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PostPosted: Wed Sep 19, 2012 1:11 pm 
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I finally found a study published by ASRA (American Society of Regional Anesiologists), January 2011, newer than the NIH article we had published in the LINKS section.

Quote:
The Management of Sublingual Buprenorphine in the Perioperative Period

David Provenzano, MD
Executive Director, Institute for Pain Diagnostics and Care, Ohio Valley General Hospital
Adjunct Assistant Professor, Department of Pharmacology, Duquesne University
Adjunct Clinical Instructor, Office of Experiential Education, Duquesne University
Pittsburgh, Pennsylvania

Introduction

Opioid-dependent patients being treated with buprenorphine compounds, including Suboxone or Subutex, present a unique perioperative care challenge for acute pain management following surgical intervention. Here, we will discuss the pharmacology of buprenorphine and propose a structured perioperative plan for the acute pain management of patients being treated with Suboxone or Subutex.

Buprenorphine Pharmacology

Buprenorphine is a semisynthetic opioid that acts as a partial m-opioid receptor agonist and antagonist at the k-opioid receptor. The binding affinity of buprenorphine at the m-opioid receptor is 1000 times higher than morphine. Oral bioavailability of buprenorphine is low because of extensive first-pass hepatic metabolism. The half-life of buprenorphine is 20-70 hours (mean 37 hrs). The analgesic effects of buprenorphine are limited by a “ceiling effect. ” Thus, increasing the dose beyond a certain point shows no further increase in analgesia. This “ceiling effect” also applies to the respiratory depression rates associated with the drug. Mean whole brain m-opioid receptor availability is decreased by 80% and 84%, respectively, by the 16 mg and 32 mg doses.

Suboxone and Subutex are sublingual tablets indicated for the treatment of opioid dependence. Both of these medications are Schedule III drugs that can be prescribed in office-based treatment programs for opioid dependence under the Drug Addiction Treatment Act (DATA) of 2000. In order for a healthcare provider to prescribe these medications, a special DEA waiver must be obtained. Subutex contains only buprenorphine while Suboxone is compromised of 2 compounds: buprenorphine and naloxone in a 4:1 ratio. The naloxone is combined with buprenorphine to deter abuse. When Suboxone is utilized appropriately via the sublingual route, naloxone does not have negative clinical effects because it is almost completely removed by first pass metabolism. If Suboxone is crushed and injected, by individuals who are dependent on full opioid agonists, the naloxone will precipitate withdrawal. The utilization of Suboxone for pain control is considered “off label use. ”

Implications for Acute Pain Management

Buprenorphine’s associated pharmacologic properties including high affinity for the opioid receptor and resulting blockade effect, long half-life, and “ceiling effect” have implications for acute pain management in opioid-dependent patients. Secondary to the above properties, access to the m-opioid receptor by other opioid formulations is limited and compromised. Analgesia from other opioids may be delayed for up to 72 hours after the last dose of buprenorphine. Below is a proposed treatment algorithm that can be followed for individuals being treated with Suboxone who are undergoing surgical intervention.

Management of individuals on buprenorphine undergoing elective surgery associated with moderate to severe pain:

Discontinue buprenorphine compounds 3-7 days prior to surgery. The patient should be transitioned to other formulations of opioid (e. g. , methadone) and non-opioid pain medications.
For postoperative analgesia, regional anesthetic techniques, opioid and non-opioid medications should be considered.
Once postoperative pain has subsided, care should be coordinated with the Suboxone-prescribing healthcare provider on an outpatient basis.
The timing of the reinitiation of Suboxone is crucial to avoid unpleasant side effects.

If opioid agonists were used for post operative pain control, these drugs will need to be discontinued prior switching back to Suboxone via an induction protocol. It is recommended that opioids be discontinued for 12-24 hours and that mild withdrawal symptoms be present. Otherwise, the reinitiation of buprenorphine can lead to the rapid onset of intense withdrawal symptoms (precipitated withdrawal).

Management of individuals on buprenorphine undergoing surgery associated with minimal pain:

Continue buprenorphine for postoperative analgesia. Utilize non-opioid analgesic medications and consider increasing the buprenorphine dose. The analgesic efficacy is not improved above 32 mg. Some practitioners have recommended switching from daily dosing to t. i. d. or q. i. d. dosing to improve analgesia, although this has not been studied prospectively to date.

Management of individuals undergoing emergent surgery on buprenorphine:

Discontinue buprenorphine.
Manage pain with opioids and non-opioid medications. Regional anesthetic techniques should also be considered. High-potency opioids may be needed, including hydromorphone and fentanyl. As the effects of buprenorphine decrease (typically 72 hours) at the m-opioid receptor, often the patient’s opioid requirements will also be reduced. Therefore, if high-dose opioids have to be initially utilized, individuals will need to be observed closely to monitor for opioid toxicity as buprenorphine’s blockade effect at the receptor declines.

Conclusion

The management of acute pain in individuals receiving buprenorphine therapy for opioid dependence treatment can be challenging. An in-depth understanding of the pharmacological properties of buprenorphine can assist in the appropriate management of these individuals. Coordinated inpatient and outpatient care is required. Practicing anesthesiologists should be prepared to see more individuals receiving this form of treatment as the prevalence of opioid dependence and illicit drug use continues to increase.

Key references

Alford DP, Compton P, Samet JH. Acute pain management for patients receiving maintenance methadone or buprenorphine therapy. Ann. Intern. Med. 2006 Jan 17;144(2):127-134.
Harrington CJ, Zaydfudim V. Buprenorphine maintenance therapy hinders acute pain management in trauma. Am. Surg. 2010 Apr;76(4):397-399.
Heit HA, Gourlay DL. Buprenorphine: new tricks with an old molecule for pain management. Clin. J. Pain 2008 Feb;24(2):93-97.
Mitra S, Sinatra RS. Perioperative management of acute pain in the opioid-dependent patient. Anesthesiology 2004 Jul;101(1):212-227.
Orman JS, Keating GM. Buprenorphine/naloxone: a review of its use in the treatment of opioid dependence. Drugs 2009;69(5):577-607


It's not as comprehensive as the NIH article, but it is more current and therefore more credible in many medical professionals' eyes. The part I bolded is the part I'm a bit uncomfortable with, because as many of us know, our tolerance with sub DOES NOT go down after 72 hours. Full agonist pain meds rarely can get past the suboxone after 72 hours and lots of us have actually experienced that.

I'm continuing to search for more comprehensive studies of this kind. We have all had SO many issues related to not getting sufficient acute pain management that the more studies we can present to our doctor the better.

Oh and the link the this is posted in ASRA's E-News at:

http://www.asra.com/e-news.php?id=2

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PostPosted: Wed Sep 19, 2012 3:21 pm 
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Thank you for finding that, Hat! I have not read the previous article you are referring to, but this article seems straightforward and easy to understand. I would feel totally comfortable printing the article and bringing it with me to a doctor's office. I hope that this article becomes general knowledge soon!!!

Amy

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PostPosted: Wed Sep 19, 2012 5:04 pm 
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Thanks Hat for posting that article. I am in agreement with you about the tolerance part. Where the heck did this doctor get that idea of tolerance going down as the Bup leaves the system? He obviously didn't ask a Bup patient after a painful surgery like I had.

Just with those mis-spoken words I would not give that article to my physician before surgery. Actually I don't know what I'll do if I ever have a painful surgical procedure again as nothing has worked before. It is almost like forcing people to buy off the street to treat their pain appropriately. And that is not something I would ever do but it did cross my mind with my painful experiences.

Good detective work Hat!

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PostPosted: Wed Sep 19, 2012 7:36 pm 
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The other thing I found interesting is this statement:

Quote:
The analgesic efficacy is not improved above 32 mg. Some practitioners have recommended switching from daily dosing to t. i. d. or q. i. d. dosing to improve analgesia, although this has not been studied prospectively to date.


There's been some controversy on this site about doses used for pain management and this article backs up the notion that one gets additional pain relief all the way up to 32 mg (but not above), which accounts for why so many of us on sub for pain take higher doses. Many people have argued that. But as it also says, it's clear that not enough studies have been done on this.

I just hope this can be helpful, because as I said, that NIH paper is from a few years back and doctors often look for more current studies. But from what I've found, that NIH article does still seem to be the gold standard as it offers more than just the one option of using strong full agonists. It also talks about using full agonists WITH a very low dose of suboxone, which seems at this point (through some experiences on this forum and Dr. J's patients' experiences) that this works better than any full agonist alone.

Amy - this is the link to the thread with the NIH paper: http://suboxforum.com/viewtopic.php?t=1812
Like I said, it has other options for treating acute pain for us.

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PostPosted: Wed Sep 19, 2012 11:25 pm 
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I have that NIH paper printed out, stapled together,

and taped to the back of my bedroom door. in black marker it says,

"If Amber is ever hospitalized, THIS needs to go with her"

LOL

Just had to add that. No matter what paper each one of us likes, or whatever, WE ALL should have some kind of information

"on hand" in case of emergencies.

My doctor gave me a little card that I carry in my wallet, saying Im a buprenorphine patient, and it has his contact info on it
plus just a FEW things on what bupe is, that there's a blocker in what Im taking, ETC.

Just wanted to take this opportune moment, and say that :wink:

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PostPosted: Thu Sep 20, 2012 1:33 am 
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That card is a great idea, Amber. Maybe I can get you to send me a sample card so I could encourage my doctor to make up cards of his own!

Amy

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PostPosted: Thu Sep 20, 2012 1:36 am 
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Amy, you can also get card(s) at NAABT, that's where I got mine, if your doc doesn't have any.

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PostPosted: Thu Sep 20, 2012 10:17 am 
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Thanks Hat! I will look there.

Amy

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PostPosted: Sat Sep 22, 2012 5:29 pm 
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My doctor's office doesn't have email, but they do have an anonymous email form for suggesting improvements for the practice. I wanted to share the article that was the subject of this thread with him, so I submitted a message with a link to the article via the anonymous email form. I mentioned that they shouldn't change a thing, gave him the link and left my name. Here is his reply:

thanks amy for the compliment. means a lot coming from you. How funny that you should mention that link. im in nashville right now for a week long symposium on addiction medicine and pain mgmt and we discussed this exact use for about 2 hours yesterday. i actually already use it for post op pain mgmt quite a bit. in fact several pain specialists have even called me personally to have me prescribe it to them for their smaller surgeries because they know that no one else understands this stuff. how funny. i fully agree. you know it was made in europe over 25 yrs ago for pain mgmgt and works fantastic. in fact the veterinarians have had it in their practices here in the us for years already. they say works great for their furry patients. why cant we treat humans that well? thx again. Andreas


Nice to hear that the subject is being brought up at this symposium!

Amy

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PostPosted: Sun Sep 23, 2012 7:25 am 
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Awesome, Amy. That also means that we are up on the same studies as the doctors are. And that's GREAT news. Sounds like you have a terrific doctor. I kind of envy you. LOL. Seriously though, good on you for sending him that.

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