UMEM Educational Pearls

Title: Treatment of Acute Pain in Patients on Buprenorphine

Category: Pharmacology & Therapeutics

Keywords: Buprenorphine, Acute Pain (PubMed Search)

Posted: 2/6/2021 by Wesley Oliver
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Buprenorphine is a partial opioid receptor agonist that has a higher binding affinity than pure opioid agonists. There can be unease in managing acute pain in patients sustained on buprenorphine for opioid use disorder due to many factors.

The main barriers to effective pain management in these patients are:

Opioid-Induced Hyperalgesia
1. Patients maintained on buprenorphine can have an increased sensitivity to pain.
2. Consider using a multimodal approach that optimizes non-opioid analgesics, such as acetaminophen and nonsteroidal anti-inflammatory drugs.
Opioid Tolerance
1. Patients maintained on buprenorphine require higher doses of opioids to treat acute pain due to the decreased effectiveness of opioids over time.
2. As in hyperalgesia, a multimodal approach can be beneficial.
3. Higher doses of supplemental opioids will be required in these patients compared with opioid-naïve patients.
4. Titrate supplemental opioids to effect and monitor for toxicity.
Opioid Withdrawal
1. Opioid withdrawal symptoms can contribute to stress and anxiety, increasing pain sensitivity.
2. To prevent withdrawal symptoms it is appropriate to continue buprenorphine throughout the episode of acute pain.
3. The patient's typical home dose of buprenorphine can be utilized.

Take Home Points
In general, the treatment strategy for acute pain in patients on buprenorphine should be:

Optimize non-opioid analgesia.
Use supplemental opioids when needed.
- Will likely require higher doses.
- Titrate to effect.
- Monitor for toxicity.
Continue buprenorphine therapy at home dose throughout the acute pain episode.

References

Coffa D, Carr D. Management of acute pain in adults with opioid use disorder. In: Crowley M, ed. UpToDate. Waltham, MA: UptoDate Inc. https://www.uptodate.com/contents/management-of-acute-pain-in-adults-with-opioid-use-disorder. Accessed February 5, 2021.
Quinlan J, Cox F. Acute pain management in patients with drug dependence syndrome. Pain Rep. 2017;2:e611.