Buprenorphine 101

Question 1

T/F: the naloxone/Narcan in Suboxone blocks other opioids from providing pain relief

Answer 1

False

Question 2

Can buprenorpine can be used for analgesia/pain relief?

Answer 2

Yes

Question 3

Once I have my DEA number, as a PA, can I prescribe buprenrophine and/or suboxone for people with opioid use disorder?

Answer 3

Yes

Question 4

Should suboxone be stopped for a patient undergoing surgery in order to provide adequate acute post-operative analgesia?

Answer 4

No

Question 5

Phases of the opioid epidemic (medication-wise)

Answer 5

Prescribed opioids (2010) –> heroin (2011) –> fentanyl (2014) –> fentanyl analogs (ex: carfentanil) (2019-2020)

Question 6

How to treat substance use disorder?

Answer 6

Suboxone (newer medication), methadone (has been around since 1940s)

Question 7

What is the opioid in suboxone?

Answer 7

Buprenorphine (long-acting opioid agonist)

Question 8

In what subset of patients is suboxone highly recommended in?

Answer 8

IV drug abuse or diversion

Question 9

Describe how Naloxone works

Answer 9

Naloxone in Suboxone is an abuse deterrent

Poor bioavailability when taken orally, prevents overdose if injected

Does NOT block opioids unless injected

Question 10

How does buprenorphine work?

Answer 10

Works by stabilizing the dysfunctional brain receptors

Question 11

3 important pharmacological differences between suboxone vs. methadone

Answer 11

1. Partial opioid agonist activity- ceiling effect- safer-less sedation
2. Strong affinity for the opioid receptor-TIGHT bind
3. Kappa opioid antagonist-helps with opioid-induced hyperalgesia

Question 12

2 important regulatory differences between suboxone vs. methadone

Answer 12

1. Does not need to be dosed through a federally regulated treatment facility
2. Scheduled III substance by DEA

Question 13

What is the ceiling effect of buprenorphone?

Answer 13

Increased dose does not cause more sedation or respiratory depression (opposite of regular opioid dose increasing)

Question 14

Can people die from opioid withdrawl?

Answer 14

Rarely

People moreso experience flu-like symptoms (nausea, muscle cramping, agitation, anxiety, opiate cravings, yelling, sweats, hypertension, or difficulty falling asleep)

Early symptoms can start within 6-12 hours from short-acting opiates or 24 hours for long-acting ones

Symptoms peak at 72 hours

Question 15

Can people die from alcohol or benodiazepine withrawl?

Answer 15

Yes

Question 16

What is the treatment for opioid withdrawl?

Answer 16

Clonidine, ibuprofen, acetaminophen, loperamide, anti-emetic

Question 17

What are some considerations for suboxone administration in the hospital setting?

Answer 17

May take up to 72 hours to dissociate from opioid receptor (long half life of 35 hours)

Slow onset (~ 1 hour)

Provides analgesia for 6-8 hours

Dosing varies from once daily to QID

Needs to dissolve orally - do not chew/swallow films/tablets

Question 18

Who can prescribe Buprenorphine?

Answer 18

Physicians, advanced practice clinicians, CRNA’s, CNW’s and CNS’s - need a DEA lisence

8 hours SUD training for DEA license - new and renewal

Used to need an X-waiver but not anymore

Question 19

How is methadone dosed/administered?

Answer 19

Must be dosed through a federally regulated Opioid Treatment Facility

Not on Prescription Monitoring Program (PMP)

Question 20

Adverse effect considerations when prescribing methadone?

Answer 20

Can prolong QTc interval

Many drug-drug interactions

Question 21

Methadone maintenance considerations in the hospital

Answer 21

Once a day dosing (liquid form)

Have pharmacy call methadone clinic to verify dose and continue same dose while hospitalized

Methadone clinic requires documentation of administration upon return to clinic

Methadone maintenance different than use of methadone for acute pain

Question 22

What are some benefits of buprenorphine?

Answer 22

Less QTc prolongation than methadone
Less respiration depression
Safe for use in kidney disease and hepatic impairment
Less neonatal abstinence symptoms when used during pregnancy and improved fetal and maternal outcomes
Schedule III (less abuse potential - SAFER)

Question 23

At what morphine milligram equivalent (MME) should you consider giving naloxone to a patient?

Answer 23

Over 50 MME

Question 24

What is the difference between buprenoprhine used for SUD and chronic pain management?

Answer 24

Dose - for chronic pain management, is dosed in micrograms

Belbuca and Butrans used for chronic pain management

Question 25

When to consider buprenorphone for chronic pain?

Answer 25

Less than 90 MME-opioid naïve or frail (ex: RA)
Tapering opioids down (stalled on taper)
Intolerable AEs from opioids (ex: nausea/constipation)

Often not covered by insurances, likely need prior authorization

No generic yet, is expensive

NOT for treatment of opioid use disorder

Question 26

What are some perioperative pain management pearls?

Answer 26

Setting expectations (having no pain is unrealistic)

Pain control does not mean opioid use

Utilize multimodal pain medications (acetaminophen, NSAIDs, gabapentinoids, muscle relaxants, limited opioids)

Partner with anesthesia for pain management options (nerve blocks, intraoperative infusions (ex: ketamine, lidocaine, dexmedetomidine, etc)

Question 27

How to address suboxone dose for a patient with a history of SUD using suboxone admitted to the hospital and needing pain control?

Answer 27

Decrease suboxone dose to make more opioid receptors available for adequate pain control

Question 28

Morphine milligram equivalent chart (flip to see)

Answer 28