Never substitute any analgesic for buprenorphine in patients with opioid use disorder: Case report

Continue outpatient buprenorphine treatment for patients with opioid use disorder admitted with acute pain, suggests a case study published in the Journal of Hospital Medicine.

This was a case of a 40-year-old woman with a history of opioid use disorder (OUD) on buprenorphine-naloxone treatment who was admitted to medicine following incision and drainage of a large forearm abscess with surrounding cellulitis. The patient reported severe pain following the procedure, which is not relieved by ibuprofen. The admitting hospitalist ordered a pain regimen for the patient, that included oral and intravenous hydromorphone and prescribed to discontinue buprenorphine-naloxone so that the short-acting opioids can take effect.

Buprenorphine is a partial opioid agonist with a long half-life and high affinity for the mu-opioid receptor. Given these properties, prior recommendations assumed that buprenorphine blocked the effectiveness of additional opioid agonists. In 2004, guidelines by the Department of Health and Human Service Center for Substance Abuse Treatment recommended discontinuing buprenorphine in patients taking opioid pain medications. These suggestions were based on limited case reports describing difficulty controlling pain in patients with OUD with a high opioid tolerance who were receiving buprenorphine.

The case-study tried to answer why discontinuing buprenorphine when treating acute pain is not necessary. It says that despite buprenorphine’s high affinity at the mu receptor, additional receptors remain available for full opioid agonists to bind and activate, providing effective pain relief even in patients using buprenorphine.

The case also provided alternatives rather than stopping buprenorphine. It suggests

• Continuing daily buprenorphine and prescribing short-acting opioid agonists, preferably those with high intrinsic activity at the mu receptor (such as morphine, fentanyl, or hydromorphone). Full opioid agonist doses to achieve analgesia for patients on buprenorphine will be higher than in opioid naïve patients due to tolerance.


• Dividing the total daily buprenorphine dose into three or four times per day dosing, since buprenorphine provides an analgesic effect lasting six to eight hours. Short-acting opioid agonists can still be prescribed on an as-needed basis for additional pain-needs.


• Temporarily increasing the total daily buprenorphine dose and dividing into three or four times per day dosing, as above. Short-acting opioid agonists can still be prescribed on an as-needed basis for additional pain-needs.

The team has provided the following recommendations

• Continue outpatient buprenorphine treatment for patients admitted with acute pain.


• Use adjunctive nonopioid pain medications and nonpharmacologic modalities to address acute pain.


• Adjust buprenorphine to address acute pain by dividing the total daily amount into three or four times a day dosing, and/or up-titrate the buprenorphine dose (federal prescribing regulations recommend a maximum of 24 mg daily, but state regulations may vary).


• Add short-acting opioid agonists on an as-needed basis in conjunction with a defined plan to discontinue short-acting opioid agonists to avoid a return to use.


• Make plans collaboratively with the patient and outpatient provider, and communicate medication changes and plan at discharge.

Lastly, the authors concluded that "concerning our case, the hospitalist can continue the patient’s buprenorphine-naloxone, even with her acute pain-needs. The patient has a baseline opioid requirement, fulfilled by continuing buprenorphine. Additional short-acting opioid agonists, such as hydromorphone, will provide analgesia for the patient, though the clinician should be aware that higher doses might be required. The practice of holding buprenorphine during episodes of acute pain is not supported by current evidence and may predispose to inadequate analgesia, opioid withdrawal, and risk of return to use and death."