Non-Ob Pain 2024 revision

What About Non-Ob Pain?

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• Patients with an opioid use disorder who are physically dependent on opioid agonist treatment (i.e., methadone or buprenorphine)
• Must be maintained on a daily equivalence before ANY analgesic effect is realized with opioids used to treat acute pain.
• Opioid analgesic requirements are often higher due to increased pain sensitivity and opioid cross-tolerance.

"Opioid Debt"

Peng, PW; Tumber, PS; Gourlay, D. Can J Anaesthesia. 2005. Alford, DP; Compton, P; Samet, JH. Ann Intern Med. 2006.

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• May antagonize effects of previously administered opioids.
• May block the effects of subsequently administered opioids.
• However, in experimental mouse and rat pain models, it was found that:

• A combination of buprenorphine and full opioid agonists (morphine, oxycodone, hydromorphone, fentanyl) resulted in additive or synergistic effects.
• Receptor occupancy by buprenorphine does not appear to cause impairment of mu-opioid receptor accessibility.

Acute Pain

Buprenorphine Stabilization Treatment: Theoretical Concern

Kogel, B et al. European J of Pain. 2005. Englberger, W et al. European J of Pharm. 2006.

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• Continue buprenorphine and titrate short-acting opioid analgesic
• D/c buprenorphine, use opioid analgesic, then re-induce
• Divide buprenorphine to every 6-8 hours
• Use supplemental doses of buprenorphine*
• If inpatient:
• D/c buprenorphine
• Start methadone 20-40mg (or other long-acting opioid) for opioid debt
• Use short-acting opioid analgesics
• Then re-induce w/ buprenorphine when acute pain resolves

Acute Pain

Buprenorphine Stabilization Treatment: Options

Alford, DP. Handbook of Office-Based Buprenorphine Treatment of Opioid Dependence. 2010. Alford, DP; Compton, P; Samet, JH. Ann Intern Med. 2006. * Book, SW; Myrick, H; Malcolm, R; Strain, EC. Am J Psychiatry. 2007.

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Chronic Pain: Buprenorphine Stabilization Treatment

• Systematic review
• Ten trials involving 1,190 patients
• Due to heterogeneity of studies, pooling results and meta-analysis not possible
• All studies reported effectiveness in treating chronic pain
• The majority of studies were observational and low quality
• Current evidence is insufficient to determine the effectiveness of SL buprenorphine for the treatment of chronic pain
• The expert opinion supports the use of buprenorphine for chronic pain in patients diagnosed with an opioid use disorder
• It needs to be dosed q6-8 hours. It does not have a ceiling effect for pain

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Cotes, J; Montgomery, L. Pain Medicine. 2014.

• Methadone stabilization dosed every 24 hours does not confer analgesia beyond 6-8 hours.
• The addition of short-acting opioid analgesics in addition to MST will not cause excessive CNS or respiratory depression due to opioid cross-tolerance.
• Increased pain sensitivity may necessitate higher doses at shorter intervals.
• Scheduled dosing or PCA not “prn” during the severe acute pain
• A short course of opioid analgesics during severe acute pain is unlikely to compromise a patient’s recovery.
• Compassionate, non-judgmental language and trauma-informed care are important!

Methadone Stabilization Treatment (MST) and Acute Pain

Alford DP, Compton P, Samet JH. Ann Intern Med 2006

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• Continue usual verified methadone dose.
• Treat pain aggressively with conventional analgesics, including opioids at higher (1.5 times) doses and shorter intervals.
• Avoid using mixed agonist/antagonist opioids (e.g., butorphanol (Stadol)) as they will precipitate an acute withdrawal.
• Careful use and monitoring of combination products containing acetaminophen.
• After obtaining the patient written consent, communicate with the MST program at the time of admission and prior to discharge.

MST and Acute Pain:Clinical Recommendations

Alford DP, Compton P, Samet JH. Ann Intern Med 2006

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• Analgesia from methadone lasts 6-8 hours, while treatment of OUD lasts over 24 hours
• MST programs typically dose methadone once per day, which will not treat pain beyond 6-8 hours
• Daily MST dosing can be a good test for pain opioid responsiveness based on the patient’s response to: “Do you get any pain relief from your once-a-day methadone dose?”

• “Yes, all day but not enough” (pain likely opioid withdrawal-mediated pain)
• “Yes, but it only lasts 8 hours” (pain may be opioid responsive)
• “No, not at all” (pain may be opioid resistant)

MST and Chronic Pain

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• While most methadone programs only administer methadone once daily, some clinics will administer split doses (a 2nd or 3rd dose for unsupervised self-administration later in the day) which would allow for simultaneous treatment of OUD and pain.
• Note that it is illegal for a clinician outside of an MST program to prescribe methadone for the treatment of OUD whether or not the patient has concurrent pain.
• It is possible to prescribe chronic opioid analgesics for a patient’s chronic pain while he/she is on MST.
• Standardization of split methadone dose is in progress.

MST and Chronic Pain

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Some considerations regarding prescribing opioid analgesics for chronic pain to a patient on MMT

• MST program can closely monitor the patient for opioid analgesic misuse, e.g., drug testing, pill counts.
• Methadone stabilization doses (>80 mg per day) should block the euphoric effects of co-administered opioid analgesics.
• An opioid analgesic may interfere with the MST program's ability to monitor patients for illicit opioid use, as prescribed opioid analgesics may interfere with drug testing.
• Patients may be tempted at the MST program to divert (e.g., sell) prescribed opioid analgesics to other patients.
• Whole person, integrative medicine modalities, mindfulness, and non-opioid multimodals.

MST and Chronic Pain

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Extended Take-Home Doses:

• Stable Patients: Up to 28 days of take-home doses.
• Unstable Patients: Up to 14 days of take-home doses.

Methadone Prescribing Regulations

Temporary Modification (March 2020):

• Issued by SAMHSA to reduce COVID-19 exposure risks in Opioid Treatment Programs (OTPs).
• States had the option to adopt the change.

Impact on Mortality:

• No increase in methadone-related mortality in states that allowed expanded take-home doses compared to those that did not.

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Updated Regulations (February 2024):

• SAMHSA permanently expanded take-home dosing flexibilities.
• States and local OTPs can choose whether to participate.

Current State of Policies:

• Several states have rescinded extended take-home privileges.
• Some states have imposed more restrictive dosing policies.

Changes and Policy Considerations

Impact of Restrictive Policies:

• More restrictive policies can influence patient experience, treatment protocols, and health outcomes.

Need for Research:

• Investigate factors influencing state and OTP facility policies.
• Assess the impact on treatment and long-term patient outcomes.

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References

Harris RA. Methadone Take-Home Policies and Associated Mortality: Permitting versus Non-Permitting States. Subst Use. 2024 Aug 16;18:29768357241272379. doi: 10.1177/29768357241272379. PMID: 39161774; PMCID: PMC11331457. Jones CM, Compton WM, Han B, Baldwin G, Volkow ND. Methadone-Involved Overdose Deaths in the US Before and After Federal Policy Changes Expanding Take-Home Methadone Doses From Opioid Treatment Programs. JAMA Psychiatry. 2022;79(9):932–934. doi:10.1001/jamapsychiatry.2022.1776 Methadone take-home flexibilities extension guidance. SAMHSA. (n.d.). https://www.samhsa.gov/medications-substance-use-disorders/statutes-regulations-guidelines/methadone-guidance

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