To The Editor: Office-based, long-term buprenorphine is a growing treatment for opioid dependence (1). Patients with opioid dependence may require treatment for pain during their opioid therapy, and such treatment can be complicated. Recently suggested recommendations for the treatment of acute pain in a buprenorphine-maintained individual include the following four options: using concomitant short-term opioid analgesics, dividing the daily buprenorphine dose, replacing the buprenorphine with another opioid analgesic, or replacing the buprenorphine with methadone and then adding an opioid analgesic (2). We present a case of postoperative pain control in a buprenorphine-maintained patient, using supplemental doses of sublingual buprenorphine for pain management.
The patient was a 32-year-old woman with opioid dependence who had been successfully maintained on sublingual buprenorphine/naloxone 24/6 mg daily for 6 months, up to and including the day she underwent surgical removal of breast implants under general anesthesia. The patient was seen in an outpatient addiction treatment clinic (by Dr. Book) and prescribed buprenorphine/naloxone 2/0.5 mg tablets for postoperative pain control, with instructions to take one to two sublingual tablets every 4 to 6 hours for pain. On her first and second postoperative days at home, she reported taking 12/3 mg every 6 hours to relieve pain, in addition to her 24/6 mg per day baseline dose, for a total daily dose of 72/18 mg of buprenorphine/naloxone. She was able to successfully and comfortably taper her dose by postoperative day 11 to her baseline dose of 24/6 mg. The patient did not report taking other analgesics, including nonsteroidals.
Although this individual case was limited by self-report, self-titration, and lack of control, the off-label use of supplemental doses of sublingual buprenorphine for acute postoperative pain in a buprenorphine-maintained individual is a novel approach. Buprenorphine is a partial m agonist shown to have a ceiling to analgesic effects in preclinical studies. Indeed, the bell-shaped dose-response curve of buprenorphine suggests that high doses may produce diminishing analgesic effects (3, 4). However, this was not the case for our patient, who had adequate pain control, with total daily doses of up to 72/18 mg following surgery that typically may require 60 mg per day of oxycodone. Furthermore, because no other respiratory depressants were used, this high dose of buprenorphine could safely be used as an outpatient dose. These findings suggest that the time-limited, off-label use of supplemental doses of sublingual buprenorphine may be an effective fifth option for management of acute pain in selected buprenorphine-maintained patients.
1.Stanton A: Results from SAMHSA/CSAT"s National Evaluation of the Buprenorphine Waiver Program, in The College on Problems of Drug Dependence 67th Annual Scientific Meeting. Orlando, Fla, CPDD, 20052.Alford DP, Compton P, Samet JH: Acute pain management for patients receiving maintenance methadone or buprenorphine therapy. Annal Intern Med 2006; 144:127–1343.Dum JE, Herz A: In vivo receptor binding of the opiate partial agonist, buprenorphine, correlated with its agonistic and antagonistic actions. Br J Pharmacol 1981; 74:627–6334.Cowan A, Lewis JW, Macfarlane IR: Agonist and antagonist properties of buprenorphine, a new antinociceptive agent. Br J Pharmacol 1977; 60:537–545
Drs. Book and Malcolm have received honoraria from Reckitt Benckiser. Dr. Strain has received speaker’s honorarium and travel funds from Reckitt Benckiser. Dr. Myrick reports no competing interests.