Posted: June 14th, 2023

A 54-year-old woman with chronic pain due to inflammatory arthritis

Read the following case studies and search for the guidelines that answers the specific questions?

Case 1

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A 54-year-old woman with chronic pain due to inflammatory arthritis presents to your clinic stating that she is having a “flare” of her arthritis but is out of her Oxycontin® and immediate-release oxycodone. She is aware that it is too early to fill her prescriptions, but she insists that she will be traveling out of state and “really needs” her medications.

Question: How do you Approach This Patient in the community setting?

What is the implications of prescribing this medication? Please provide evidence.

Case 2
A 27-year-old woman on buprenorphine-naloxone (Suboxone®) for treatment of opioid dependence is admitted to the hospital with severe abdominal pain due to a perforated gastric ulcer. She received hydromorphone in the ED, and is urgently taken to the operating room. Postoperatively, she is on a patient-controlled analgesic (PCA) pump containing fentanyl. Her last dose of buprenorphine-naloxone was 20 h prior to the surgery; her daily dose is 16 mg.

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Question: How can Pain be Managed in Patients who are Taking Buprenorphine-Naloxone? What Adjustments to her Medication Regimen can be Recommended?
Case 1:

Approaching the patient:

When dealing with patients with chronic pain, it is important to assess the severity of pain, level of disability, and quality of life. A good history and physical examination should be performed to establish the cause and severity of the pain. When prescribing medications, healthcare providers should ensure that the benefits outweigh the risks, and the treatment is individualized to meet the patient's specific needs.

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Implications of prescribing medications:

Prescribing opioids for chronic pain is a complex issue, and the risk of abuse and addiction should always be taken into account. Oxycontin® and immediate-release oxycodone are high-risk medications with high potential for misuse, dependence, and addiction. Healthcare providers should be aware of the potential for addiction and should avoid overprescribing opioids. When opioids are used, they should be prescribed in the lowest effective dose and for the shortest duration possible. Prescribers should also be aware of their state's prescription drug monitoring program (PDMP) requirements and use the PDMP to help prevent overprescribing and diversion of controlled substances.

Case 2:

Managing pain in patients taking buprenorphine-naloxone:

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Buprenorphine-naloxone is a partial opioid agonist and antagonist combination used for the treatment of opioid dependence. Patients on buprenorphine-naloxone have a high tolerance to opioids, and traditional opioid analgesics may not provide adequate pain relief. In such cases, alternative pain management strategies should be considered. Non-opioid analgesics, such as acetaminophen and nonsteroidal anti-inflammatory drugs, can be used to manage mild to moderate pain. For severe pain, an opioid analgesic with a high affinity for the mu-opioid receptor, such as fentanyl, should be used.

Adjustments to medication regimen:

When patients on buprenorphine-naloxone require surgery, the medication regimen should be carefully managed to ensure adequate pain control while minimizing the risk of withdrawal. Buprenorphine-naloxone should be continued up to the time of surgery, and an opioid analgesic with a high affinity for the mu-opioid receptor, such as fentanyl, should be used for postoperative pain management. The buprenorphine-naloxone can be restarted after the opioid analgesic has been discontinued, and the patient is stable. The patient's buprenorphine-naloxone dose may need to be increased temporarily to compensate for the increased metabolism of the medication due to surgery and pain.

Sources
Centers for Disease Control and Prevention (CDC). (2020). Clinical Guidance for Treating Pregnant and Parenting Women with Opioid Use Disorder and Their Infants. https://www.cdc.gov/pregnancy/documents/treating-pregnant-women.pdf

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National Institute on Drug Abuse (NIDA). (2020). Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition). https://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition/evidence-based-approaches

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