Buprenorphine for pain management in the emergency department

Buprenorphine is a DEA schedule III narcotic. Any clinician with authority to prescribe DEA schedule III medications may prescribe buprenorphine in intravenous, intramuscular, transmucosal or transdermal preparations for the treatment of pain. 

Conceptually, buprenorphine is best thought of as a safer opioid. Understanding the potential benefits of buprenorphine should not encourage overall increased use of opioids in your ED practice. 

If pain and suffering can be relieved without an opioid, that remains the safest option. But if an opioid is required, buprenorphine may be a safer, more effective option for your patient than the commonly used ED opioids--morphine, hydromorphone, oxycodone, and hydrocodone.

Why Buprenorphine?

In the ED we are often confronted with patients who have a combination of pain and distress from opioid withdrawal and/or opioid related cravings and anxiety.  Clinically distinguishing between what is pain driven by an acute medical process and what is driven by opioid addiction is often impossible.

Traditionally, this has left us with two basic options:

1. Treat pain with an opioid ( all to often hydromorphone) When a patient suffering from the disease of opioid addiction receives strong dose of opioid the environmental context of that euphoric drug reward becomes hard wired into their reward neurocircuitry.  If the drug reward occurs in the ED, the entire ED environment from its appearance on the street to the providers, sights, and sounds of the ED may become encoded as a powerful drug associated environmental cue. As a result, when exposed to the ED, the patient may experience drug craving, enhanced withdrawal symptoms, anxiety, and dysphoria. Patients in recovery, may feel impulses to relapse, patients actively using may become preoccupied and anxious in anticipation of a possible drug reward. Thus, routine use of opioids in the ED may both worsen addiction states and limit the ability of the ED to serve its intended purpose to effectively diagnose and treat acute medical conditions. Additionally, the exaggerated symptoms and distress place a patient at risk for iatrogenic harm and over-testing.  These behaviors are beyond the conscious control in many patients with addiction who suffer from disordered mesolimibic reward neurocircuitry.  (More here on the neurobiology of addiction)

2. Restrict opioids. Effective analgesia can be achieved with a sophisticated regimen that includes the core multimodal approach--regional blocks, acetaminophen, NSAID, and gabapentin/pregabalin--combined with antihyperalgesics--low dose ketamine, clonidine, and lidocaine. However, effectively tailoring this approach can be logistically challenging and requires training that many emergency providers have not traditionally had access to. The final result, too often, is simply suffering from undertreated pain.

Buprenoprhine may be a safer alternative for analgesia in patients with signs of opioid use disorder.

Buprenorphine’s unique pharmacology has several advantages compared to morphine:

• Effective analgesia and treatment of opioid related withdrawal and anxiety, without euphoria and intoxication (reduced euphoric drug reward).

• Reduced risk of respiratory depression and over-sedation

• Effective anti-hyperalgesia (more on opioid induced hyperalgesia HERE)

• Very long duration of action: 6-8 hours from a single dose.

• Links acute pain management to recovery treatment. (Patients exposed to buprenorphine may be more likely to seek long-term treatment on buprenorphine)

Who NOT to use buprenorpine on:

1. Patients likely to be admitted or heading to the operating room. If the inpatient teams are not experienced using buprenorphine it may cause confusion and complicate standard pain regimens.
2. Patients on methadone. If a patient is on long-term methadone it can take several days or more to wash out and be ready for buprenorphine.  A single dose greater than 24 hours ago is unlikely to cause a problem, but any regular user who has established a steady state should be excluded.
3. Patients who have recently used their opioid of choice. Heroin users and users of other opioid agonists should be actively withdrawing before receiving buprenorphine. (Use this SCALE if you are unsure) Most patients know about buprenorphine, but nevertheless you are obligated to explain that buprenorphine may precipitate withdrawal i.e. make them "dope sick," if they have used heroin in the last 12 hours or a long acting opioid in the last 24 hours.

Example case: Heroin injecting patient with an abscess in need of drainage

Following the American Society of Anesthesiology 2012 guidelines for perioperative pain management a multimodal strategy should be used.

Begin with a non-opioid multimodal base

Acetaminophen 1G PO/IV
Ibuprofen 600mg PO / Ketorolac 15mg IV
Gabapentin 600-1200mg PO

If pain remains not controlled:

Discuss recent use of opioids to clarify type, timing, and amount of opioid.
If YES to recent use then: 

Ketamine 10-20mg IV slow push or over 10minutes as piggy back

and

Ketamine 20-30mg IV over one hour infusion

 If NO to recent use:

(No short-acting opioids in 12 hours)
(No long-acting opioids in 24 hours)
(Not on methadone and no sporadic methadone use in 2-3 days)
AND
clinical exam suggestive of withdrawal symptoms--restless, sweating, dilated pupils, etc...

Administer sublingual or IM/IV buprenorphine for acute pain

0.3mg IV/IM or 2mg sublingual tablet

Administer transdermal Buprenorphine for post-procedural pain

place 20mcg/hr transdermal patch for post procedural analgesia

Place regional block if anatomically feasible (after patient is comfortable from above regimen) 

Do not leave a patient in pain as you prepare for a block

Do not rely solely on block alone for pain control.

Consider ketamine if pain remains uncontrolled. Additional analgesic adjuvants include lidocaine, clonidine, magnesium, and dopaminergic antagonists ( droperidol or haldol).

At discharge

Consider a second dose of sublingual buprenorphine just before leaving the ED to help as the patch is kicking in. Provide non-opioid analgesics--acetaminophen, ibuprofen.  Gabapentin and clonidine may also be considered.  

A full agonist opioid in addition to the bup patch is not normally recommended. In particular, prescribing Norco to a patient with opioid addiction is generally a bad idea because it is a weak dose of opioid compounded with a liver toxin. As they rationally seek analgesic effect (around 20mg hydrocodone) the patient may overdose on acetaminophen.

Buprenorphine can also be prescribed for pain in tablet form for the first few days as the patch develops strength. Unfortunately, Medical will not cover buprenorphine for pain without prior authorization, limiting the access for many patients.

If a full agonist is prescribed (again, generally not needed) consider a brief course of IR morphine tablets for break through pain. 

Advise the patient that the patch may reduce the high they get from heroin. Best case scenario is that the patch is an aid to lower their daily habit or a entry point for long term treatment. Worse case scenario patient gets long lasting pain control and then takes it off if they don't like it and returns to heroin.  Use all available resources to help your patient establish long term treatment for their addiction.

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