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Cutting-edge information on Buprenorphine and its use in medicine.
BUPE2024: Buprenorphine in Medicine is a “virtual conference/resource” for those looking to learn about this exciting molecule and apply it in clinical practice for pain management and addiction medicine. Learn the latest research and practice from experts in the field.
Presentations are available NOW! CMEs and CPEs are available!¹ Plus, attendees will receive a copy of our Journal of Opioid Management special issue on Buprenorphine. It is part of your registration and available for download immediately after you register.
Sign up today! Take advantage of great content, great presenters, our special issue on buprenorphine and get continuing education credit too!
Buprenorphine was conceived by Alan Cowan as a safer opioid analgesic relative to morphine which reduced dysphoria and craving by blocking dysphoria through blocking kappa opioid receptors. It was later found to have a ceiling on respiratory depression demonstrated by the Leiden group of opioid researchers. Its utility as a safer long-acting opioid agonist relative to methadone lead to its adoption into maintenance therapy for those battling substance use disorders. In 2019 the Department of Health and Human Services pain management guidelines recommended the use of buprenorphine, a schedule III opioid, before considering schedule II opioids in managing moderate to severe pain. As the field of pain medicine turns away from traditional strong opioids, alternative options in pain management now include buprenorphine as a frontline opioid analgesic when oral analgesia is necessary. Join us as we explore the expanding role of Buprenorphine in medicine and pain management.
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(¹BUPE2024 Presentations are available CME and CPE credit. Past BUPE2021 Presentations are available however you cannot claim CMEs for BUPE2021 videos. But, the education from those BUPE2021 presentations is still worth the time!)
CONFERENCESCHEDULE
This is a talk that highlights the specific ways in which buprenorphine is different from other opioids used to treat pain. It will specifically discuss analgesia, tolerance, respiratory depression and the unique role buprenorphine can play in patients who suffer from both pain and depression.
This study identified, evaluated, and synthesized the literature examining the efficacy and tolerability of buprenorphine for pain in patients with active cancer.
There is a great deal of confusion associated with conversion from CII opioids to buprenorphine products. The data presented supports that patients can be converted from high-dose opioid medication to buprenorphine products safely and effectively. This presentation will provide a road map to help guide practitioners interested in applying this to their clinical practice.
The purpose of the research was not only to discover if conversion to a partial agonist CIII medication from full agonist CII medications would be achievable without sacrificing analgesia but also to provide guidance to providers interested in pursuing this option in clinical practice.
Complex pharmacology makes perioperative buprenorphine management (PBM) challenging. More clinicians are managing buprenorphine than ever before given the elimination of the X-waiver, however they must be well versed in PBM to optimize pain control and minimize relapse risk. This presentation will provide an update on emerging trends in PBM.
, Jacqueline Cleary, PharmD, Amanda McFee Winans, PharmD, BCPS, CACPBuprenorphine is becoming more popular in the palliative care field as more patients who were started on opioids for cancer-related pain are living longer, but there is not much formal training on buprenorphine, including various challenges in prescribing and managing this medication.
More patients are on chronic opioids, as patients who were initially started on full agonist opioids for cancer-related pain are living longer. Despite doing well from the cancer standpoint, some patients have difficulty tapering off their opioids because they have been taking them for years. Given the potential complications of chronic full agonist opioids, it is important to manage these patients in a safer way. However, there are various challenges including lack of education for patients and healthcare professionals and lack of product availability.
Buprenorphine has emerged as an alternative opioid that is safe and effective for the treatment of cancer pain.
Opioids remain the cornerstone for the treatment of moderate to severe cancer pain. Due to benefits over full agonist opioids (FAO), buprenorphine has emerged as an alternative treatment.
This symposium will review new in vitro research to understand the complexity of buprenorphine pharmacologic effects as it relates to both analgesia and adverse events. Evidence will also be presented to further support buprenorphine’s use as an analgesic.
This presentation describes an Education Program/Module, including the rationale for opioid use disorder (OUD) treatment for patients with buprenorphine, an evidence-based ED buprenorphine induction pathway, and electronic medical record tools, and how it changed the attitudes of emergency physicians towards buprenorphine treatment and demonstrated an increase in willingness and confidence to prescribe it for patients with OUD.
Bone marrow transplant (BMT) offers potential cure for otherwise incurable diseases. However, BMT brings about multisystemic pain and management challenges in patients with pre-existing opioid tolerance. Buprenorphine-based pilot prospective clinical trial showed more effective pain control in sickle cell disease patients’ refractory BMT-related pain while minimizing opioid dose escalation and opioid adverse effects.
DEA licensed pharmacists are often seen in the VA system, but it is not a universal practice. I became the first DEA licensed CPP in VISN 8 and now provide independent OUD and complex pain care. I aim to describe how a DEA licensed CPP can impact the current opioid epidemic.
The University of Washington has developed a cross-titration protocol for conversion from full agonist opioids to buprenorphine for chronic pain. A retrospective analysis was performed to evaluate the effectiveness and safety of this protocol.
The 2022 DoD/VA Opioid Clinical Practice Guidelines (CPG) suggests the use of buprenorphine instead of full agonist opioids for patients receiving daily opioids for the treatment of chronic pain. This is part of an ongoing project to increase awareness of the CPG and aid clinician and patient decision making.
In this presentation, we’ll discuss the pharmacology behind transitioning to buprenorphine with a potent full mu agonist in play, explore what makes this so challenging, and how to complete a transition successfully. We’ll discuss real-life examples of transitioning patients from either fentanyl or high-dose methadone to buprenorphine.
A qualitative exploration of mothers’ experiences of stigma before, during and after treatment.
A detailed look at the intra-cellular nuances of buprenorphine that makes this molecule so special.
Description of a standardized perioperative approach to optimize analgesia, minimize relapse risk, set patient and provider expectations, achieve prescribing consistency, mitigate risk, and maintain continuity through transitions of care. This dosing approach optimizes non-opioid therapies while continuing the patient’s home buprenorphine in a divided dose approach the day of surgery.
There is limited evidence and no clear consensus suggesting best practices for perioperative buprenorphine management in patients with opioid use disorder. As such, we aimed to develop a standardized perioperative management approach with the goals of (1) optimizing perioperative analgesia, (2) minimizing relapse risk, (3) setting expectations for patients and clinicians, (4) achieving prescribing consistency and mitigating risk among clinicians not familiar with perioperative buprenorphine management, and (5) maintaining continuity throughout care transitions. An interprofessional expert focus group convened to develop a consensus algorithm based upon buprenorphine’s unique pharmacologic features and published perioperative management recommendations. The resulting consensus algorithm continues the patient’s home buprenorphine dose in order to minimize relapse risk, but utilizes a divided dose approach starting the day of surgery if moderate to severe post-operative pain is expected. This strategy leverages the analgesic effects of buprenorphine while allowing for additional opioid binding to optimize analgesia. A patient-centered multimodal perioperative approach including local and/or regional anesthetics and nonopioid adjuncts is employed. Post-operative care is optimized by preoperative planning, including standardized patient assessment, perioperative communication with the buprenorphine prescriber, and education for patients and clinicians. Overall, integrating an understanding of pharmacology and clinical impact through the use of a readily adaptable algorithm
such as the divided dose approach is key to optimizing patient care in this high-risk population.
1. Larochelle MR, Bernson D, Land T, et al.: Medication for opioid use disorder after nonfatal opioid overdose and association
with mortality: A cohort study. Ann Intern Med. 2018; 169: 137-145. DOI: 10.7326/M17-3107.
2. Mattick RP, Breen C, Kimber J, et al.: Buprenorphine maintenance versus placebo or methadone maintenance for opioid
dependence. Cochrane Database Syst Rev. 2014; 2: CD002207.
3. Atluri S, Sudarshan G, Manchikanti L: Assessment of the trends in medical use and misuse of opioid analgesics from
2004 to 2011. Pain Phys. 2014; 2(17): E119-E128.
4. Moore DJ: Nurse practitioners’ pivotal role in ending the opioid epidemic. J Nurs Pract. 2019; 15: 323-327.
5. HHS.gov: HHS expands access to treatment for opioid use disorder. 2021. Available at https://www.hhs.gov/about/
news/2021/01/14/hhs-expands-access-to-treatment-for-opioiduse-disorder.html. Accessed January 19, 2021.
, Amanda R.M. Winans, PharmD, Linda Demma, MD, PhD, Jacqueline Cleary, PharmDBackground: Availability and access to opioid agonist treatment (OAT) are limited despite its evidence of effectiveness in treating opioid use disorders (OUDs). COVID-19 pandemic has inadvertently exacerbated the problems of restricted access to OAT and, at the same time, has increased odds of harm due to opioid use.
Objectives: We examined (a) adaptations conceived or implemented in the buprenorphine (BPN)-based OAT service delivery at the national, regional, or local level during the COVID-19 pandemic and (b) the impact of such transformations on the quantitative and qualitative aspects of service delivery. We focused exclusively on BPN-based OAT.
Methods: We carried out a systematic electronic database search in PubMed and Google Scholar. We included all types of articles. Additionally, we looked up relevant websites of international and national government agencies working in the field of drug abuse.
Results: We included 21 articles from 10 countries in the review and summarized the results in a narrative format. The majority of literature was from developed countries. We observed changes in the BPN initiation, dosing, and dispensing protocols, and particular emphasis on telemedicine. There was limited literature on service provisions for the vulnerable population. The changing modes of service delivery have possibly increased the number of new patients and reduced the risk of exposure owing to limited in-person contact.
Conclusion: Newer adaptations to meet with the challenges of COVID-19 pandemic in the BPN-based OAT delivery tend to be innovative, flexible, and patient
centered. Although it is too early to comment on these newer adaptations’ impact, the outcome’s directions appear to be positive.
Buprenorphine (BPN), FDA approved for opioid use disorder (OUD), requires an induction protocol for the patient in mild to moderate withdrawal. This can be problematic in outpatient practice due to complicated medical management. An emerging technique in literature uses a novel approach, called microinduction. In this method, escalating microdoses of BPN are administered, without requiring the patient to stop the opioid agonist. Our addiction treatment center used a microdosing technique to transit patients from methadone to BPN, without requiring opioid abstinence. Our case series is novel as it was outpatient microinduction from methadone to BPN in 7 days or less.
We report a case in which sublingual buprenorphine was used to help transition a patient off intravenous (IV) opioid analgesics medications post-multiple abdominal procedures. Intravenous opioids are commonly used in inpatient surgical pain management for patients with severe pain who are unable to take oral medications. Typically, a short course of IV analgesics is used, followed by transition to oral analgesic regimen. However, in patients with poor gastrointestinal absorption, pain control can be challenging. We present this case to highlight how sublingual buprenorphine can be a useful agent for acute pain management, especially when conventional strategies provide suboptimal responses.
Objective: To examine syringe services program (SSP) participants’ interest in long-acting injectable buprenorphine.
Design: SSP participants completed a 136-item questionnaire by phone. Items assessed quantitative ratings of interest in sublingual and injectable buprenorphine, preference for sublingual versus injectable buprenorphine, and reasons for preferences.
Setting: Two large urban SSPs.
Participants: SSP participants ≥18 years of age with current or lifetime opioid use disorder (OUD).
Main outcome measure(s): (1) Interest in sublingual and injectable buprenorphine, respectively, on a scale from 0 to 10 (0 = no interest and 10 = high interest); and (2) preference for sublingual buprenorphine versus injectable buprenorphine. Participants were also asked whether they agreed with statements that presented potential reasons for preferring each formulation.
Results: A total of 104 unique participants were interviewed, of which 72 (69 percent) were currently receiving or considering buprenorphine treatment. Among these 72 participants, the median level of interest in starting or continuing sublingual buprenorphine was 8 out of 10 (interquartile range [IQR]: 6-10) and in starting injectable buprenorphine was 5 out of 10 (IQR: 1-9). Thirty-six (50 percent) preferred sublingual, 27 (38 percent) preferred injectable, and 9 (13 percent) preferred neither or declined to answer. Participants who preferred injectable buprenorphine most commonly agreed that the convenience of the monthly injection was the reason for their preference.
Conclusions: Among SSP participants with OUD, we found moderate interest in injectable buprenorphine. Introducing this new form of buprenorphine treatment at SSPs could help meet the needs of individuals who are not well-served by standard OUD treatment models.
The continued escalation of patients treated for opioid use disorder (OUD) has called for an increase in access to OUD therapies. Pharmacists have previously demonstrated value in collaborative treatment of various disease states and have recently begun to address gaps in OUD care by facilitating buprenorphine therapy. This presentation will review current literature describing the pharmacist’s role in facilitating buprenorphine as part of the OUD care team. Studies were included in the review if a pharmacist was part of a care model in which buprenorphine was prescribed for OUD and excluded if there was a pain management indication for therapy, a limited pharmacist role, or a survey methodology used. Key characteristics identified include: 1) Pharmacist Role 2) Collaborating Prescriber Type 3) Clinic Setting 4) Pharmacist Practice Type and 5) Outcomes. Findings revealed that pharmacists are a valued member of buprenorphine care teams across a variety of settings and have a positive impact on important patient outcomes such as treatment retention and relapse. Few published collaborative care models exist, suggesting pharmacists may be underutilized in caring for this expanding patient population. Pharmacists are well prepared to take a more active role in buprenorphine management to help address the enduring opioid crisis.
Opioids are an important tool in the treatment of pain, but opioid overdose has become a serious health issue. Most opioid-related deaths are caused by respiratory depression, and the risk of respiratory depression is compounded because of the risks of abuse and diversion, which makes the need for safer opioids even more urgent. However, the atypical opioids (buprenorphine, tramadol, and tapentadol), with mechanisms of action not purely driven by μ-opioid receptor agonism, may be safer than conventional opioids, eg, morphine, oxycodone, and fentanyl. The purpose of this narrative review is to describe the clinical and experimental evidence regarding opioid-induced respiratory depression in the context of the mechanisms of action of the atypical opioids. Among the atypical opioids, tramadol has an advantage of being a Schedule IV drug, and thus having a relatively low abuse potential—but its effects, including its effect on respiratory drive, are dependent on cytochrome P450 2D6 metabolizer status. Tapentadol appears to affect respiratory drive, but this has not been well investigated. Buprenorphine is a Schedule III drug, thus having less abuse potential than the majority of opioids. Experimentally, a ceiling effect on the respiratory depression has been reported with intravenous buprenorphine. In addition, experimental hypercapnic stress in healthy volunteers demonstrated no respiratory depression following the administration of a single dose of the buccal film formulation of buprenorphine when compared with placebo. Overall, the data suggest that atypical opioids may be a safer option than conventional opioids for the treatment of pain.
, Richard L. Rauck, MDThe chronic use of full opioid agonists presents risks to aging adults, especially since the longstanding use of opioids for chronic pain is associated with tolerance, along with opioid misuse, opioid use disorder (OUD), and inadvertent respiratory depression. Older adults are particularly at a high risk of complications given a higher prevalence of physical and mental health co-morbidities. Buprenorphine, used off-label for pain management, as a safer option, likely requires additional therapeutic resources to assist geriatric patients in this transition.
Buprenorphine is emerging as a valuable tool in palliative care, in addressing safety concerns for patients on long term opioid therapy with serious illness, in reducing harm of unhealthy prescribed opioid use, and in the treatment of opioid use disorder. Managing the Complexities of Treating Older Adults with Longstanding Chronic Pain or Opioid Use Disorder with Buprenorphine and Integrative Health
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I am looking forward to a rational discussion about Buprenorphine in pain management and those battling opioid use disorders!
