Conversion of Chronic Pain Patients from FullOpioid Agonists to Sublingual Buprenorphine

Daitch, Jonathan S.; Frey, Michael E.; Silver, David; Mitnick, Carol; Daitch, Danielle; Pergolizzi, Joseph V.

doi:10.36076/ppj.2012/15/es59

Cited by 62 publications

(45 citation statements)

References 19 publications

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“…35,36,47,48 Participants were rotated to buprenorphine for various indications, including inadequate analgesia with escalating opioid doses, intolerable adverse effects, and risky regimens (eg, high dose and/or coprescription with benzodiazepines). 39,40,46,47,[49][50][51][52][53] Other reasons included aberrant opioid use. [35][36][37][38]48,54,55 Opioid use disorder was present in some participants in 13 of 22 studies (59.1%), [35][36][37][38][41][42][43][44][45]47,48,52,53 whereas in 4 of 22 studies (18.2%) 27,39,40,46,[49][50][51]54,55 OUD was an exclusion criterion; however, in 2 of these studies, participants either had some aberrant opioidrelated behavior 54 or were opioid dependent by naloxone challenge.…”

Section: Study Populationsmentioning

confidence: 99%

“…35,37,54 Individuals who were switching from methadone hydrochloride or transdermal fentanyl were instructed to wait longer (about 36-72 hours). 38,[47][48][49][50]54 In 2 protocols, participants were randomized to structured buprenorphine tapering conditions 35,56 ; in 1 study, participants were allowed to switch to the steady-dose group if they could not tolerate the tapering. 35 Another protocol required that patients were unable to taper their previous opioid use before being offered buprenorphine rotation.…”

Section: Rotation Protocolsmentioning

confidence: 99%

“…Rotation to buprenorphine was associated with little harm to patients, as suggested by the 4 sleep disruption. 36,38,49,52,54 Skin irritation was common in participants who were using transdermal buprenorphine. 51 The severity of adverse effects was, overall, mild and associated with the opioid class.…”

Section: Adverse Events or Adverse Effectsmentioning

confidence: 99%

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Evaluation of Buprenorphine Rotation in Patients Receiving Long-term Opioids for Chronic Pain

et al. 2021

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IMPORTANCE Individuals with chronic pain who use long-term opioid therapy (LTOT) are at risk of opioid use disorder and other harmful outcomes. Rotation to buprenorphine may be considered, but the outcomes of such rotation in this population have not been systematically reviewed.OBJECTIVE To synthesize the evidence on rotation to buprenorphine from full μ-opioid receptor agonists among individuals with chronic pain who were receiving LTOT, including the outcomes of precipitated opioid withdrawal, pain intensity, pain interference, treatment success, adverse events or adverse effects, mental health condition, and health care use. EVIDENCE REVIEW PubMed, CINAHL, Embase, and PsycInfo were searched from inception through November 3, 2020, for peer-reviewed original English-language research that reported the prespecified outcomes of rotation from prescribed long-term opioids to buprenorphine among individuals with chronic pain. Two independent reviewers extracted data as well as assessed risk of bias and study quality according to the Preferred Reporting Items for Systematic Reviews and Metaanalyses (PRISMA) reporting guidelines. Quality of evidence was assessed with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. FINDINGS A total of 22 studies were analyzed, of which 5 (22.7%) were randomized clinical trials, 7 (31.8%) were case-control or cohort studies, and 10 (45.5%) were uncontrolled pre-post studies, which involved 1616 unique participants (675 female [41.8%] and 941 male [58.2%] individuals). Six of the 22 studies (27.3%) were primary or secondary analyses of a large randomized clinical trial.Participants had diverse pain and opioid use histories. Rationale for buprenorphine rotation included inadequate analgesia, intolerable adverse effects, risky opioid regimens (eg, high dose and/or sedative coprescriptions), and aberrant opioid use. Most protocols were adapted from protocols for initiating treatment in patients with opioid use disorder and used buccal or sublingual buprenorphine. Very low-quality evidence suggested that buprenorphine rotation was associated with maintained or improved analgesia, with a low risk of precipitating opioid withdrawal. Steadydose buprenorphine was better tolerated than tapered-dose buprenorphine. Adverse effects were manageable, and severe adverse events were rare. Only 2 studies evaluated mental health outcomes, but none evaluated health care use. Limitations included a high risk of bias in most studies. CONCLUSIONS AND RELEVANCEIn this systematic review, buprenorphine was associated with reduced chronic pain intensity without precipitating opioid withdrawal in individuals with chronic pain who were receiving LTOT. Future studies are necessary to ascertain the ideal starting dose, formulation, and administration frequency of buprenorphine as well as the best approach to buprenorphine rotation.

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Section: Study Populationsmentioning

confidence: 99%

Section: Rotation Protocolsmentioning

confidence: 99%

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Evaluation of Buprenorphine Rotation in Patients Receiving Long-term Opioids for Chronic Pain

et al. 2021

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“…Several studies suggest that buprenorphine has similar equi-analgesic properties as full mu-opioid receptor agonists, like morphine and transdermal fentanyl [26]. Studies on the effectiveness of buprenorphine rotation in patients with CNCP and OUD suggested a positive effect on pain [23,[27][28][29][30][31]. However, these studies had a small sample size [23,31], were retrospective in nature [27,28,30], or participants could self-administer additional oxycodone [29].…”

Section: Introductionmentioning

confidence: 99%

“…Studies on the effectiveness of buprenorphine rotation in patients with CNCP and OUD suggested a positive effect on pain [23,[27][28][29][30][31]. However, these studies had a small sample size [23,31], were retrospective in nature [27,28,30], or participants could self-administer additional oxycodone [29]. Additionally, buprenorphine has a lower risk of respiratory depression, sedation and overdose [32,33].…”

Section: Introductionmentioning

confidence: 99%

Beneficial Effects of Opioid Rotation to Buprenorphine/Naloxone on Opioid Misuse, Craving, Mental Health, and Pain Control in Chronic Non-Cancer Pain Patients with Opioid Use Disorder

Schellekens

Veldman

Suranto

et al. 2021

JCM

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Patients with chronic non-cancer pain (CNCP) often use opioids for long periods of time. This may lead to opioid use disorder (OUD) and psychiatric symptoms: mainly depression and anxiety. The current study investigated the effect of buprenorphine/naloxone (BuNa) rotation on opioid misuse, craving, psychiatric symptoms and pain in patients with CNCP and OUD. Forty-three participants with CNCP and OUD were converted from a full mu-receptor agonist opioid (mean morphine equivalent dose: 328.3 mg) to BuNa, in an inpatient setting. Opioid misuse, craving, co-occurring psychiatric symptoms, and pain perception were determined at baseline and after a two-month follow-up, using the following self-report questionnaires: Current Opioid Misuse Measurement (COMM), Visual Analog Scale (VAS-craving and VAS-pain) and Depression, Anxiety and Stress Scale (DASS), respectively. VAS-craving and VAS-pain were also determined immediately after conversion. A total of 37 participants completed the protocol. The mean COMM decreased from 17.1 to 6.7 (F = 36.5; p < 0.000), the mean VAS-craving decreased from 39.3 to 5.3 (−86.6%; F = 26.5, p < 0.000), the mean DASS decreased from 12.1 to 6.6 (F = 56.3, p < 0.000), and the mean VAS-pain decreased from 51.3 to 37.2 (−27.4%, F = 3.3; p = 0.043). Rotation to BuNa in patients with CNCP and OUD was accompanied by reductions in (i) opioid misuse, (ii) opioid craving, (iii) the severity of co-occurring psychiatric symptoms, and (iv) self-reported pain. BuNa as opioid agonist treatment may therefore be a beneficial strategy in CNCP patients with OUD. The limited sample size and the observational nature of this study underline the need for the replication of the current findings in large-scale, controlled studies.

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Access to Primary Care Clinics for Patients With Chronic Pain Receiving Opioids

et al. 2019

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IMPORTANCE Opioid-prescribing policies and guidelines aimed at reducing inappropriate opioid prescribing may lead physicians to stop prescribing opioids. Patients may thus encounter difficulties finding primary care practitioners willing to care for them if they take opioids. OBJECTIVES To assess practitioner willingness to accept and continue prescribing opioids to new patients with pain and whether this willingness differs across payer types. DESIGN, SETTING, AND PARTICIPANTS This survey study used a simulated patient call audit method. A brief telephone survey was administered to all clinics followed by a call using a patient script simulating an adult patient with chronic pain who was taking long-term opioids. The patient had Medicaid or private insurance. Calls were made between June 22 and October 30, 2018, to 667 primary care clinics that served a general adult population in Michigan. Clinics that accepted both Medicaid and private insurance, took new patient appointments, and were successfully recontacted for the simulated call were eligible for the study. MAIN OUTCOMES AND MEASURES Prevalence of clinics' acceptance of new patients receiving prescription opioids overall and by clinic characteristics and insurance type. RESULTS Of the 194 eligible clinics, 94 (48.4%) were randomized according to insurance type to receive calls from research assistants posing as children of patients with Medicaid and 100 (51.5%) to receive calls from those with private insurance. Overall, 79 (40.7%) stated that their practitioners would not prescribe opioids to the simulated patient. Thirty-three clinics (17.0%) requested more information before making a decision. Compared with single-practitioner clinics, clinics with more than 3 practitioners were more likely (odds ratio [OR], 2.99; 95% CI, 1.48-6.04) to accept new patients currently taking opioids. No difference was found in access based on insurance status (OR, 0.92; 95% CI, 0.52-1.64) or whether the clinic offered medications for opioid use disorders (OR, 1.10; 95% CI, 0.45-2.69). CONCLUSIONS AND RELEVANCE The findings suggest that access to primary care may be reduced for patients taking prescription opioids, which could lead to unintended consequences, such as conversion to illicit substances or reduced management of other medical comorbidities.

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Conversion of Chronic Pain Patients from FullOpioid Agonists to Sublingual Buprenorphine

Cited by 62 publications

References 19 publications

Evaluation of Buprenorphine Rotation in Patients Receiving Long-term Opioids for Chronic Pain

Evaluation of Buprenorphine Rotation in Patients Receiving Long-term Opioids for Chronic Pain

Beneficial Effects of Opioid Rotation to Buprenorphine/Naloxone on Opioid Misuse, Craving, Mental Health, and Pain Control in Chronic Non-Cancer Pain Patients with Opioid Use Disorder

Access to Primary Care Clinics for Patients With Chronic Pain Receiving Opioids

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