Conversion of Chronic Pain Patients from FullOpioid Agonists to Sublingual Buprenorphine

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.

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Conversion from High-Dose Full-Opioid Agonists to Sublingual Buprenorphine Reduces Pain Scores and Improves Quality of Life for Chronic Pain Patients

Pain Medicine ◽

10.1111/pme.12520 ◽

2014 ◽

Vol 15 (12) ◽

pp. 2087-2094 ◽

Cited By ~ 26

Author(s):

Danielle Daitch ◽

Jonathan Daitch ◽

Daniel Novinson ◽

Michael Frey ◽

Carol Mitnick ◽

...

Keyword(s):

Quality Of Life ◽

Chronic Pain ◽

High Dose ◽

Sublingual Buprenorphine ◽

Pain Scores ◽

Opioid Agonists ◽

Chronic Pain Patients ◽

Pain Patients

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Does the use of short-acting opioid for breakthrough pain improve pain scores and quality of life in chronic pain patients?

Journal of Pain ◽

10.1016/j.jpain.2009.01.271 ◽

2009 ◽

Vol 10 (4) ◽

pp. S50

Author(s):

K. Luu ◽

B. Huh

Keyword(s):

Quality Of Life ◽

Chronic Pain ◽

Breakthrough Pain ◽

Short Acting ◽

Pain Scores ◽

Chronic Pain Patients ◽

Pain Patients

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Medical Cannabis for the Management of Pain and Quality of Life in Chronic Pain Patients: A Prospective Observational Study

Pain Medicine ◽

10.1093/pm/pnaa163 ◽

2020 ◽

Vol 21 (11) ◽

pp. 3073-3086 ◽

Cited By ~ 1

Author(s):

Ramin Safakish ◽

Gordon Ko ◽

Vahid Salimpour ◽

Bryan Hendin ◽

Imrat Sohanpal ◽

...

Keyword(s):

Quality Of Life ◽

Chronic Pain ◽

Observational Study ◽

Medication Use ◽

Medical Cannabis ◽

Opioid Medication ◽

Chronic Pain Patients ◽

Pain Patients ◽

Observation Period

Abstract Objective To evaluate the short-term and long-term effects of plant-based medical cannabis in a chronic pain population over the course of one year. Design A longitudinal, prospective, 12-month observational study. Setting Patients were recruited and treated at a clinic specializing in medical cannabis care from October 2015 to March 2019. Subjects A total of 751 chronic pain patients initiating medical cannabis treatment. Methods Study participants completed the Brief Pain Inventory and the 12-item Short Form Survey (SF-12), as well as surveys on opioid medication use and adverse events, at baseline and once a month for 12 months. Results Medical cannabis treatment was associated with improvements in pain severity and interference (P < 0.001) observed at one month and maintained over the 12-month observation period. Significant improvements were also observed in the SF-12 physical and mental health domains (P < 0.002) starting at three months. Significant decreases in headaches, fatigue, anxiety, and nausea were observed after initiation of treatment (P ≤ 0.002). In patients who reported opioid medication use at baseline, there were significant reductions in oral morphine equivalent doses (P < 0.0001), while correlates of pain were significantly improved by the end of the study observation period. Conclusions Taken together, the findings of this study add to the cumulative evidence in support of plant-based medical cannabis as a safe and effective treatment option and potential opioid medication substitute or augmentation therapy for the management of symptoms and quality of life in chronic pain patients.

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Sublingual Buprenorphine/Naloxone and Multi-Modal Management for High-Risk Chronic Pain Patients

Journal of Clinical Medicine ◽

10.3390/jcm10050973 ◽

2021 ◽

Vol 10 (5) ◽

pp. 973

Author(s):

Shane Kaski ◽

Patrick Marshalek ◽

Jeremy Herschler ◽

Sijin Wen ◽

Wanhong Zheng

Keyword(s):

Chronic Pain ◽

High Risk ◽

Pain Score ◽

Rating Scale ◽

Pain Treatment ◽

Pain Clinic ◽

Sublingual Buprenorphine ◽

Significant Downward Trend ◽

Chronic Pain Patients ◽

Pain Patients

Patients with chronic pain managed with opioid medications are at high risk for opioid overuse or misuse. West Virginia University (WVU) established a High-Risk Pain Clinic to use sublingual buprenorphine/naloxone (bup/nal) plus a multimodal approach to help chronic pain patients with history of Substance Use Disorder (SUD) or aberrant drug-related behavior. The objective of this study was to report overall retention rates and indicators of efficacy in pain control from approximately six years of High-Risk Pain Clinic data. A retrospective chart review was conducted for a total of 78 patients who enrolled in the High-Risk Pain Clinic between 2014 and 2020. Data gathered include psychiatric diagnoses, prescribed medications, pain score, buprenorphine/naloxone dosing, time in clinic, and reason for dismissal. A linear mixed effects model was used to assess the pain score from the Defense and Veterans Pain Rating Scale (DVPRS) and daily bup/nal dose across time. The overall retention of the High-Risk Pain Clinic was 41%. The mean pain score demonstrated a significant downward trend across treatment time (p < 0.001), while the opposite trend was seen with buprenorphine dose (p < 0.001). With the benefit of six years of observation, this study supports buprenorphine/naloxone as a safe and efficacious component of comprehensive chronic pain treatment in patients with SUD or high-risk of opioid overuse or misuse.

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The Nature and Adaptive Implications of Pain-Affect Dynamics

10.1093/oso/9780190627898.003.0013 ◽

2018 ◽

Author(s):

Mary C. Davis ◽

Chung Jung Mun ◽

Dhwani Kothari ◽

Shannon Moore ◽

Crys Rivers ◽

...

Keyword(s):

Chronic Pain ◽

Functional Health ◽

Affective Experience ◽

Motivational Systems ◽

Chronic Pain Patients ◽

Pain Affect ◽

Dynamic Relations ◽

Pain Patients ◽

Dynamic Interplay

Because pain is in part an affective experience, investigators over the past several decades have sought to elaborate the nature of pain-affect connections. Our evolving understanding of the intersection of pain and affect is especially relevant to intervention efforts designed to enhance the quality of life and functional health of individuals managing chronic pain. This chapter describes how pain influences arousal of the vigilance/defensive and appetitive/approach motivational systems and thus the affective health of chronic pain patients. The focus then moves to the dynamic relations between changes in pain and other stressors and changes in positive and negative affect as observed in daily life and laboratory-based experiments. A consensus emerges that sustaining positive affect during pain and stress flares may limit their detrimental effects and promote better functional health. The authors consider the implications of increased understanding of the dynamic interplay between pain and affective experience for enhancing existing interventions.

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Opioid induced hyperalgesia: A focus on opioid use in chronic pain

Mental Health Clinician ◽

10.9740/mhc.n155462 ◽

2013 ◽

Vol 2 (12) ◽

pp. 395-397

Author(s):

Julie L. Cunningham

Keyword(s):

Chronic Pain ◽

Side Effects ◽

Treatment Option ◽

Opioid Therapy ◽

Opioid Use ◽

Chronic Pain Patients ◽

Opioid Induced Hyperalgesia ◽

Pain Patients ◽

Established Treatment

Opioids are a well-established treatment option for chronic pain. However, opioid therapy is associated with many side effects, including opioid induced hyperalgesia (OIH). This article reviews studies which have evaluated OIH in chronic pain patients on opioids.

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Significant pain reduction in chronic pain patients after detoxification from high-dose opioids

Journal of Opioid Management ◽

10.5055/jom.2006.0041 ◽

2006 ◽

Vol 2 (5) ◽

pp. 277 ◽

Cited By ~ 59

Author(s):

Michael J. Baron, MD, MPH ◽

Paul W. McDonald, PhD

Keyword(s):

Chronic Pain ◽

High Dose ◽

Pain Condition ◽

Opioid Dose ◽

Pain Scores ◽

Patient Pain ◽

Opioid Induced Hyperalgesia ◽

Pain Sensitization ◽

Pain Patients

Opioid tolerance is a well-established phenomenon that often occurs in patients taking opioids for the treatment of chronic pain. Typically, doctors need to periodically elevate patients’ opioid doses in an attempt to manage their underlying pain conditions, resulting in escalating opioid levels with only moderate to negligible improvement in pain relief. Recently, opioid-induced hyperalgesia has been recognized as a potential form of central sensitization in which a patient’s pain level increases in parallel with elevation of his or her opioid dose. Here, we report a retrospective study of patients undergoing detoxification from high-dose opioids prescribed to treat an underlying chronic pain condition which had not resolved in the year prior. All patients were converted to ibuprofen to manage pain, with a subgroup treated with buprenorphine during detoxification. Selfreports for pain scores were taken at first evaluation, follow-up visits, and termination. Twenty-one of 23 patients reported a significant decrease in pain after detoxification, suggesting that high-dose opioids may contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of the preexisting pain condition.

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Review of the Performance of Quantitative Sensory Testing Methods to Detect Hyperalgesia in Chronic Pain Patients on Long-term Opioids

Anesthesiology ◽

10.1097/aln.0000000000000530 ◽

2015 ◽

Vol 122 (3) ◽

pp. 677-685 ◽

Cited By ~ 20

Author(s):

Nathaniel P. Katz ◽

Florence C. Paillard ◽

Robert R. Edwards

Keyword(s):

Chronic Pain ◽

Controlled Trial ◽

Controlled Study ◽

Injection Pain ◽

Heat Pain ◽

Cold Pain ◽

Chronic Pain Patients ◽

Opioid Induced Hyperalgesia ◽

Pain Patients

Abstract Background: Opioid-induced hyperalgesia is a clinical syndrome whereby patients on long-term opioids become more sensitive to pain while taking opioids. Opioid-induced hyperalgesia is characterized by increased pain intensity over time, spreading of pain to other locations, and increased pain sensation to external stimuli. To characterize opioid-induced hyperalgesia, laboratory methods to measure hyperalgesia have been developed. To determine the performance of these methods, the authors conducted a systematic review of clinical studies that incorporate measures of hyperalgesia in chronic pain patients on long-term opioids. Methods: PubMed and Cochrane databases were searched (terms: opioid induced hyperalgesia, study or trial, and long-term or chronic). Studies published in English were selected if they were conducted in chronic pain patients on long-term opioids and incorporated measures of hyperalgesia; acute/single-dose studies and/or conducted in healthy volunteers were excluded. Results: Fourteen articles made the final selection (11 were selected from the search and 3 others were found from additional sources); there was one randomized controlled trial, one prospective controlled study, three prospective uncontrolled studies, and nine cross-sectional observation studies. Hyperalgesia measurement paradigms used included cold pain, heat pain, pressure pain, electrical pain, ischemic pain, and injection pain. Although none of the stimuli were capable of detecting patients’ hyperalgesia, heat pain sensitivity showed some promising results. Conclusions: None of the measures reviewed herein met the criteria of a definitive standard for the measurement of hyperalgesia. Additional studies that use improved study design should be conducted.

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