Presentations

Buprenorphine: Not Just Another Opioid – Understanding the World’s Most Interesting Opioid

Andrea Rubinstein, MD

In this talk we will delve deep into the pharmacology of this drug and how its receptor interactions are unique and then we will take that understanding and apply it to clinical usage to see how this drug behaves in a variety of situations.

Buprenorphine has recently been recommended by the Department of Veterans Affairs and the Department of Defense for use in place of traditional, full agonist opioids. Because of this shift in the recommendations, it is vitally important that providers fully understand this drug. There remains a lot of misconceptions and misunderstanding about how this drug works and this talk aims to address this.

Specifically we will look at the safety profile of this drug, including it’s ceiling effect on respiratory depression. Then we will look at efficacy, how well does this drug work in the treatment of pain. We will look at analgesia, tolerance and anti-hyperalgesic properties of buprenorphine. We will discus why this drug is so versatile anyhow versatility is a key asset when it comes to using buprenorphine for the treatment of pain.

The last section of this talk will look at the specific area of preoperative use of buprenorphine and why buprenorphine should be continued throughout the preoperative period.

CME and CPE credits are available for this presentation.

Presentation Slide Handouts: Click Here for Presentation Handouts

DOI: 10.5055/bupe.24.rp.1035

Impact of an Education Module on the Knowledge and Attitudes of EM Physicians Towards Prescribing Buprenorphine / Naloxone for Opioid Use Disorder

Amy Zosel, MD, MSCS; Jennifer Hernandez-Meier, PhD, MSW; Julie Owen, MD, MBA

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.

CME and CPE credits are available for this presentation.

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DOI: 10.5055/bupe.24.rp.1095

Buprenorphine for Cancer Pain: Results from a Systematic Review

Maria Silveira MD MA MPH, Victoria Powell MD, University of Michigan – VA, Ann Arbor MI

This study identified, evaluated, and synthesized the literature examining the efficacy and tolerability of buprenorphine for pain in patients with active cancer.

We conducted an updated systematic review of buprenorphine’s effect on cancer-related pain, including both new studies and additional study designs.

Buprenorphine may be safer and better tolerated than full mu-opioid receptor (MOR) agonists. Whether it effectively controls cancer-related pain is unclear. A prior review (Cochrane 2015) did not support prioritizing buprenorphine over full MOR agonists for cancer-associated pain.

CME and CPE credits are available for this presentation.

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DOI: 10.5055/bupe.24.rp.1075

Buprenorphine: Opioid Agonist-Antagonist Benefits for Opioid Resistant Pain Uncontrolled By Full-Agonist Opioids during Hematopoietic Stem Cell Transplant for Sickle Cell Disease

Mayuko Sakae, MD, Assistant Clinical Professor, City of Hope National Medical Center, Los Angeles, CA

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.

CME and CPE credits are available for this presentation.

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DOI: 10.5055/bupe.24.rp.1065

Conversion of CII Opioid Medications to Buprenorphine in the Chronic Pain Population – Insights and Clinical Pearls

Amanda Zimmerman, PA-C, West Forsyth Pain Management, Winston Salem, NC

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.

Patients who met inclusion criteria were stratified into subgroups based on their pre-conversion morphine milligram equivalents, whether they remained on opioids for breakthrough pain post-conversion, and their pre-and post-conversion numerical rating scale pain scores. Outcomes of interest included the differences between pre-and post-conversion numerical rating scale pain scores and daily morphine milligram equivalents for each subgroup.

Of 157 patients reviewed, 87.9% were successfully converted to buprenorphine buccal film. Overall, numerical rating scale pain scores were stable after conversion. Statistically significant reductions were demonstrated in the <90 daily morphine milligram equivalent subgroup. Postconversion daily morphine milligram equivalents decreased by 85.4% from baseline. Change in daily morphine milligram equivalents is representative of patients who remained on breakthrough pain medication.

Results demonstrate continued analgesia after conversion to buprenorphine buccal film despite reductions in daily morphine milligram equivalents. Most patients were able to convert directly from their long-acting opioid to buprenorphine buccal film and stabilized without the use of concurrent opioids for breakthrough pain. Aggressive titration strategies were associated with greater success.

This data proves that conversion from full agonist CII medications is possible without sacrificing analgesia while reducing the risk of adverse events associated with full agonist CII medications.

CME and CPE credits are available for this presentation.

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DOI: 10.5055/bupe.24.rp.1060

Clinical Pharmacist with DEA License: Efforts to Increase Access to Buprenorphine in a Veteran Population

Shelley Stevens, PharmD, BCPS, Pain Clinical Pharmacist Practitioner (CPP), North Florida/South Georgia Veterans Health System (NF/SG VHS)

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.

Opioid overdoses continue to rise in the United States. In 2021, a record 80,411 reported overdoses occurred in the US alone, nearly double that in 2017. Buprenorphine’s pharmacology is ideal for management of patients with opioid use disorder (OUD) with or without chronic pain.
Within the VA, clinical pharmacist practitioners (CPP) are uniquely equipped to operate with significant scope of practice to prescribe medications including controlled substances, an opportunity to vastly increase access to care for veterans suffering from OUD, complex opioid dependency or pain.

CME and CPE credits are available for this presentation.

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DOI: 10.5055/bupe.24.rp.1010

Emerging Trends in Perioperative Buprenorphine Management

Amanda L. Engle, PharmD, BCPS, Jacqueline Cleary, PharmD, BCACP, Amanda Winans, PharmD, BCPS, CACP

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.

Historically, there has been limited evidence and no clear consensus suggesting best practices for perioperative buprenorphine management (PBM). Previously published PBM strategies included a wide variation in dosing, complexity, and clinical decision making points. Importantly, there are limited published algorithms reporting corresponding patient outcomes data.

CME and CPE credits are available for this presentation.

Keywords: perioperative buprenorphine management (PBM), buprenorphine, perioperative, pain

Presentation Slide Handouts: Presentation Handouts

DOI: 10.5055/bupe.24.rp.1000

Review Presentation Questions

Outpatient Cross-Titration to Buprenorphine for Chronic Pain

Katherin Peperzak, MD, Medical Director, Center for Pain Relief at UWMC-Roosevelt, Department of Anesthesiology & Pain Medicine, University of Washington

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.

Various protocols for micro-induction of buprenorphine in patients with opioid use disorder have been published. There is a paucity of literature similarly describing micro-induction in patients converting from full agonist opioids to buprenorphine for chronic pain. As the prescription opioid epidemic continues to be problematic and more patients are being converted to buprenorphine, we are working to provide more guidance on goal dosages of buprenorphine and how to safely cross-titrate to that goal.

CME and CPE credits are available for this presentation.

Presentation Slide Handouts: Presentation Handouts

DOI: 10.5055/bupe.24.rp.1005

Partial Agonist, Full Barrier: A Case-Based Discussion on Challenges with Buprenorphine in Chronic Pain Management

Tonya S. Hershman,  PharmD, BCPS, Michelle Park, MD

Buprenorphine 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. Many healthcare providers do not have much formal training on initiating, maintaining, and tapering the various buprenorphine products. These providers may not be able to effectively educate patients given the lack of education. Also, patients research these products on their own and are hesitant to try them because of misinformation. Even if patients are informed thoroughly about buprenorphine, there are barriers to obtaining them including insurance denial and lack of product availability at pharmacies. Given the above challenges, easily accessible best practices as well as avenues for healthcare professionals to educate and guide each other are needed.

CME and CPE credits are available for this presentation.

Presentation Slide Handouts: Click Here for Park and Hershman Slides Handouts.

DOI: 10.5055/bupe.24.rp.1030

Buprenorphine Use in the Military Health System (MHS)

Nicole Cornish, PharmD

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.

The CPG’s updated recommendation is supported by buprenorphine’s lower risk of overdose and misuse. In comparison to full mu-opioid agonists, buprenorphine possesses a superior safety profile with respect to respiratory depression, even in non-dependent individuals, and fatal overdose when not combined with other sedating medications.

CME and CPE credits are available for this presentation.

Presentation Slide Handouts: Contact us.

DOI: 10.5055/bupe.24.rp.1025

Buprenorphine for the Treatment of Pain in Cancer Patients

Marcin Chwistek, MD, FAAHPM, Dylan Sherry, MD,  Leigh Kinczewski, CRNP

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.

CME and CPE credits are available for this presentation.

Presentation Slide Handouts: Click here for presentation handouts – Buprenorphine for the Treatment of Pain in Cancer.

DOI: 10.5055/bupe.24.rp.1015

The “Micro”cosm: Magnifying the Nuance of Low Dose Buprenorphine Inductions

Tanya Uritsky. PharmD, BCPP,  Emily Casey, PharmD

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.

Now that the X-wavier is a thing of the past, patients with Opioid Use Disorder (OUD) who previously lacked access to buprenorphine may have access to lower-barrier care and may be looking to make the transition from either methadone or illicit fentanyl to buprenorphine. This can be quite challenging and both fentanyl and methadone are highly potent drugs and can result in a difficult transition to buprenorphine.

CME and CPE credits are available for this presentation.

Presentation Slide Handouts: Contact us.

DOI: 10.5055/bupe.24.rp.1050

Buprenorphine: The Opioid that Cried ‘Partial Agonist’

Jeffrey J. Bettinger, PharmD; Jacqueline Cleary, PharmD, BCACP

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.

CME and CPE credits are available for this presentation.

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DOI: 10.5055/bupe.24.rp.1040

“My addiction doesn’t define me:” Healing from the stigma of addiction for mothers with opioid use disorder

Christine Bakos-Block, PhD, LCSW-S, Francine Vega, MS, CCC-SLP, A. Sarah Cohen, MS, Tiffany Champagne-Langabeer, PhD

A qualitative exploration of mothers’ experiences of stigma before, during and after treatment.

About 1 in 8 children under age 17 live with a parent who has a substance use disorder. Research on treatment access identifies stigma as a significant barrier to treatment, particularly among mothers with young children. Well-meaning but punitive state policies further perpetuate stigma, which harms families and children.

CME and CPE credits are available for this presentation.

Presentation Slide Handouts: Contact us.

DOI: 10.5055/bupe.24.rp.1020

CLICK HERE for Live Video Presentation December 16, 2021 at 2:30pmET

Buprenorphine Update – Intracellular Nuances of Buprenorphine

Gregory Acampora, MD

A detailed review and update on Buprenorphine as well as a detailed look at the intra-cellular nuances of buprenorphine that makes this molecule so special.

This presentation is from BUPE2021, and CME credits are not available for it. However, it still has excellent learning value.

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Pharmacists Role in Buprenorphine Management for Opioid Use Disorder

Jacqueline Cleary, PharmD, BCACP
Amanda Winans, PharmD, BCPS
Amanda Engle, PharmD, BCPS

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.

This presentation is from BUPE2021, and CME credits are not available for it. However, it still has excellent learning value.

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Facilitating discontinuation of intravenous opioids by concurrent use of sublingual buprenorphine
with rapid microdosing induction: A pain management case study

Taylor Purvis, MD

Co-authors on the original paper: Arjun Tara, DO; Gregory Acampora, MD; Jingping Wang, MD, PhD; Karina De Sousa, BS; Yi Zhang, MD, PhD

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 sub-optimal responses.

This presentation is from BUPE2021, and CME credits are not available for it. However, it still has excellent learning value.

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The divided dose approach to perioperative buprenorphine management in patients with opioid use disorder

Amanda L. Engle, PharmD, Amanda R.M. Winans, PharmD, Linda Demma, MD, PhD, Jacqueline Cleary, PharmD

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.

This presentation is from BUPE2021, and CME credits are not available for it. However, it still has excellent learning value.

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.

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DOI: 10-5055-bupe-21-rp-0055

Managing the Complexities of Treating Older Adults with Longstanding Chronic Pain
or Opioid Use Disorder with Buprenorphine and Integrative Health

Juliette Perzhinsky, MD, MSc, FACP
John Hopper, MD, DFASAM, FACP, FAAP
David Gaffney, LMSW, BCDCH

The 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.

This presentation is from BUPE2021, and CME credits are not available for it. However, it still has excellent learning value.

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