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Severe COPD and Chronic Pain


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This question was submitted through pcssNOW.org:

For a patient with severe COPD in chronic pain, i think suboxone or other buprenorphine would be safest, and if the Butrans patch is not affordable, is there another regimen that could be tried, even is off label but accepteable in the state of SC. Can that example of what i could use, what starting dose, and what I can titrate to be illustrated?

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I’m not aware of specific data on treating pain with buprenorphine among patients with COPD who lack a DSM diagnosis. Patients with severe COPD would typically have been excluded from studies examining bup/nx maintenance treatment of DSM-IV opioid dependence or DSM-5 opioid use disorder.  Here’s link from a prior Listserv question on using buprenorphine for air hunger and COPD, which might have some useful information for your case: http://pcss.invisionzone.com/topic/1221-does-bup-help-with-air-hunger-in-copd-patients/.

In general, if after weighing the pros/cons with the patient you elect to start buprenorphine treatment, careful titration would be prudent with low dose initiation and close monitoring. Typically for someone who lacks physical dependence, a starting test dose could be as low as 0.5mg or 1mg. The smallest dose preparation is Zubsolv (0.7/0.18 bup/nx tablet). Given the greater absorption and bioavailability of Zubsolv compared to other preparations, a 0.7mg dose of Zubsolv has a comparable bioequivalence of about 1mg for the standard tablet/film formulations.  Many patients report greater pain relief benefit with split dosing regimens. The final daily dose will vary but should target the minimally effective dose while considering functional goals, tolerable pain relief, and avoidance of adverse effects. Prior to initiation, it would be prudent to review state guidelines and document clinical rationale along with informed consent about pros/cons and options. 

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At what point would you recommend Belbuca over Zubsolv or Suboxone for patients at higher risk of opioid induced respiratory depression (such as severe COPD) but who also have opioid dependence?  Studies excluded patients with serious illness, but many patients with serious illness also have opioid dependence and chronic pain.  It appears for buprenorphine, our choices are Butrans (very low dose, slower to titrate given once weekly patch changes), then maybe Belbuca up to 900mcg q12h, then Suboxone 1mg (half of 2mg film).

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In addition to a lack of effectiveness data, regulatory restrictions preclude the use of Belbuca for opioid use disorder treatment, even off-label. However, the bup-products FDA-approved for opioid use disorder treatment may be used off-label for non-OUD indications, such as for pain. If the primary treatment indication is opioid use disorder, and the patient is transitioning from full mu opioids, treatment with a bup/nx-product would likely lower overall risk including in cases of severe COPD. The recent JAMA-IM article (ref below) suggesting sustained-release morphine tolerability with refractory breathlessness in COPD might assuage some of the respiratory concerns. However, careful monitoring and slow titration would be prudent as you've alluded to. The use of bup/nx-containing films might help as the medication is evenly distributed throughout the film, allowing for cutting into even fragments such as 1/2 of a film as you mentioned or even smaller. 

https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2769373

Verberkt CA, van den Beuken-van Everdingen MHJ, Schols JMGA, Hameleers N, Wouters EFM, Janssen DJA. Effect of Sustained-Release Morphine for Refractory Breathlessness in Chronic Obstructive Pulmonary Disease on Health Status: A Randomized Clinical Trial. JAMA Intern Med. Published online August 17, 2020. doi:10.1001/jamainternmed.2020.3134

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