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14 Articles in Volume 18, Issue #9
Assessing Arthralgia in Children
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

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.

The author also states that for patients with pain and OUD on methadone maintenance, the methadone may be the best choice for treating their pain. I agree with this, but it is important to note for prescribers that methadone is not a long-acting analgesic; thus, when it is used for treating chronic pain, it must be given in divided doses, 3 to 4 doses a day, whereas 1 daily dose will suffice in preventing withdrawal symptoms.

Dr. Reznikoff was right to point out that physicians working in pain management should consider obtaining certification in addiction care, and thus, avoid off-site referrals. However, the existing 8-hour buprenorphine courses focus on the technical aspects of buprenorphine, and do little in the way of explaining the psychological parts of treating addiction.

In my national 21-CME remedial/proactive opioid prescribing course, I have met dozens of clinicians who have taken the buprenorphine course and now have a stable of patients on the medication, but few of these doctors have attended a 12-step meeting (such as Narcotics Anonymous) or recommended group therapy/supported 12-step groups to their patients. I believe this additional training would go a long way toward improving addiction treatment and best serve the patient’s long-term interests.

–Jennifer Schneider, MD, PhD

Dear Dr. Schneider,

I appreciate your feedback. I offered OIH as one example of a common occurrence when transitioning patients with chronic pain and OUD from full agonist opioids to buprenorphine, a partial agonist. Patients often express concern about pain control after transitioning to buprenorphine, yet may be surprised to discover their pain improves. This is particularly true for patients with Chronic Pain Syndrome and no nociceptive pain generator sufficient to explain the degree of pain. Many reasons (including OIH) may explain this paradoxical pain improvement. The important point is that providers need not let concern about chronic pain deter them from transitioning high-risk patients away from full agonist opioids.

I did not propose that methadone be used for pain control in patients with pain and OUD. Rather, I proposed that it be used for the treatment of OUD. Of the FDA-approved treatments for OUD, methadone is a better option than buprenorphine or naltrexone for such patients because it has the least interaction with other full agonist opioids. In patients with OUD and pain, methadone should be given by a licensed addiction clinic that can directly observe the therapy. Methadone clinics do not schedule or dose methadone for its analgesic effects. If a patient enrolled in a methadone program has pain of sufficient severity to warrant opioids, their methadone dose is not adjusted; instead they are referred for separate pain treatment, typically with opioids other than methadone.

In other words, at the time of diagnosis of OUD in a chronic pain patient, the provider should consider whether the patient is likely to have future instances when pain will warrant full agonist opioids. If so, the provider may consider methadone the preferred choice for the treatment of OUD. If not, buprenorphine would be an acceptable option as well.

I agree with you that the 8-hour training to become buprenorphine waivered does not seem adequate. Recent data shows that while the number of buprenorphine waivers has increased steadily, use of those waivers has not similarly increased. However, I differ on the best additional training for buprenorphine-waivered providers. Waivered providers needing additional support should access the Provider’s Clinical Support System, a free, evidence-based resource that provides expert assistance to providers caring for patients with addictions. A similar support network available to many buprenorphine waivered providers is the Extension for Community Health Outcome program.

While 12-step groups and 12-step facilitated treatments may serve as an adjunct to addiction treatment with buprenorphine, there is not, to my knowledge, evidence to support improved outcomes using those principles for OUD, whereas the evidence to support the use of MAT is strong. That evidence usually includes behavioral counseling in addition to MAT, but it does not need to be 12-step oriented.

My goal in writing the article was to urge providers treating pain to consider pain and addiction as two diseases that can be treated successfully together. I hoped to reassure pain providers that pain outcomes need not be undermined by addiction treatment, and that improving skills to recognize and treat OUD within the context of a pain clinic represents best care. I also hoped to encourage pain providers to obtain a buprenorphine waiver. I believe you and I likely very much agree on those central points.

–Charles Reznikoff, MD, FACP

Last updated on: December 3, 2018
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