Patients who have Acute Pain
Patients who are suffering from acute pain can receive treatment for the pain while still taking buprenorphine. Note that buprenorphine itself is usually not sufficient for acute pain management because the duration of analgesia is relatively short. However, in some buprenorphine-maintained patients you can treat pain with buprenorphine (though this use is off-formulary) by increasing and dividing the daily dose and administering it every 6-8 hours (i.e. a patient maintained on 24 mg could take 6 mg every 6 hours).
Note that this will be less effective among patients with a developed opioid tolerance. Additionally, note that buprenorphine blocks the effectiveness of other opioids so they will also have limited effectiveness among buprenorphine patients.
Follow these clinical guidelines when treating acute pain in patients who are maintained on buprenorphine:
- First try to manage the patient's pain with non-opioid analgesics as well as non-pharmacologic therapies and increasing and dividing the buprenorphine dose. Parenteral buprenorphine is another option.
- If a stronger analgesic is needed, continue buprenorphine maintenance and titrate a short-acting opioid to effect. Note that a higher dose opioid agonist may be needed since it will be competing with buprenorphine at the mu receptor. You may want to consult a more experienced buprenorphine provider or pain or addiction expert.
- Administer the opioid analgesic on a scheduled basis (rather than as needed) to avoid breakthrough pain.
Follow these clinical guidelines for patients who will be withdrawn from buprenorphine while the pain is treated:
- Taper the patient off of buprenorphine, then treat the pain with full opioid agonist analgesics. When the pain has subsided, discontinue the analgesics and re-induce the patient back onto buprenorphine.
- Patients who are hospitalized with acute pain (for instance, for emergency surgery) can be switched from buprenorphine to methadone during their hospital stay. Usually a dose of 30-40 mg of methadone will suffice. If pain persists or opioid withdrawal occurs, the methadone dose can be increased in 5-10 mg increments or additional narcotics can be used. When the pain is gone, the patient can be tapered off of methadone and re-induced onto buprenorphine.
Related Resources:
Description:
This brief article gives recommendations for treating buprenorphine patients who have acute pain.
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Annals of Internal Medicine (4 votes)
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Description:
Recommendations and general principles for physicians on managing acute pain in buprenorphine patients.
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Physician Clinical Support System (PCSS) (3 votes)
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This journal article (2006) discusses how to approach the treatment of acute pain in buprenorphine or methadone-maintained patients.
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Annals of Internal Medicine (5 votes)
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This chapter provides information on using buprenorphine in patients who have special circumstances, including patients who have comorbid medical conditions or pain, pregnant patients, and adolescents.
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Substance Abuse and Mental Health Services Administration (SAMHSA) (3 votes)
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Description:
Presentation discussing the treatment of acute and chronic pain in buprenorphine-maintained patients.
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Integrated Substance Abuse Program, UCLA (3 votes)
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