From Rare to Reality: The Challenge of Controlling Pain in Patients on Buprenorphine in the Acute Care Setting

Abstract

Prescription opioid use has increased dramatically in the past 20 years with prescriptions for opioids and overdoses both increasing by 400% in what is now being called an opioid epidemic. The CDC’s Guidelines for Prescribing Opioids for Chronic Pain were released in March 2016 and the result has been increasing scrutiny of opioid prescriptions. For pain patients, this means minimizing opioid use and decreasing reliance, while others are being tapered off opioids altogether. Opioid tapers are predictably revealing unanticipated levels of opioid use disorder and unsupportable demand for enrollment in opioid assisted treatment (OAT) via buprenorphine/naloxone (Suboxone®) or methadone treatment programs. In July 2016, the Department of Health and Human Services released a final rule increasing prescribing limits of buprenorphine/naloxone (Suboxone®) to allow qualifying providers to treat up to 275 patients rather than capping panel size at 100. In addition to increased use in the treatment of opioid use disorder, there are new formulations of buprenorphine approved for chronic pain management. Therefore, while opioid use overall is decreasing, use of buprenorphine itself is dramatically increasing and introducing new challenges to treatment in trauma and acute pain settings based on its unique pharmacology. In recent years, case reports highlighting the challenge of managing pain when patients are treated with buprenorphine were published but until now were rarely seen in practice. It is, therefore, incumbent on all providers in these settings to become intimately familiar with buprenorphine and prepare to safely and effectively manage pain in these challenging patients.