Palliative Care Interest Group Hosts Expert Case Discussion of Buprenorphine
Experts sharing their experiences and findings were Shamekia Wells, MSN, ACACNP-BC, ACHPN, and Eden Mae Rodriguez, Pharm.D., BCPS, from UT Southwestern; and Sina Najafi, D.O., from Baylor Scott & White Health.
The October 2022 meeting of the DFW Palliative Medicine Interest Group included a presentation for medical practitioners and medical students on the use of buprenorphine. This quarterly educational session included:
general history and overview of buprenorphine
discussion of cases from UT Southwestern and Baylor Scott & White
hospice case study
question and answer sessions
Expert speakers sharing their experiences and findings were Shamekia Wells, MSN, ACACNP-BC, ACHPN, and Eden Mae Rodriguez, Pharm.D., BCPS, from UT Southwestern; and Sina Najafi, D.O., from Baylor Scott & White Health.
Wells and Rodriguez covered the discovery of buprenorphine (C-III) in 1966 through its development and FDA approval for long-term management of severe pain. They shared documented beneficial actions of buprenorphine versus schedule II opioids, such as decreased respiratory depression and hyperalgesia, high binding affinity, slow dissociation, less craving/sedation/dysphoria, and improved mood over time. Common side effects are nausea, constipation, and headaches.
Dosages are typically given in forms such as SL tablet, SL film, buccal film, transdermal patch, or injection. Additive effects may occur when used with benzodiazepines or CNS depressants. Buprenorphine concentrations increase with moderate to severe hepatic impairment, so clinicians should use caution when combined with products treating hepatic failure.
Buprenorphine Breakthrough Pain Options
Cases of buprenorphine treatment discussed by the clinicians included a variety of patients seeking pain management while decreasing opioid use for different reasons.
1. 62-year-old female with cholangiocarcinoma and chronic back pain recovered from a wedge biopsy but suffered with nausea, vomiting, and abdominal pain. She was discharged with overall better pain control using buprenorphine SL and IV, with oxycodone and hydromorphone discontinued.
2. 30-year-old female bedbound heroin user with septic shock from extensive diffuse soft tissue wounds required debridement and multiple wound vacs over a four-month hospital stay. Her pain was uncontrolled with IV opioids, ketamine, methadone, PO oxycodone, IV dilaudid (for wound care), gabapentin, duloxetine, Robaxin, IV Toradol, and IV acetaminophen. She was successfully weaned off methadone and discharged to a rehab center with ongoing Suboxone therapy and no further use of opioids.
3. 50-year-old female treated for CML, chronic pancreatitis, chronic pain, PUD, IBS, and PTSD was undergoing chemotherapy. After treatment with dilaudid PO and IV PRN and steroids, she was placed on methadone but unable to wean off opioids. Opioids were held after she developed posterior reversible encephalopathy syndrome. After recovering, she successfully transitioned to buprenorphine and discharged to palliative care team with satisfactory pain control.
The panel also discussed trends in medication assisted treatment (MAT) in hospice care. Kelley Newcomer, M.D., UT Southwestern, VNA Hospice, noted that MAT-Waivered hospice providers willing to assume MAT in hospice patients is uncommon. It is unrelated to the terminal diagnosis, and could be continued, but cancer patients will likely be switched from buprenorphine to traditional opiates. A Butrans patch is used for opiate-naïve patients who need continuous low-dose pain relief.
A PDF of the PowerPoint presentation is available, as is a video recording of the online educational program.