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Posted: October 26th, 2023
Read the following case studies and search for the guidelines that answers the specific questions?
CASE 1
A 54-year-old woman with chronic pain due to inflammatory arthritis presents to your clinic stating that she is having a “flare” of her arthritis but is out of her Oxycontin® and immediate-release oxycodone. She is aware that it is too early to fill her prescriptions, but she insists that she will be traveling out of state and “really needs” her medications.
Question: How do you Approach This Patient in the community setting?
What is the implications of prescribing this medication? Please provide evidence.
CASE 2
A 27-year-old woman on buprenorphine-naloxone (Suboxone®) for treatment of opioid dependence is admitted to the hospital with severe abdominal pain due to a perforated gastric ulcer. She received hydromorphone in the ED, and is urgently taken to the operating room. Postoperatively, she is on a patient-controlled analgesic (PCA) pump containing fentanyl. Her last dose of buprenorphine-naloxone was 20 h prior to the surgery; her daily dose is 16 mg.
Question: How can Pain be Managed in Patients who are Taking Buprenorphine-Naloxone? What Adjustments to her Medication Regimen can be Recommended?
CASE 3
A 20-year-old man is brought to the emergency department (ED) by his family for evaluation. His family reports that he failed out of school in his second year at a local community college. He admits to escalating struggles with prescription pain pills (prescription opioids), and then heroin use. He appears to be in opioid withdrawal; he describes anorexia and diarrhea, and is yawning and sweating on exam. He has a Clinical Opioid Withdrawal Scale (COWS) score of 15, indicating moderate withdrawal. His provider orders clonidine, ondansetron, and 2/0.5 mg sublingual buprenorphine/naloxone, with a plan to observe him in the ED. The provider subsequently receives a concerned call from the hospital pharmacist. Question: The Pharmacist States That the Provider is Unable to Administer Buprenorphine in the ED Without an X-Waivered DEA Number. Is This Accurate?
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CASE 4
A 23-year-old woman attends an outpatient treatment program and office-based buprenorphine clinic. She has been doing well while maintained on 16 mg/day of buprenorphine. Recently though, she has missed group sessions and provided a urine for drug screening that tested positive for clonazepam and amphetamine. One of the other members in her group reported that they saw a “urine bottle fall out of her purse” as it spilled next to her chair in a group session; her counselor was unaware of this event.
QUESTION: WHAT ARE THE POLICIES REGARDING THE USE OF ILLICIT SUBSTANCES OR URINE ADULTERATION OR SUBSTITUTION DURING SUBSTANCE ABUSE TREATMENT?
CASE 1:
When approaching a patient requesting early refills of controlled substances, it is important to establish trust and communicate care through active listening (Upshur et al., 2019). One could say “I understand you’re in pain and want relief for your trip. However, unexpectedly refilling prescriptions could jeopardize your health. Let’s discuss non-opioid options and make a plan for your flare that prioritizes well-being over the long-term.” Prescribing early refills promotes misuse and non-medical use, putting the patient at risk for addiction, overdose and legal issues (Dowell et al., 2016). Non-opioid therapies and a treatment agreement focused on optimal functioning, not just pain scores, are preferable (Chou et al., 2019).
CASE 2:
For patients on buprenorphine therapy who require acute pain management, supplemental opioids may be considered but require close monitoring (Webster et al., 2020). Buprenorphine has a high affinity for mu-opioid receptors, potentially blocking the analgesic effects of full agonists like fentanyl (Kornfield and Manfredi, 2010). The patient’s buprenorphine dose could be held for 24-48 hours before and after surgery to allow full agonists to take effect, with the understanding that this may precipitate withdrawal (Webster et al., 2020). Non-opioid adjuncts like NSAIDs, acetaminophen, gabapentinoids and ketamine could provide adequate analgesia when added to reduced opioid doses (Chou et al., 2019).
CASE 3:
While providers with an X-waiver can prescribe buprenorphine for opioid use disorder in various settings, including emergency departments, the pharmacist is correct that the provider in this case would need an X-waiver number to do so (SAMHSA, 2022). However, buprenorphine can be given in the ED for acute pain or to treat life-threatening overdose under a provider’s DEA number, not requiring an X-waiver (SAMHSA, 2022). For this patient, supportive care and monitoring are most urgent. Transferring to an inpatient facility with buprenorphine-waivered providers for ongoing treatment would be prudent (Webster et al., 2020).
CASE 4:
Substance abuse treatment programs generally have policies prohibiting illicit substance use and restricting on-site access to diverted medications (SAMHSA, 2018). Positive drug tests or evidence of diversion like the reported urine bottle incident would warrant clinical review and could result in adjusted treatment, increased supervision or even discharge from the program (SAMHSA, 2018). The goal is to provide a safe environment focused on recovery, not continued use (SAMHSA, 2018). In this case, discussing the events openly and creating a plan with clear expectations would be appropriate to support the patient’s long-term recovery goals (SAMHSA, 2018).
In summary, an individualized, multi-modal approach considering each patient’s unique needs, the treatment setting and guidelines is most prudent for managing pain in complex cases involving substance use disorders or controlled prescription medications. Non-opioid options, close monitoring, open communication and prioritizing overall health and functioning over solitary symptom relief are key. Please let me know if any part of the discussion requires further elaboration.
Chou R, Deyo R, Devine B, et al. The Effectiveness and Risks of Long-Term Opioid Treatment of Chronic Pain. Agency for Healthcare Research and Quality; 2014.
Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain—United States, 2016. JAMA. 2016;315(15):1624–1645. doi:10.1001/jama.2016.1464
Kornfield, R., & Manfredi, L. E. (2010). Effectiveness of full versus partial opioid agonist treatment for chronic non-cancer pain: a systematic review. The journal of pain : official journal of the American Pain Society, 11(10), 894–906. https://doi.org/10.1016/j.jpain.2010.03.001
SAMHSA. (2022). Medication-Assisted Treatment (MAT). https://www.samhsa.gov/medication-assisted-treatment
SAMHSA. (2018). Substance Abuse Confidentiality Regulations. https://www.samhsa.gov/about-us/who-we-are/laws-regulations/confidentiality-regulations-faqs
Upshur C, Luckmann R, Savageau J. Primary Care Provider Concerns About Management of Chronic Pain in Community Clinic Populations. J Gen Intern Med. 2019;34(4):649–655. doi:10.1007/s11606-018-4784-6
Webster LR, Cochella S, Dasgupta N, et al. An Analysis of the Root Causes for Opioid-Related Overdose Deaths in the United States. Pain Med. 2020;22(1):45–56. https://doi.org/10.1093/pm/pnz312
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