#15 Buprenorphine for Chronic Pain with Dr. Will Becker

July 27, 2023 | By Kenneth Morford

Audio

Video

Crush chronic pain with buprenorphine. Learn how to assess chronic pain and opioid use disorder (OUD) in patients on long-term opioid therapy, when to consider buprenorphine, and how to make the switch. We’re joined by addiction medicine and pain management expert, Dr. William Becker (Yale School of Medicine).  

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The Curbsiders Addiction Medicine are proud to partner with  The American College of Addiction Medicine (ACAAM) to bring you this mini-series.  ACAAM is the proud home for academic addiction medicine faculty and trainees and is dedicated to training and supporting the next generation of academic addiction medicine leaders. Visit their website at acaam.org to learn more about their organization.

Show Segments

• Disclaimer 0:52
• Intro, guest bio 1:18
• Case from Kashlak; Definitions 4:22
• Assessing chronic pain and long-term opioid use 5:22 
• Treatment options when patients are not benefitting from opioids 11:55 
• Buprenorphine for chronic pain 14:28
• Assessing OUD in patients on long-term opioid therapy 15:54
• Buprenorphine mechanism of action 19:17
• When to consider buprenorphine for chronic pain 21:12
• Buprenorphine formulations 24:25
• Switching from full agonist opioids to buprenorphine 29:02
• Adding full agonists to buprenorphine 39:30
• Take Home Points 46:07
• Plug 47:38
• Lightning round 48:32
• Outro 50:20

Buprenorphine for Chronic Pain Pearls

1. Adequate time (30-40 minutes) should be allotted to have an in-depth conversation with the patient to understand how their pain is impacting them.
2. The focus should be on assessing the patient’s pain and pain experience, not on whether the opioids are working or not.
3. Changes in the patient’s pain-related function over the past year should be assessed.
4. Patients’ buy-in or agreement that opioids are not working is necessary before exploring other treatment options.
5. Buprenorphine is a partial mu-opioid receptor agonist that can be used for chronic pain and often has fewer side effects than full mu-opioid receptor agonists.
6. Buprenorphine provides analgesic effects at low doses and partial agonist effects at the mu-receptor at higher doses, creating a ceiling effect against respiratory depression.
7. Buprenorphine can be considered for patients no longer benefitting or experiencing harm from long-term opioid therapy.
8. Buprenorphine can be considered for use in opioid-naive patients after exhausting non-opioid and non-pharmacologic pain management modalities.
9. There are different formulations of buprenorphine for chronic pain and OUD, with different doses required for each.
10. Two methods can be used to transition to buprenorphine: the traditional method and the overlap method (sometimes known as low-dose buprenorphine initiation), with the overlap method preferred for certain patients.

Buprenorphine for Chronic Pain

Assessing Chronic Pain and Long-term Opioid Use

Assessing chronic pain and long-term opioid use requires adequate time to have an in-depth conversation to understand how the patient is being impacted by their pain. Dr. Becker recommends at least 30-40 minutes for this discussion. Focus on assessing the patient’s pain and pain experience. Collecting this information can help clinicians determine whether the patient is benefitting from opioid therapy and whether the benefits outweigh any harm.

Key questions to ask during the history may include: 

• What is a typical day like for you?
• How does pain limit you throughout the day?

• How has your pain and function changed over time? 
• How have things been for you dealing with this pain over the past year? (listen for declining function and/or sedentary lifestyle)

When opioids are not benefiting the patient

If the picture is one of declining function, adverse effects from opioids, or lack of meaningful benefit in the patient’s own view, it implies either low benefit or absence of benefit from opioid therapy. If a patient describes a sedentary lifestyle with declining function and/or adverse side effects of opioids, it may be a sign that there is a low or absence of benefit from using opioids for chronic pain. 

Dr. Becker’s Tip: Don’t ask the patient what life would be like without opioids, as this could trigger a distressing memory of running out of opioids and experiencing withdrawal or uncontrolled pain. The goal is to get a big picture of how things have been over 6 months to a year with respect to pain-related function. It is important to get the patient’s buy-in or agreement that opioids aren’t working. Listen for statements of ambivalence, like feeling stuck or not feeling well for a period of time. Then guide the discussion to explore other options that can help. Focus on what the patient has to gain from making a change to the treatment plan. Safety is important but often doesn’t resonate with patients as opposed to focusing on feeling better and functioning better. Once you have agreement, explore changes to the opioid regimen and other treatment options. 

Assessing for OUD in Patients on Long-term Opioids

DSM-5 criteria should be used to assess OUD in patients on long-term opioids. However, it can be tricky to tease apart symptoms of OUD from those of uncontrolled pain or “opioid burden.” For example, tolerance and withdrawal are expected for patients on long-term opioid therapy and don’t apply towards an OUD diagnosis in the absence of other criteria (Hasin et al., 2013). DSM-5 criteria related to the negative consequences of opioid use can also be difficult to discriminate from the consequences of uncontrolled pain (Manhapra & Becker, 2018). 

In Dr. Becker’s expert opinion, he typically doesn’t think an OUD diagnosis is appropriate unless the patient clearly demonstrates loss of control over opioid use. One caveat is that loss of control criteria may not be related to OUD if a patient is struggling while undergoing a clinician-driven opioid taper.

Buprenorphine to Treat Chronic Pain

Buprenorphine is a partial opioid agonist that typically has fewer side effects than full opioid agonists, such as sedation, respiratory depression, and opioid-induced hyperalgesia. Promising evidence supports using buprenorphine to treat chronic pain among people who have previously been prescribed opioids (Powel et al, 2021; Gordon et al, 2010; Gimbel et al, 2016) and people who are opioid-naive (Steiner et al, 2011; Davis, 2012; Fishman and Kim, 2018), as well as some evidence to support using buprenorphine to co-manage chronic pain and OUD among people with OUD (Neumann et al, 2013; Ellis et al, 2021). A switch to buprenorphine from full agonist opioids may improve pain control and quality of life for some patients (Daitch, 2014; Webster, 2016; Becker, 2020). Further studies are needed to strengthen the evidence of buprenorphine on chronic pain outcomes. 

Buprenorphine Medication Profile

Buprenorphine was initially developed as a pain medication. At very low doses it has a high affinity for the mu-opioid receptor with potent analgesic effects. Its partial agonist effects kick in as the dose increases creating a ceiling effect against respiratory depression (Webster, 2020 – Figure 3). So at low doses, it provides analgesic effects similar to full agonist opioids, and at higher doses, it provides partial agonist effects. 

When to Consider Buprenorphine for Chronic Pain

Buprenorphine may be considered when patients are no longer benefitting or experiencing harms from long-term opioid therapy. In some cases, buprenorphine may be considered in opioid-naive patients after exhausting non-opioid and non-pharmacologic pain management modalities. 

According to Dr. Becker’s expert opinion, he’s more likely to start buprenorphine in older patients who are opioid-naive. He tries to avoid this approach in younger patients to prevent the development of physiologic dependence. 

Buprenorphine Formulations 

Buprenorphine is available in several formulations. The transdermal patch and buccal film are FDA-approved for chronic pain, while the sublingual film, tablet, and extended-release injection are FDA-approved for OUD. For co-occurring chronic pain and OUD, the only on-label use is the sublingual formulation. The major difference between the formulations approved for chronic pain vs OUD is dose. For OUD, the dose is typically 8-24 mg daily with the best outcomes demonstrated at higher doses of 16-24 mg/day (Fareed et al, 2012). For chronic pain, the dose is much lower starting at 100 micrograms per day. 

Transitioning to Buprenorphine

There are two methods for transitioning a patient from long-term opioids to buprenorphine: 

1. Traditional method: Stop the full agonist opioid abruptly, wait for withdrawal symptoms (depending on the half-life of the opioid), then initiate a treatment dose of buprenorphine. 
2. Overlap method: Similar to low-dose buprenorphine initiation. Start a low dose of buprenorphine while the patient continues the full opioid agonist, uptitrate the buprenorphine dose daily, and then stop the full agonist once the buprenorphine is at a therapeutic dose. 

The overlap method has become Dr. Becker’s preferred approach. Here are some of his tips for using this method successfully: 

• Make sure the patient understands the process via teach-back. 
• Determine which formulation the patient will switch to by calculating the morphine milligram equivalents (MME). Higher MME typically requires SL formulation to provide higher buprenorphine doses.
• Understand your patient’s insurance coverage for certain buprenorphine products before starting this process, as all products may not be covered by insurance.
• Consider reducing the full agonist dose on Days 4 and 5 of the overlap to minimize the amount of pills the patient needs to take. 
• Overdose is less of a concern due to the partial agonism of buprenorphine. 

Adding Full Agonist Opioids to Buprenorphine

Dr. Becker considers adding full agonist opioids if the patient does not have co-occurring OUD and has successfully transitioned to buprenorphine but still has breakthrough pain. Treatment of acute pain is another scenario when adding full agonists is appropriate. Importantly, adding full agonists to buprenorphine will not precipitate withdrawal and patients may still gain analgesic benefits from the full agonist when buprenorphine is on board. He typically uses oxycodone 5-10 mg PRN but considers other types of full agonists depending on the presence of underlying conditions (e.g., renal insufficiency; Owsiany, 2019) and patient preference. Differences in receptor binding affinity for the mu-opioid receptor may also play into the decision to use a particular full agonist. Hydromorphone has a higher binding affinity than oxycodone and theoretically may provide improved pain control to patients on buprenorphine. 

Take Home Points

1. When assessing chronic pain in a patient on long-term opioids, focus on function over a period of 6-12 months.
2. Have a pitch to offer buprenorphine as an option to help patients feel better if they are no longer benefiting from full agonists. 
3. Switching to buprenorphine can be well-tolerated and easy to do, especially with the overlap method.
4. Be transparent with patients and flexible in available treatment options to maximize buy-in and engagement. 

Links

1. VA/DoD Clinical Practice Guidelines for the use of Opioids in the Management of chronic pain
2. SAMHSA TIP 54: Managing Chronic Pain in Adults With or in Recovery from Substance Use Disorders

Goal

Listeners will be able to assess and treat patients with buprenorphine for chronic pain.

Learning objectives

After listening to this episode listeners will…  

1. Develop an approach for opioid reassessment for individuals on long-term opioid therapy. 
2. Describe the evidence for using buprenorphine to treat chronic pain.
3. Recognize indications to consider buprenorphine for the management of chronic pain.
4. Describe the pharmacology of buprenorphine and its different formulations.
5. Describe methods to transfer patients from full agonist opioids to buprenorphine. 

Disclosures

Dr. William Becker reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures. 

Citation

Morford KM, Becker W, Roy P, Chan, CA. “#15 Buprenorphine for Chronic Pain with Dr. Will Becker”. The Curbsiders Addiction Medicine Podcast. https://thecurbsiders.com/episode-list July 27th, 2023.