Guidelines for Acute Pain Management for Buprenorphine Maintenance Patients
There is considerable confusion and misinformation regarding the treatment of acute pain in patients receiving buprenorphine. This protocol is designed to dispel these myths, as well as provide evidenced based suggestions for treatment.
The first myth is that a patient on buprenorphine does not require additional pain relief, since buprenorphine itself is a narcotic. This is equivalent to saying that a Chronic Obstructive Pulmonary Disease (COPD) patient on 2 liters of oxygen chronically shouldn’t need additional oxygen if he develops pneumonia. The buprenorphine used to treat addiction in an Opioid Maintenance Therapy (OMT) patient treats his addiction and not his pain.
The second myth states that if an OMT patient receives narcotic analgesics, it will induce withdrawal like symptoms. This myth originates in the fact that an opioid abuser with a high tolerance to opioids may experience withdrawal symptoms if he takes buprenorphine while still on street drugs, due to the sudden displacement of the street drugs by buprenorphine. But if someone is taking buprenorphine to treat addiction he will NOT develop withdrawal symptoms if he takes a full opioid agonist, because buprenorphine is already blocking the mu receptor.
The third myth is that buprenorphine blocks the receptors responsible for pain relief, so additional opioid analgesics will not have any effect. While buprenorphine does block the mu 2 receptor, which is responsible for the euphoric effects of opioids, it does NOT block the delta, kappa or mu 1 receptors which are responsible for pain relief. In fact, if given full agonist opioid pain medication, the patient will receive pain relief without the usually associated euphoria, because of buprenorphine’s block of the mu 2 receptor. This leads us to the fourth myth.
The fourth myth is that buprenorphine should be discontinued before full agonist opioids are given. The reasons that this myth is false are listed above but it is important to understand one additional point. If buprenorphine is discontinued before giving full agonist opioids, the patient will then experience the euphoric effects of the drug, thereby increasing risk of relapse. If buprenorphine is continued and the full agonist is given, the patient will obtain pain relief, but without the euphoric effects, thereby reducing the risk of relapse.
There is one final point that needs to be clarified regarding the use of buprenorphine to treat acute pain. While once daily dosing will prevent withdrawal symptoms in the OMT patient, the pain relief from buprenorphine only lasts 6-8 hours, requiring TID to QID dosing if it is going to be effective for pain relief.
The final subject that frequently comes up is the issue of procedural sedation and general anesthesia. As can be seen by the previous discussion, no alteration in treatment is necessary in either case. The patient can be treated as though they were on any other opioid medication for the treatment of pain.
Hopefully this brief discussion has addressed and helped clarify several of the myths surrounding the treatment of acute pain, and provided guidance for the optimal care of the OMT patient.
Protocol for Acute Pain Management for Buprenorphine Maintenance Patients:
1. Continue the patient’s regular dose of buprenorphine and have the treating physician prescribe their usual short acting opioid analgesics to obtain pain relief. (Note: We do not prescribe the short acting opioid; that is the responsibility of the dentist or physician treating the short term painful condition.) If the patient does receive opioid analgesics from another provider, the patient must inform this office prior to starting the opioid analgesic.
2. If the patient is on less than 32 mg of buprenorphine, it may be possible to increase the patient’s does of buprenorphine temporarily, and provide TID or QID dosing.
3. The naloxone doesn’t have anything to do with anything. Don’t switch the patient to Subutex!
1. Ann. Intern. Med. 2006; 144:127-134
“Acute Pain Management for Patients Receiving Maintenance Methadone or Buprenorphine Therapy.”
2. J. of Pain and Symptom Management Vol 29 No. 3, March 2005
Buprenorphine: Considerations for Pain Management
3. British J. of Pharm. 2006 147, S153-S162
“75 years of opioid research: the exciting but vain quest for the Holy Grail.”
4. IUPHAR Database. Int’l Union of Pharmacology (2008-08-01)
Dr. Vance C. Shaw, MD, FASAM
Diplomate of the American Board of Addiction Medicine