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Average pain scores decreased from 7.2 to 3.5, and quality of life scores increased from 6.1 to 7.1 for 35 patients converted from high-dose full-opioid agonists to SL buprenorphine therapy for more than 60 days. Clinicians should consider buprenorphine SL conversion for all patients on high-dose opioids, particularly patients with severe pain (7-10) unrelieved by their current opioid regimen or patients for whom the clinician does not feel comfortable prescribing high-dose opioids.

Background: Sublingual buprenorphine-naloxone (buprenorphine SL) is a preparation that is used to treat opioid dependence. In addition, the Drug Enforcement Administration (DEA) has acknowledged the legality of an off-label use to treat pain with a sublingual buprenorphine preparation. Buprenorphine SL is unique among the opioid class of analgesics; this compound has a high affinity for the mu-receptor, yet only partially activates it. Thus, buprenorphine SL can provide analgesia, yet minimize opioid side effects. Many patients on high doses of traditional opioid medication develop tolerance. Despite escalating medication dosage, a subset of patients had a paradoxical increase in pain, which has been characterized as opioid-induced hyperalgesia (OIH). Buprenorphine SL, on the other hand, may even be anti-hyperalgesic and may have utility in treating these challenging patients. Objective: To determine the effectiveness of converting patients from traditional full agonist opioid medication to sublingual buprenorphine, as well as to identify patient groups that are most likely to benefit from this therapy. Patients who underwent conversion either had developed tolerance with diminished analgesia or were experiencing side effects on their opioid medications. Study Design: An observational report of outcomes assessment. Setting: An interventional pain management practice setting in the United States. Methods: Retrospective data from clinical records was compiled on 104 de-identified chronic pain patients whose personal information had been redacted (60 men and 44 women, aged 21-78) and who had previously been treated with opioid-agonist drugs; they were converted to buprenorphine SL in tablet form during the study. Chronic pain was defined as persistent pain for at least 6 months. Data collected from patient profiles included age, sex, diagnosis, medication history, pre-induction opioid intake, reason for detoxification, preinduction Clinical Opiate Withdrawal Score (COWS), and if applicable, cause of buprenorphine SL cessation. Pain levels and Quality of Life scores were recorded before and after conversion to buprenorphine SL. Outcome Measures: Level of analgesia for patients who continued conversion to sublingual buprenorphine for more than 2 months. Results: After initiation of buprenorphine SL therapy for more than 2 months, the mean pain scores on a scale from 0-10 decreased by 2.3 points (P < 0.001). Patient Quality of Life (QoL scale) was not significantly affected by buprenorphine SL therapy (P = 0.14). The success rate was highest for patients using morphine, oxycodone, and fentanyl before buprenorphine SL induction. These patient groups had a 3.7 point decrease in pain for those taking morphine, a 2.5 point decrease in pain for those taking oxycodone, and a 2.2 point decrease for those taking fentanyl. The smallest pain reduction was seen in the patient group using oxymorphone before conversion with a 1.1 point decrease in pain. Patients taking between 100-199 mg morphine equivalent per day experienced the greatest reduction (2.7 points) in pain scores. Patients taking between 200 and 299 mg morphine equivalent before buprenorphine SL induction exhibited a decrease of over 2 points on average. Patients taking > 400mg morphine equivalent reported the smallest reduction in pain scores, on average a 1.1 point decrease. Limitations: This study is limited by its observational nature. Conclusions: Patients continuing buprenorphine SL therapy for more than 60 days reported significant decreases in pain (2.3 points). Patients on doses of opioid medication between 100-199 mg morphine equivalents seemed to fare better with conversion to buprenorphine SL than patients on the highest doses (> 400 mg morphine equivalents). The opioid drug used by the patient before buprenorphine SL induction appears to have some effect on buprenorphine SL conversion success. Patients previously taking morphine, oxycodone, and fentanyl had the greatest decrease in pain after conversion to buprenorphine SL. Key Words: Sublingual buprenorphine-naloxone, buprenorphine, buprenorphine SL, opioid dependence, opioid conversion, opioid-induced hyperalgesia, analgesia, full agonist opioids, opioid tolerance.

Background: Failed back surgery syndrome is common in the United States. Management of post lumbar surgery syndrome with multiple modalities includes interventional techniques, resulting in moderate improvement, leaving a proportion of patients in intractable pain. The systematic reviews of long-term benefits and risks of spinal cord stimulation (SCS) for patients with failed back surgery syndrome showed limited to moderate evidence and cost effectiveness. However, with the exponential increase in surgery in the United States, spinal cord implants are also increasing. Thus, the discussion continues with claims of lack of evidence on one hand and escalating increases in utilization on the other hand. Study Design: A systematic review of SCS in patients with failed back surgery syndrome. Objectives: This systematic review is undertaken to examine the evidence from randomized controlled trials (RCTs) and observational studies to evaluate the effectiveness of SCS in post lumbar surgery syndrome and to demonstrate clinical and cost effectiveness. Methods: Review of the literature was performed according to the Cochrane Musculoskeletal Review Group Criteria as utilized for interventional techniques for randomized trials and the Agency for Healthcare Research and Quality (AHRQ) criteria for observational studies. The 5 levels of evidence were classified as Level I, II, or III with 3 subcategories in Level II based on the quality of evidence developed by the U.S. Preventive Services Task Force (USPSTF). Data sources included relevant literature of the English language identified through searches of PubMed and EMBASE from 1966 to December 2008, and manual searches of bibliographies of known primary and review articles. Outcome Measures: The primary outcome measure was pain relief (short-term relief ≤ one-year and long-term > one-year). Secondary outcome measures of improvement in functional status, psychological status, return to work, and reduction in opioid intake were utilized. Results: The indicated evidence is Level II-1 or II-2 for long-term relief in managing patients with failed back surgery syndrome. Limitations: The limitations of this review included the paucity and heterogeneity of the literature. Conclusion: This systematic review evaluating the effectiveness of SCS in relieving chronic intractable pain of failed back surgery syndrome indicated the evidence to be Level II-1 or II-2 for clinical use on a long-term basis. Key words: Chronic low back pain, neuropathic pain, failed back surgery syndrome, FBSS, post lumbar surgery syndrome, electrical stimulation, spinal cord stimulation

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