Managing acute pain in patients on suboxone

[Interpolfanclub]

Seeing this more often given where I practice. Still not quite sure what to do with it. Had a patient their PCP recommended I treat only with fentanyl and it seemed to work. What is everyone doing with these patients?

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[Rendar5]

The problem there is that IV fentanyl doesn't last long and that if you're going to go the way of the patch, then he's going to go into hyperacute withdrawal when it wears off and he takes his next suboxone dose. So fentanyl does seem to be a good cure if they're pain's not going to last long for whatever reason (procedure or whatnot)

 

[Pharmavixen]

There's comprehensive info on buprenorphine here:

Clinical situations may arise in which a full agonist may be required for patients who currently are being treated with Buprenorphine, such as in the treatment of acute pain. Although this medication interaction has not been studied systematically, the pharmacological characteristics of Buprenorphine suggest that it may be difficult to obtain adequate analgesia with full agonists in patients stabilized on maintenance Buprenorphine.

Data nonspecific to Buprenorphine suggests that, in patients maintained chronically on methadone, the acute administration of full mu agonists for analgesia can be effective. If the necessity should arise for the use of a full mu agonist for pain relief in a patient maintained on Buprenorphine, the Buprenorphine should be discontinued until the pain can be controlled without the use of opioid pain medications. It must be recognized that treatment with full mu agonists for pain relief will produce increased opioid tolerance and a higher degree of physical dependence.

I have extensive experience with methadone maintenance pts. In an acute pain situation (we see lots of broken jaws) you give the usual methadone dose as a baseline and add whatever opioids are needed on top. These pts often require higher doses and shorter dosing intervals d/t high tolerance.

The tricky thing with suboxone is it's got very high affinity for the mu receptor, even though it's only a partial agonist. So you'd want to give an opioid with high affinity, and fentanyl is like that. (But that's only if the buprenorphine is still on board.)

We recently had a guy on suboxone who had severe acute (injury) and chronic (neuropathic) pain. So we avoided the whole opioid dilemma by not giving opioids, instead giving nortriptyline & ketorolac, and his buprenorphine like usual. In a more severe trauma situation, I agree with the website, and I'd recommend d/cing the buprenorphine until the pt doesn't need opioids any more. Then you can give whatever opioid you like.

 

[WilcoWorld]

I've had good experience using low-dose ketamine to treat pain in people with high-tollerance to opiates. I haven't used it in patients on buprenorphine yet, but it's worth a shot (no pun intended).

 

[Interpolfanclub]

I've had good experience using low-dose ketamine to treat pain in people with high-tollerance to opiates. I haven't used it in patients on buprenorphine yet, but it's worth a shot (no pun intended).

Thanks for the suggestions. What dose of ketamine are you using in mg/kg? Do you get any dissociation at all? Or does it just relieve their pain?

 

[WilcoWorld]

Thanks for the suggestions. What dose of ketamine are you using in mg/kg? Do you get any dissociation at all? Or does it just relieve their pain?

A lot of sources will say 0.1mg/kg, but I've gone as high as 0.5mg/kg before seeing dissociation.

I don't have references to support this, but in my experience, if the patient's tolerance is from being medically treated with opioids, then the lower side of the range works. If the patient's tolerance stems from years of street drug use, then the patients seem to require the higher side of the dose range.

In summary: I'm using this for management of acute pain, giving it IV, and will start at 0.1-0.2mg/kg (selecting the dose that'll be easy for my nurse to draw up). Then I titrate to effect, which seems to be achieved in almost everyone by the time I get to 0.5mg/kg.