenorphine.

Although there has been a theoretical concern that buprenorphine could block the effects of subsequently administered opioid analgesics, recent studies have suggested that concurrent use of opioid analgesics is effective in patients receiving buprenorphine maintenance therapy for OUD. Notably, the patient may need higher-than-usual doses of the short-acting opioid because of cross-tolerance, increased pain sensitivity, and buprenorphine’s high binding affinity. The risks of opioids, including the risks of addiction and overdose death, should be reviewed regularly with every patient receiving opioids. In higher-risk patients, such as those with OUD, a discussion of risks should take priority. Every opioid prescription should be accompanied by a prescription for naloxone, an opioid overdose reversal agent.

For this particular patient, who is currently receiving buprenorphine—naloxone at a dose of 16 mg/4 mg once daily, the best approach is to split this dose such that the patient takes 4 mg/l mg four times daily, add oxycodone 10 mg every 4 hours as needed for pain for 2 to 3 days only, and carefully review the risks of opioids with him, including the risks of relapse and overdose.

Continuing his buprenorphine-naloxone at the current dosing interval without adding additional analgesics would not be appropriate because he is already experiencing acute, severe pain, and nonopioid analgesics were not effective when tried in the emergency department.

Stopping his buprenorphine—naloxone and adding either oxycodone or a nonopioid analgesic (e.g., ibuprofen) would not be appropriate for several reasons:

  • Stopping the buprenorphine would put the patient at risk for relapse in terms of his OUD
  • Providing a full opioid agonist in the absence of buprenorphine would likely increase this risk further.
  • Resuming buprenorphine after monotherapy with a pure mu receptor agonist would require careful supervision and timing. To avoid precipitated withdrawal, buprenorphine can be resumed through a lowdose buprenorphine or a traditional buprenorphine initiation approach.

In a low-dose buprenorphine initiation, patients continue the full agonist while taking small doses of buprenorphine (often in low milligram doses; i.e., 0.25 mg) and gradually increase to therapeutic levels over a period of days. In a traditional induction, the full opioid agonist needs to be stopped for 1 to 2 days, until mild symptoms of opioid withdrawal start to occur, before buprenorphine can be resumed. This patient did not experience pain relief with a potent nonsteroidal antiinflammatory drug (ketorolac) in the emergency department, making the possibility of sufficient analgesia with ibuprofen even less likely.1

Footnotes

  1. NEJM Pain Management and Opioids ↩