the treatment of pain, and buprenorphine/naloxone has been used off-label as an analgesic for chronic pain. 144 Buprenorphine has safety advantages over full mu agonists because respiratory depression tends to plateau as dose increases, and it is also less subject to dose escalation. Use of buprenorphine/ naloxone to treat OUD no longer requires specific training, but a waiver from the Drug Enforcement Administration (DEA) is required to prescribe it. Practitioners are encouraged to receive training prior to use and there are new, short trainings that are freely available (see the following link: https:// elearning.asam.org/products/buprenorphine- mini-course-building-on-federal-prescribing- guidance#tab-product_tab_overview.) Transitioning from a full agonist opioid to the partial opioid agonist of buprenorphine requires careful attention to timing and may best be accomplished with consulting with an HCP experienced in its use. See the following link for support: https://pcssnow.org/. Check the prescribing information for safe induction practice, 153 and consider the following safety principles with buprenorphine analgesia treatment as endorsed by an expert panel: 144 • Buprenorphine may produce acute opioid withdrawal in patients on full mu agonists • Patients discontinue all opioids the night before initiation (time depending on duration of action) • After mild withdrawal is present, initiate 2-4 mg (repeated at two-hour intervals, if well tolerated, until withdrawal symptoms resolve) • Typically, 4-8 mg will be needed the first day • Reevaluate on day two and increase dose if needed • Total dose given on day two can then be prescribed as the daily dose • Unlike treatment for OUD, buprenorphine for analgesia should be given in three-to-four daily doses
Other patients with poor pain control and function who do not tolerate taper well may do better with a very slow taper over many months or even years. 144 Tapering decision points are shown in the following flow chart with the reminder that follow- up timing should be frequent and individualized (Figure 4). 72 Patients who continue on high-dose or otherwise high-risk regimens should be monitored, provided with overdose education and naloxone, and periodically encouraged toward appropriate therapeutic changes. 72 BEFORE MOVING ONTO THE NEXT SECTION, PLEASE COMPLETE CASE STUDY 2 ON THE NEXT PAGE. Managing OUD Methadone and buprenorphine are used to treat OUD, a process known as medication treatment for OUD (MOUD) when combined with behavioral therapy. 69 Buprenorphine works by suppressing and reducing opioid cravings. Methadone reduces cravings and withdrawal and also blunts the effects of opioids. Buprenorphine is widely used and encouraged for treating patients with OUD. 1,18 One reason is buprenorphine’s antagonistic action at the kappa receptor, as this effect is associated with reducing opioid withdrawal symptoms along with helping to attenuate anxiety and depression. 1 HCPs should treat OUD with buprenorphine/ naloxone if authorized by the DEA Drug Addiction Treatment Act of 2000 waiver or should refer the patient for addiction treatment. 144 Recent practice guidelines released by the Substance Abuse and Mental Health Services Administration within HHS are available here: https://www.samhsa.gov/ newsroom/press-announcements/202104270930. Approaching OUD as a chronic illness can help patients to stabilize, achieve remission of symptoms, and establish and maintain recovery. 18
Table 9. Common Opioid Withdrawal Symptoms 144
Physical symptoms
Tremor Diaphoresis
Agitation
Insomnia
Myoclonus
Diffuse pain/hyperalgesia Hyperthermia Hypertension Cramping/diarrhea Pupillary dilation Piloerection Release of stress hormones Pain increase
Affective symptoms
Dysphoria Anhedonia
Anxiety
Depression Hopelessness/suicidal ideation
Follow-up and behavioral health support is very important during tapering. HCPs should acknowledge patient fears of pain, stigma, withdrawal, and abandonment while reassuring them that many patients have improved function after tapering, although the pain might be worse at first. 72,93 This is a time to collaborate with mental- health and other specialists and to watch closely for signs of OUD, anxiety, depression, and suicidal ideation. At least weekly follow-up has been used in successful tapers. 72 In some patients on long-term opioid therapy, even on higher-than-recommended doses, with demonstrated benefit and no evident adverse effects, aberrant behavior, or major risks, taper may not be the best course of action. 144 Reports of harms after involuntary opioid discontinuation include overdoses, termination of care, emergent hospital or emergency department visits, and suicidal ideation or behavior. 144 Though other patient factors may also contribute to these behaviors, opioid stoppage in such patients, particularly when abrupt or nonconsensual, may put them at risk for poor outcomes. 144 Buprenorphine or Slow Taper in Select Patients Patients with worsened pain and function despite high daily opioid doses may exhibit a poor response to taper, whether or not OUD criteria are met, and may benefit from transitioning to buprenorphine. 72 Buccal and cutaneous patches of low-dose buprenorphine are FDA-approved for
Figure 4.
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