This article is more than 5 years old. Information may no longer be current.

Buprenorphine effectively manages opioid use disorders, acute pain

ORLANDO, Fla. — Initiating buprenorphine is appropriate for patients with opioid use disorders during hospitalization and can aid in managing acute pain associated with the disorder in buprenorphine treated patients, according to a presentation at Hospital Medicine 2018.

Over the past two decades, there has been a dramatic rise in drug overdose deaths, increasing from a 3% per year increase between 2006 and 2014 to an 18% per year increase between 2014 and 2016, Anika Alvanzo, MD, MS, from Johns Hopkins Medicine, said during her presentation. These increases can be largely attributed to the rise of the synthetic opiates, she said.

“Clearly, we are in an opioid epidemic and we as physicians have a role to play in addressing this epidemic,” Alvanzo said.

Hospitalizations for poisoning by prescription opioids, sedatives and tranquilizers and opioid use/dependence have also dramatically increased, she said. Such hospitalizations can act as a “teachable moment” for many patients, according to Alvanzo.

Pharmacotherapy for opioid use disorders

There are three medications that have been approved by the FDA for opioid use disorder, including buprenorphine, methadone and naltrexone, Alvanzo said.

“Buprenorphine prescribed at discharge significantly increases the likelihood of treatment engagement, with about three-quarters of patients in treatment 1 month later,” she said.

Alvanzo strongly urged the audience to consider getting their buprenorphine certification, so that in addition to being able to order the drug within the hospital they can also prescribe it at discharge.

“Instead of buprenorphine taper protocols for opioid withdrawal, we should look at having buprenorphine initiation protocols to create bridges to treatment for patients,” she suggested.

Acute pain management for patients with opioid use disorder

In individuals who inject opioids, there has been a rise in hospital admissions for painful conditions, according to Alvanzo.

“Previously, we’ve had a lot of concerns with buprenorphine,” Alvanzo said.

But, “buprenorphine is actually an effective opioid analgesic,” she said.

“What we have seen from emerging data is that buprenorphine-maintained patients are doing just as well as patients who are maintained with methadone in respect to their postoperative pain, analgesia requirements and complications,” she added.

Hospitalists can continue to use buprenorphine perioperatively, Alvanzo said, noting that there is no need to transition to methadone.

Buprenorphine can also be continued for patients admitted to the hospital for acute pain and who are already maintained on buprenorphine, she said.

“What is unclear at this point is how to handle patients who are not already on buprenorphine,” she said.

New clinical assessment to o l for alcohol withdrawal

“Alcohol still kills more people than opioids,” Alvanzo said.

In the United States, around 88,000 deaths each year are alcohol-related and about 25% of adults with alcohol use disorder will develop alcohol withdrawal syndrome in their lifetime, she said.

Alvanzo and colleagues developed the Brief Alcohol Withdrawal Scale (BAWS) to assess five symptoms of alcohol withdraw syndrome, including tremor, diaphoresis, agitation, orientation and hallucinations.

“Because the tool is not based solely on subjective data, it can be used both on the floor and in intensive care settings,” Alvanzo said. “We used a score of 3 as our threshold for initiation of medication using the symptom triggered protocol.”

BAWS is briefer and more objective than the Clinical Institute Withdrawal Assessment (CIWA), she said. Additionally, its performance is comparable to the CIWA in nonmedically complex patients, she said.

“We are actually looking at the data on our medicine floor, so hopefully later this year we will be able to publish data for performance in medically complex patients,” Alvanzo said. – by Alaina Tedesco

Reference:

Alvanzo A. Update in Addiction Medicine. Presented at: Hospital Medicine 2018; April 9-11; Orlando, Fla.

Disclosure: Alvanzo reports consulting for Emmi Solutions and Indivior, Inc.