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13 Articles in Volume 18, Issue #9
Children, Opioids, and Pain: The Stats & Clinical Guidelines
How to Fit into a New Practice
How to Talk to Your Chronic Pain Patients
How to Treat Opioid Use Disorder in Pregnant Women
Intranasal Ketamine for Acute Pain in Children
Medication Selection for Comorbid Pain Management (Part 3)
MR Neurography: Using Peripheral Nerve Imaging as a Pain Diagnostic
Naloxone in Schools; Buprenorphine Conversions; OUD Management
Opioid Conversion Calculations and Changes
Pes Anserine Tendino-Bursitis as Primary Cause of Knee Pain in Overweight Women
Self-Management of Chronic Pain in Primary Care
The Homebound Adolescent: Managing Chronic Pain Conditions in the Pediatric Population
The Opioid Band-Aid: The State of Pain Pills, Congressional Bills, and Healthcare in the US

Naloxone in Schools; Buprenorphine Conversions; OUD Management

December 2018 PPM Letters to the Editor from practitioner peers and patients
Pages 9-10
Page 1 of 2

Should Naloxone Be Stored in Schools?

There is a growing trend of naloxone being stored in school health offices across the United States, including at the elementary level, in case of emergency. PPM asked its Editorial Advisors for their take on whether this is a good idea:

NO: “I can think of a number of reasons why naloxone should not be utilized in a non-medical setting. First, is the individual trained to use this medicine? I doubt in a public school setting this would be the case. There are side effects that require special knowledge. So overall I think it would be a bad idea. Why not put efforts into treating why there may be a drug problem?”

–Kern Olson, MD

PERHAPS: “If the problem is serious enough and if the local authorities are supporting it with all the resources needed, I do not see anything wrong. It has to be part of a comprehensive educational plan involving the local communities.”

–Sri Nalamachu, MD

YES: “Opioid overdoses in children are on the rise whether it’s accidental exposure to opioids from parents or adolescents using substances. Many illicit drugs are being contaminated with fentanyl leading to overdoses as well. Especially after the Surgeon General’s Advisory on Naloxone and Opioid Overdose, increasing access in the community, including schools, to naloxone is critical.”

–Courtney Kominek, PharmD

Buprenorphine Conversion Conundrum

Dear PPM,

What conversion factors do you use to convert products to buprenorphine (transdermal, film, and tablets)? From what I could find on CMS, buprenorphine products do not have an associated MME conversion factor.

As partial opioid agonists, these products are not expected to be associated with overdose risk in the same dose-dependent manner as doses for full agonist opioids. The conversion factors for drugs prescribed or provided as part of medication-assisted treatment for opioid use disorder should not be used to benchmark against dosage thresholds meant for opioids prescribed for pain.

–Julia Galea, PharmD

Dear Dr. Galea,

There is no official conversion factor for transitioning from a full agonist opioid to buprenorphine. Since buprenorphine has a higher mu-receptor affinity compared to other full opioid agonists, it will bump these off the receptor in a manner similar to naloxone. Although buprenorphine is a partial mu agonist/kappa antagonist, it has excellent analgesia often exceeding that of full agonist opioids. But the analgesic benefit, like the CO2 accumulation (and risk for opioid-induced respiratory depression) eventually reach a plateau.

At oral morphine dose equivalents of 60 to 90 mg per day, you can reasonably make a direct switch to buprenorphine with the expectation of no or minimal opioid withdrawal. As doses exceed 90 mg per day orally, the risk of opioid withdrawal is significantly increased.

When considering a switch, it is important to note that transdermal buprenorphine absorption is 15%, while the buccal film in the form of Belbuca offers 45 to 60% absorption. Doing the math, a Butrans patch delivering 20 mcg/hour is 480 mcg per day, at 15%, equals 72 mcg absorbed per day. The lowest strength of Belbuca is 75 mcg (dosed twice daily is 150 mcg per day) and with about 50% absorption equals 75 mcg absorbed per day. Therefore, dosing options for Belbuca offer much higher exposure to buprenorphine for analgesia because it is available as 900 mcg for twice daily dosing.

The reason CMS does not list an MME for buprenorphine is because the presumed conversion at lower doses cannot be the same as higher doses, and consideration must be given to the fact that buprenorphine will displace full agonist opioids from the receptors, and analgesic benefit at very high doses will eventually plateau.

You are correct, that buprenorphine as a single entity drug has almost no risk of respiratory depression. But, if combined with various sedative hypnotics such as amitriptyline, diphenhydramine, benzodiazepines, and alcohol, respiratory depression may occur. Unfortunately, since buprenorphine is technically an opioid, if there is a death, it would be reported as an “opioid-related death.”

–Jeffrey Fudin, PharmD

Opioid Use Disorder (OUD) Management Approaches

Dear PPM,

I would like to offer some additional perspective to the article titled “Managing Opioid Use Disorder” by Charles Reznikoff, MD, FACP, published in the September 2018 issue. As someone who is certified in both addiction medicine and pain management, I found this article very interesting. However, it also raised some concerns.

In the hypothetical case presented of a patient who frequently exceeds her prescribed dose of 10 mg short-acting oxycodone four times a day, Dr. Reznikoff wrote: “The prescribing physician believes she does this to self-medicate her untreated depression.” This could be true, yet the article does not address the importance of evaluating or treating the patient for depression, nor does the author discuss getting to know the patient, such as through dialogue or psychological assessment. I believe this is an important part of treating addiction before turning directly to medication-assisted treatment (MAT). Moreover, this hypothetical patient might be not an addict but rather a “chemical coper,” using oxycodone IR, the most popular and effective opioid for anxiety and depression, to treat her psychological symptoms.

Later in the article, Dr. Reznikoff hypothesizes that buprenorphine may be more effective at controlling pain than methadone “due to its long half-life, which prevents daily withdrawal episodes, or because the full agonist was causing opioid-induced hyperalgesia, or a result of the somaticized pain.” With regard to hyperalgesia, I believe he is introducing a very controversial matter that does not particularly help in addressing Opioid Use Disorder (OUD). According to the literature, the concept of opioid-induced hyperalgesia (OIH) has never been shown to be clinically relevant in a chronic pain setting.

Last updated on: December 3, 2018
Continue Reading:
Letters to the Editor: Recovery Centers Reject MAT, Cannabis for Chronic Headaches, Central Pain
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