Presentations

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.

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

Review of the adaptations in opioid agonist treatment during the COVID-19 pandemic:
Focus on buprenorphine-based treatment

Abhishek Ghosh, MD, DM;
Chandrima Naskar, MD;
Fazl-e Roub, MD, DM;
Debasish Basu, MD, DNB, MAMS

Background: 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.

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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.

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Buprenorphine: Not Just Another Opioid – Mythbusting the Worlds Most Interesting Opioid

Andrea Rubinstein, MD

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.

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Atypical opioids and their effect on respiratory drive

Lynn Webster, MD;
Richard L. Rauck, MD

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.

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Opioid Stewardship Across the Continuum of Care

Mary Lynn McPherson, PharmD, MA, MDE, BCPS; Tanya Uritsky, PharmD; Kelly Mendoza, MS, PharmD, BCPS

In the presentation “Opioid Stewardship Across the Continuum of Care”, Dr. McPherson, Dr. Uritsky and Dr. Mendoza describe ways to measure success in opioid stewardship across four practice arenas – outpatient, inpatient, palliative care, and hospice. Additionally, they discuss examples of best practices as part of opioid stewardship as well as recognizing/exposing the barriers to implementing opioid stewardship.

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icoo.20.pp.0091 Opioid Stewardship Across the Continuum of Care Handouts

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.

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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.

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Buprenorphine: The Opioid that Cried ‘Partial Agonist”

Jeffrey 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.

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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.

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Rapid micro induction of sublingual buprenorphine from methadone in an outpatient setting: “A case series”

Gurpreet Singh Guliani, MD

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.

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Interest in long-acting injectable buprenorphine among syringe services program participants

Hannah Epstein, BS;
Andres Perez-Correa, MD;
Jason Beltre, BS;
Christine Fitzsimmons, ASN;
Pia Marcus, BA;
Franklin Ramirez, BA;
L. Synn Stern, RN, MPH;
Brianna L. Norton, DO, MPH;
Aaron D. Fox, MD, MS;
Andrea Jakubowski, MD, MS

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.

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Buprenorphine in Palliative Care

Katrina Nickels, MD, Addiction Medicine Fellow, University of Kentucky
Stephanie Abel, PharmD, BCPS, Opioid Stewardship Program Coordinator, University of Kentucky HealthCare
Monika Holbein, MD, Director of Supportive Oncology, West Virginia University
Kathleen Broglio, DNP, Nurse Practitioner Section Palliative Medicine, Dartmouth Hitchcock

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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Why buprenorphine is superior for the management of opioid use disorder and pain

Nitin K. Sekhri, MD

Opioid abuse represents a public health crisis that has significant associated morbidity and mortality. Since beginning in the early 1990’s, the opioid abuse epidemic has been difficult to control due to regulatory, economic, and psychosocial factors that have perpetuated its existence. This era of opioid abuse has been punctuated by three distinct rises in mortality, precipitated by unique public health problems that needed to be addressed. Patients affected by opioid abuse have been historically treated with either methadone or naltrexone. While these agents have clinical utility supported by robust literature, we the authors posit that buprenorphine is a superior therapy for both opioid use disorder (OUD) as well as pain. This primacy is due to the pharmacological properties of buprenorphine which render it unique among other opioid medications. One such property is buprenorphine’s ceiling effect of respiratory depression, a common side effect and complicating factor in the administration of many classical opioid medications. This profile renders buprenorphine safer, while simultaneously retaining therapeutic utility in the medical practitioner’s pharmacopeia for the treatment of opioid use disorder and pain.

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