Buprenorphine 101 Flashcards
T/F: the naloxone/Narcan in Suboxone blocks other opioids from providing pain relief
False
Can buprenorpine can be used for analgesia/pain relief?
Yes
Once I have my DEA number, as a PA, can I prescribe buprenrophine and/or suboxone for people with opioid use disorder?
Yes
Should suboxone be stopped for a patient undergoing surgery in order to provide adequate acute post-operative analgesia?
No
Phases of the opioid epidemic (medication-wise)
Prescribed opioids (2010) –> heroin (2011) –> fentanyl (2014) –> fentanyl analogs (ex: carfentanil) (2019-2020)
How to treat substance use disorder?
Suboxone (newer medication), methadone (has been around since 1940s)
What is the opioid in suboxone?
Buprenorphine (long-acting opioid agonist)
In what subset of patients is suboxone highly recommended in?
IV drug abuse or diversion
Describe how Naloxone works
Naloxone in Suboxone is an abuse deterrent
Poor bioavailability when taken orally, prevents overdose if injected
Does NOT block opioids unless injected
How does buprenorphine work?
Works by stabilizing the dysfunctional brain receptors
3 important pharmacological differences between suboxone vs. methadone
- Partial opioid agonist activity- ceiling effect- safer-less sedation
- Strong affinity for the opioid receptor-TIGHT bind
- Kappa opioid antagonist-helps with opioid-induced hyperalgesia
2 important regulatory differences between suboxone vs. methadone
- Does not need to be dosed through a federally regulated treatment facility
- Scheduled III substance by DEA
What is the ceiling effect of buprenorphone?
Increased dose does not cause more sedation or respiratory depression (opposite of regular opioid dose increasing)
Can people die from opioid withdrawl?
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
Can people die from alcohol or benodiazepine withrawl?
Yes
What is the treatment for opioid withdrawl?
Clonidine, ibuprofen, acetaminophen, loperamide, anti-emetic
What are some considerations for suboxone administration in the hospital setting?
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
Who can prescribe Buprenorphine?
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
How is methadone dosed/administered?
Must be dosed through a federally regulated Opioid Treatment Facility
Not on Prescription Monitoring Program (PMP)
Adverse effect considerations when prescribing methadone?
Can prolong QTc interval
Many drug-drug interactions
Methadone maintenance considerations in the hospital
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
What are some benefits of buprenorphine?
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)
At what morphine milligram equivalent (MME) should you consider giving naloxone to a patient?
Over 50 MME
What is the difference between buprenoprhine used for SUD and chronic pain management?
Dose - for chronic pain management, is dosed in micrograms
Belbuca and Butrans used for chronic pain management
When to consider buprenorphone for chronic pain?
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
What are some perioperative pain management pearls?
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)
How to address suboxone dose for a patient with a history of SUD using suboxone admitted to the hospital and needing pain control?
Decrease suboxone dose to make more opioid receptors available for adequate pain control
Morphine milligram equivalent chart (flip to see)
