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Buprenorphine for Pain -- What are essential elements of counseling for patients?

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When counseling patients without OUD on opioids for non-cancer pain, what are essential elements of that risk/benefit discussion? Hoping to use as a template to help train more providers to use bupe as an option for pain.

Would love effective quotes you use for this discussion and feedback on what should or shouldn't be on this list. Thanks!

The 2019 HHS Opioid tapering guidelines include using buprenorphine but don't detail this practical information (attached).


·         Buprenorphine is Effective for pain

o   Smoother longer lasting pain control

§  Explain opioid withdrawal between doses short-acting opioids

o   Improved opioid hyperalgesia

o   FDA approved for moderate to severe pain buccal & transdermal

§  Sublingual off-label for pain

·         But widely used

·         Less side effects than traditional opioids

o   Most think more clearly, feel more alert

o   Less constipation

o   May have less depression or irritability

·         Safer opioid option

o   More active in spinal cord than brain

o   Less overdose risk/respiratory depression

o   Fewer drug interactions

o   No dose adjustments for renal function

·         Also used to treat opioid use disorder (OUD)

o   First used for pain in US in 1980s

o   Used for addiction starting in 2000

§  Being prescribed for pain doesn’t mean you have addiction

·         Route of administration different from most medicines

o   Sublingual or buccal absorption

o   Very little oral bioavailability

·         Starting buprenorphine while taking opioids requires special instructions

o   Must Initiate after period of withdrawal

o   Or use microdosing to overlap with current opioid

§  Small amounts of sublingual buprenorphine (Bernese)

§  Transdermal buprenorphine patch to sublingual

·         Dosing for pain is generally lower than for OUD

o   Pain dosed 2-4 times/day

§  1-2mg TID to start

§  4-12mg/day typical dose

§  Max typically 8mg TID (24mg/day)

·         For acute pain, multiple ways to get pain relief


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[using the attached diagrams]

  • When you first start taking a short-acting opioid like hydrocodone, it's like a miracle how great it works to relieve your pain.  When it wears off, it's time to take another one.  Every time you take it, though, it does a little less and, when it wears off, the pain comes back little more and a little sooner.  Day after day, week after week, month after month this continues to progress.
  • Eventually, you may experience not only pain but also anxiety and even some withdrawal symptoms.  You take your opioid pain medication and get some relief.  However, it's nowhere near the relief you used to experience.  That never seems to happen anymore. What does always happens is that it wears off - usually too soon.  You look at the clock to see if it's time to take your medication and realize that you have to wait.  We even have a name for this - clock-watching.
  • This is tolerance, NOT addiction.
  • Finally, it's time to take your medication and you get some relief.  Again, nothing close to the relief you once used to get.  This will go on forever.  It will never end as long as we continue to prescribe short acting opioids.  You live your life a few hours at a time.  
  • If you run our or decide to stop taking the opioid you are left with prolonged pain, anxiety, and possibly withdrawal symptoms.  That's when people will sometimes do what they would't normally do like take someone else's pain medication or look to just about anything else for relief. 
  • Buprenorphine is a long-acting, partial agonist opioid.  That means it only partially actives the opioid receptor and it stays in your system for more than a day after you take it. It helps with hyperalgesia which is increased sensitivity to pain caused by opioids. It can be used to gradually taper-off opioids without intolerable withdrawal symptoms or it can be continued on as maintenance for pain indefinitely.

Opioid Tolerance.pdf Buprenorphine.pdf

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From Greg Rudolf, certified in addiction and pain medicine:
I usually preface the recommendation for bup with a discussion about typical unintended negative consequences of chronic use of commonly prescribed opioids. If they are on a short-acting opioid like oxycodone or hydrocodone I highlight the expected “ups and downs” in levels (you described it as going in and out of withdrawal in one of your prior messages) and I Iike to point out that this is never the intended use of short-acting opioids, which are most helpful in treating acute pain from injury or surgery, or when used episodically (not daily) for a condition characterized by spikes of pain. When used multiple times daily over the long term, tolerance, “hyperkatifeia” (https://en.m.wikipedia.org/wiki/Hyperkatifeia)and opioid-induced hyperalgesia are not only common but expected. Most patients have not heard about OIH and that is typically received as revelatory.
Of note, these issues can all be present with “long-acting” opioids too, albeit with less pronounced instability of levels. MS Contin, for example, generally wears off well within 8hrs between doses for most. Methadone was the subject of a landmark study by Compton demonstrating OIH. Of course short-acting opioids are typically added in combination.
I also discuss the mechanism of opioid overdose, ie opioid receptors in the brainstem, and effects on alertness, mood and cognition via affects on cortical processing. Many patients will admit to knowing they are at least mildly impaired in this regard; others will not. I tell them “You may be right, but when you’ve been on a medication the same way every day for years it can be hard to know how it is affecting you”.
After this discussion, I talk about buprenorphine and its unique and complex pharmacology within the opioid class, and how it generally resolves most or all of the above issues with other opioids.
1) very long half life producing stable levels which results in more even pain control and better sleep, no change in mood or energy level between doses, no more “looking at the clock to see if it is ok to take the next dose”
2) Very potent analgesic effects, up there with the highest potency opioids and characterized as 50-100x morphine
3) Despite very high potency it is less affecting to the brain because its activity is directed at spinal level opioid receptors primarily, whereas other opioids target brain primarily. This renders bup not only less affecting cognitively and behaviorally, but also safer due to minimal effect at brain stem. This is a good time to explain to the Pt that it is for these specific reasons that bup is used and effective in treatment of OUD.
4) I then go back to the concept of OIH and emphasize that bup uniquely acts as a kappa opioid receptor antagonists and therefore “reboots” opioid pathways, as the KOR is implicated in development of tolerance and OIH. This same mechanism is preserved for pts that stay on bup for pain over time; that is, they do not develop tolerance and OIH. I tell pts I have a lot of folks I have been working with for 10+ years, and nobody ever needs a dose increase unless there is an acute event. In fact most people decrease their dose over time without even trying to, they just don’t feel the need to take as much. Basically the opposite of other opioids in this regard.
The article I authored and sent you goes into all of the above and then some, with references. For pts who might appreciate seeing something in writing and would not be put off by a journal article, I would suggest giving it to them.
Bottom line: give pts credit for having the intelligence to understand the pharmacologic advantages of bup. They need to know that this is not just about “the opioid crisis” and doctors wanting everybody off “real” opioids. This is actually about improving the patient’s pain control and quality of life, and doing so in a very safe and sustainable fashion.

Rudolf Bup for chronic pain review 2020.pdf

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