Advantages of Simultaneous Administration of Buprenorphine With Opioids.
Given the mortality and morbidity burden of opioid use disorder, strategies to prevent further addiction are key goals among public health officials and clinicians. Nonetheless, there continue to be circumstances in which patients need adequate acute pain control. The perioperative phase is a vulnerable time for patients with opioid use disorders, but there is very little research on managing post-operative pain in these patients.
Meanwhile, the Substance Abuse and Mental Health Services Administration has made medication-assisted treatment (MAT) a priority to address the opioid problem. Emphasis was placed on buprenorphine as a novel office-based MAT with the introduction of the Suboxone, a combination buprenorphine/naloxone sublingual product available in a 4/1mg ratio.
Early records indicate the sap from Papaver somniferum (opium poppy) was used for both analgesic and euphoric effects.1 The poppy plant accumulates several benzylisoquinoline alkaloids including morphine, codeine, and thebaine. Thebaine is the raw material for hydrocodone, hydromorphone, oxycodone, and other semisynthetic opiates.
To separate analgesia from euphoria, synthetic opioids were created. Unfortunately, with more analgesic potency also came increased abuse potential. In 1966, buprenorphine was synthesized; it included a cyclic propyl group which yields antagonistic effects, hence its agonist-antagonist properties.2 It seemed the long sought-after safe potent oral analgesic had been found.
Instead of achieving stardom as a pain reliever, buprenorphine became tasked for MAT because of its unique actions. Buprenorphine is a mu-opioid receptor partial agonist with properties that can provide long-lasting craving and withdrawal suppression. It has the added benefit of partial blockade of the effects of mu-opioid receptor full agonists such as heroin, oxycodone, and fentanyl. A ceiling effect on respiratory depression adds to the protective quality of this drug. It ultimately garnered attention with Suboxone’s approval in 2002 for detoxification and long-term maintenance therapy in opioid dependency.
Historically, the predicted results of mixing agents with agonist effects of varied potency at the mu-opioid receptor were based on an understanding of in-vitro binding affinities.3 With a more sophisticated understanding of the pharmacokinetic and pharmacodynamics interactions of buprenorphine, clinicians can now use this medication knowing that all mu-receptor active agents interact competitively, regardless if they are full or partial agonists.4
When patients on buprenorphine require an interventional procedure that often results in acute pain, the question arises: How do we treat this patient?
Solving the perioperative strategy for a patient receiving psychopharmacology for opioid use disorder (specifically a buprenorphine product), must encompass provision for adequate analgesia while protecting the patient from a relapse. This is especially true in the face of the current opioid crisis, with increased risk of death risk from a single exposure to adulterated illicit high potency synthetic opioids.
Clinicians and patients historically have been skeptical about using buprenorphine products in time-proximity to mu-opioid receptor full agonists; there are concerns about precipitated withdrawal and hindered analgesia. Given the high mu-receptor affinity of buprenorphine, providers of perioperative care have been worried about inadequate or complicated analgesia management. Fortunately, a more sophisticated understanding of buprenorphine that accounts for specific dose-timing proves that the simultaneous administration of buprenorphine with mu-opioid receptor full agonists is not only possible, it can produce advantages.
Developing a treatment protocol
Developing an evidence-based strategy to satisfy the conflicting priority of peri-proceduralists and addiction specialists during perioperative care of such patients required a review of extant literature to propose a consensus guideline. The goal was to create a simple yet sound protocol allowing for cooperation and communication between stakeholders.
Dr Acampora is an instructor in psychiatry at Massachusetts General Hospital and fulltime faculty at Harvard Medical School. He reports no disclosures concerning the subject matter of this article.
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