Butrans/Suboxone + oxycodone

[Charcoales]

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When/if ever is this a valid combo?... keep seeing this combo from a certain doc is it the case that butrans could be used for maintenance and the oxycodone is as needed... not sure tho...

 

[radio frequency]

So...I’ve seen it a few times. Just because somebody is an addict doesn’t mean they don’t also have severe pain issues, cancer, broken bones, etc unfortunately. But it’s not ideal.

Had a patient on Suboxone getting a new script for oxycodone. Contacted the prescriber, who explained the legit reason they needed it. They were confident because it was a different kind of addiction they previously had and because of their many years of clean living that they’d be fine. The prescriber had been to an addiction conference recently and had heard that the new thinking was to keep the patient on Suboxone at the same dose and start the opioid as well. So we did. It was supposed to be a one time fill; a temporary measure to get them through an acute incident of severe pain.

Unfortunately, things with this patient have quickly gone downhill and now the aim is to get the patient to stop seeking opioids (ie, stop intentionally hurting themselves to get opioids). Which is pretty depressing as I counseled them very specifically about the risks and need to minimize use and so did the prescriber. Addiction is a tough beast to kick and once an addict always an addict.

Based on my one small case study, I recommend proceeding with great caution and documenting everything.

I’d love some feedback from any doctors in pain management who have worked with patients with addiction as this is a difficult situation as a pharmacist.

One other thought: patients will need to be well counseled to never skip their Butrans or Suboxone or vary their dose as it can change their overdose risk with their extra opioid.

Edited to add: there was some contraindication (a real, verifiable one) to NSAIDs with this patient from what I remember as well. It was a bad situation all around, but also one where if the patient was admitted for the pain usually treated outpatient, insurance would almost surely not pay.

 

[Corytrade]

If they are on Subuxone, because of addiction, our clinic would never give an opioid outpatient. As the previous poster noted it will always get out of hand, just depends on how long it will take.

 

[radio frequency]

If they are on Subuxone, because of addiction, our clinic would never give an opioid outpatient. As the previous poster noted it will always get out of hand, just depends on how long it will take.

I’m really curious what happens with your patients when they have greater pain. Do they get hospitalized to treat their pain when they have cancer? Or a broken bone? Or do they just get APAP/ibuprofen?

 

[Subvisual]

It's a pretty exceptionally bad idea if they're not inpatient. The partial agonist properties of the buprenorphine will make the dosing and effect of a pure agonist really hard to predict.

 

[BigBoss]

That's one stupid combo.

 

[ldiot]

For acute inpatient pain it's ok to continue buprenorphine with opioids if it's anticipated that opoids will only be needed for a day or so, but high doses will likely be required. If they will be needed for longer period (multiple days) I would stop buprenorphine and then restart when opioids are no longer needed, keeping in mind that opioid requirements will drop pretty quickly as the buprenorphine is eliminated so close monitoring for respiratory depression and frequent dose adjustments is important. The rationale for this is obvious based on the high affinity binding of buprenorphine.

With all that being said I would never send them home with a script. They need very high doses of opioids to overcome the buprenorphine and have a high potential to abuse it. If their acute pain is tolerable enough to go home they should be given something else, and if not they should keep them for another day