When Opioids Fail in Chronic Pain Management

Abstract

Clinicians are increasingly being challenged by patients who are treated for chronic pain with high-dose opioids that can cause medical, social, and societal harm. These patients may best be improved by psychological approaches, adjuvant medications, and opioid reduction or removal, rather than ever-escalating dosing that has become common. Opioid reduction or removal can be a difficult process that, when done incorrectly, may cause patient dissatisfaction or severe discomfort. Buprenorphine, a partial opioid agonist, is slowly becoming recognized as an effective pain treatment, possessing a wide safety margin while offering the opportunity for stabilization of opioid dosing or even removal. We have developed a protocol for hospitalization of the most fragile or toxic patients detailed herein that can permit a comfortable conversion to buprenorphine from prior high-dose full agonist opioid therapy. Seventy-six consecutive patients with serious medical, psychological, or addiction comorbidities, treated with morphine equivalent doses exceeding hundreds of milligrams per day, were followed after conversion for up to 25 months. Two-thirds reported moderate to dramatic improvements of pain and functional status with an increase seen in employment. Median length of hospital stay was 2 days, and the median daily buprenorphine discharge dose was 8 mg. No adverse reactions or outcomes were observed. A brief hospitalization for conversion from high-dose opioid therapy to a safer, more effective buprenorphine regimen can produce life-altering improvement.

Buprenorphine–Naloxone Therapy in Pain Management

“…[58] In addition, clinical studies, including a randomized clinical trial, have shown that substantial pain relief (66–82% pain reduction) can also be achieved in chronic pain patients who were placed on sublingual buprenorphine after failed other opioid therapies. [59, 60]…”

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

“…Of the 128 articles, 22 qualified for inclusion in this study (Figure). These articles represented 5 RCTs (22.7%), 27,[35][36][37][38] 7 case-control or cohort studies (31.8%), 39-45 and 10 uncontrolled pre-post studies (45.5%), [46][47][48][49][50][51][52][53][54][55] which involved a total of 1642 unique participants (Table 1). However, Roux et al 36 randomized 51 participants but included only 25 in their analysis, decreasing the total number of participants to 1616 (675 female [41.8%] and 941 male [58.2%] individuals).…”

“…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.…”

“…35,47,51 Pain interference may decrease after rotation to buprenorphine, but only 4 studies examined this outcome and all had high risk of bias. 35,37,47,54 Neumann et al 37 found a 21.4% improvement in self-reported function overall but was underpowered to detect a difference that was specific to the buprenorphine group. Studies used varied measures of pain interference.…”

Managing long-term high-dose prescription opioids in patients with non-cancer pain: The potential role of sublingual buprenorphine

“…A prospective study by Berland and colleagues studied patients with chronic pain experiencing worsening pain and function despite opioid use. 25 This study included patients on significant doses of opioids (median 400 mg oMED) and with multiple comorbidities. Following rotation to buprenorphine-naloxone, 67% of participants reported better pain control and 60% reported better function.…”