Successful use of buprenorphine-naloxone medication-assisted program to treat concurrent pain and opioid addiction after cancer therapy

Abstract

Cancer pain is often treated with opioids, a therapeutic regimen that can become a challenge in patients with an opioid use disorder (OUD). While use of the buprenorphine-naloxone combination is an effective medication-assisted treatment (MAT) for OUD, its use in pain patients with OUD has been controversial due to concerns that co-administration of buprenorphine can reduce or block analgesia and precipitate opioid withdrawal in those patients requiring full opioid agonists. Data on its use in cancer pain patients are lacking. In this case series, the authors explore the frequency of buprenorphine-naloxone use and its outcomes in patients in a Comprehensive Care Center (CCC) Pain Registry. OUD was deduced from an International Classification of Diseases (ICD-10) diagnostic code for opioid-related disorders recorded in the electronic medical records. Of 2,320 chronic cancer pain patients, 125 patients had ICD-10 code for opioid-related disorders, and 43 had a diagnosis of opioid abuse of whom 11 received buprenorphinenaloxone combinations. Eight patients on 18 (6-24) mg per day of buprenorphinenaloxone remained in therapy for 4 (2-7) years without opioid abuse relapse. This assessment was based on clinician's notes, the Prescription Monitoring Program, random urine drug screening, and the absence of Urgent Care Center visits for opioid withdrawal or overdose. When short-term opioids were administered for acute pain, these patients were able to taper down and stop them quickly without an opioid abuse relapse. Buprenorphine-naloxone was effective as the sole analgesic in selected patients. Given its success at the CCC, buprenorphine-naloxone should be made available and strongly considered as a treatment for patients suffering from OUD during and following cancer treatment and when cancer pain reduces or resolves.

Consensus-Based Guidance on Opioid Management in Individuals With Advanced Cancer-Related Pain and Opioid Misuse or Use Disorder

“…Across all scenarios, participants expressed concern about buprenorphine’s efficacy for pain, even when they agreed buprenorphine was an appropriate choice to treat comorbid pain and OUD. Although there is not a large body of evidence for buprenorphine products for cancer pain, work in patients with chronic pain and preoperative patients, as well as early work in patients with cancer, demonstrate buprenorphine/naloxone is effective . Research on cancer-related pain is a critical gap that demands further investigation, especially regarding the role of buprenorphine/naloxone among individuals at elevated risk for opioid harms with traditional full-agonists …”

Opioid Therapy in Cancer Patients and Survivors at Risk of Addiction, Misuse or Complex Dependency

“…Cancer patients who have overcome OUD or some other substance use disorder as well as the “chippers,” the slang term for occasional recreational opioid users, may be at special risk for using opioids on a more consistent basis when they are exposed to the stresses of moderate to severe pain ( 46 ). Cancer patients who are on opioid agonist therapy, using buprenorphine or methadone, are sometimes prescribed short-acting opioids to manage cancer pain in addition to their maintenance therapy, with the strategy that they will eventually be able to taper and discontinue these short-term opioids without OUD relapse ( 47 ). A case report in the literature describes a buprenorphine maintenance in a non-cancer patient who was successfully treated with tramadol 50 mg three times a day to manage orthopedic pain in addition to his buprenorphine treatment prior to surgery.…”

Mental Health and Chemical Dependency Services at US Cancer Centers

“…49 The use of opioids to address pain can become a challenge, especially in patients with preexisting or new-onset opioid use disorders. [50][51][52] Careful evaluation to identify at-risk groups, early recognition and timely treatment of opioid use disorders, 52 and access to specialized substance use disorder programs such as buprenorphine/naloxone 51 and other nonpharmacologic treatments can be better accomplished when CD treatment services are available at cancer centers.…”