IAPCD Members in Print - Books, Articles, Abstracts
IAPCD Member Education - Free CME/CPE
In February, several of IAPCD's board members participated in an expert roundtable discussion in collaboration with the National Institute on Drug Abuse (NIDA), along with the American Academy of Pain Management, the American Academy of Pain Medicine, the American Pain Foundation, the American Pain Society, and the College on Problems of Drug Dependence.
IAPCD members can access the three enduring materials from this program entitled "Abuse, Addiction, and Pain Relief: Time for Change," including:
- An archived webcast featuring Herbert D. Kleber, MD; Rollin M. Gallagher, MD, MPH; and Howard A. Heit, MD
- A newsletter (coming in August '08)
- A monograph (coming in September '08)
The link to the enduring materials is http://www.medcme.org/abuse.asp
Books
Scott M. Fishman, MD has published Responsible Opioid Prescribing - A Physician's Guide in conjunction with the Federation of State Medical Boards. The book grew out of an initiative launched 10 years ago by the FSMB that created the Model Guidelines for the Use of Controlled Substances for the Treatment of Pain. The book focuses on incorporating the Model Policy into day-to-day practice. The Federation of State Medical Boards has given us permission to post the table of contents and the book's foreword to the iapcd.org. Click here to download the PDF.
Articles
Lynn R. Webster and co-authors Youngmi Choi, MD, PhD, Himanshu Desai, MD, Linda Webster, RPSGT, and Brydon J. B. Grant, MD have published the results of their study to assess the relation between medications prescribed for chronic pain and sleep apnea in the journal Pain Medicine. The article is entitled "Sleep-Disordered Breathing and Chronic Opioid Therapy" and its publisher, Blackwell Publishing, has given IAPCD permission to provide a link to the full text article. Click here to download the PDF.
The article details an observational study of chronic pain patients on opioid therapy who received overnight polysomnographies. Generalized linear models determined whether a dose relation exists between methadone, non-methadone opioids, and benzodiazepines and the indices measuring sleep apnea. The authors conclude that sleep-disordered breathing was common in chronic pain patients on opioids, and the dose-response relation of sleep apnea to methadone and benzodiazepines calls for increased vigilance.
Abstracts
R. Chavez, W. Dillin and L. Amass
Buprenorphine Treatment as an Alternative to Orthopedic Surgery in Patients on Prescription Opiates with Lumbosacral or Cervical Spine Disc Disease
The P.A.I.N. Institute, Inc., Redondo Beach, CA and Kerlan-Jobe and Friends Research Institute, Inc. Los Angeles, CA.
ABSTRACT: Buprenorphine's analgesic properties are well known, but using the sublingual tablet (Subutex®/Suboxone®) preoperatively to stabilize pain in opiate-dependent chronic pain patients awaiting orthopedic surgery is unique and novel. Worsening pain in these patients may be due to opioid-induced hyperalgesia and mistaken as a signal to proceed with surgery. Buprenorphine's antihyperalgesic effects may benefit these patients by reducing pain and enabling surgery to be postponed or cancelled. This report describes results with 18 opioid-tolerant patients taking prescription opiates for severe pain due to lumbosacral (n=16) or cervical spine (n=2) disc disease. All patients were preoperative and referred before scheduling surgery by orthopedic and neurosurgeons to The P.A.I.N. Institute for buprenorphine treatment. Patients (11 male; 7 female) averaged 48 years old (range 33-69) and were mostly white (89%), insured (83%), working (95%) and college educated (95%).
Patients had been maintained on prescription opiates for a mean of 4.9 years (range 1-15), 12 had none, and 6 had between 1 and 5 prior surgeries. After treatment with Subutex® (n=13) or Suboxone® (n=5), 89% (16/18) no longer required surgery. Surgery is being considered for one patient after 13 months on Subutex® and another had surgery and has since returned to Subutex®. To date, 89% (16/18) have continued buprenorphine maintenance at a mean daily dose of 19.1 mg (range 1-32) for a mean of 16.7 months (range 2-31). No patient has become tolerant to buprenorphine, nor has there been any medication misuse, diversion or safety issues. Pain ratings on a 10-point scale averaged 6.9 before and decreased to 2.7 during treatment. These clinical findings support using Subutex®/Suboxone® for pain reduction in preoperative, opiate-dependent chronic pain patients. The potential medical and economic benefits of buprenorphine treatment for avoiding surgical complications, time and work lost, and monetary costs to society are tremendous.
Article Summary
A Role for Buprenorphine in Pain Management
Heit HA, Gourlay DL. Buprenorphine: New tricks with an old molecule for pain management. Clin J Pain. 2008;24:93-97.
Buprenorphine is an established drug for the treatment of addiction, but off-label use of buprenorphine as a primary analgesic is a unique option to the prescriber. In their article, Heit and Gourlay describe the pharmacokinetics of buprenorphine and illustrate its use with case studies. The article is meant to provide guidelines to the practitioner caring for patients who are on opioid agonist therapy (OAT) with sublingual buprenorphine (with or without naloxone; an abuse deterrent) for the treatment of pain.
A semisynthetic derivative of the morphine, buprenorphine is a highly lipophilic partial mu opioid agonist, an antagonist of the κ receptor. These properties give the drug a broader safety profile than full mu opioid agonists, such as morphine, heroin, and methadone. As a partial mu opioid receptor agonist, buprenorphine offers a wider safety profile compared to other full mu agonists.
Withdrawal symptoms may be fewer and less severe upon termination because of buprenorphine's slow dissociation from receptors. The drug's effects typically last 24 hours or longer, making it a useful medication for the treatment of addiction. Buprenorphine may interfere with the effectiveness of full mu opioid agonists, and it is contraindicated in opioid-dependent individuals. At high doses, the drug's effects plateau. It is this "ceiling effect" that confers clinical safety, especially with regard to respiratory depression, and a low risk of physical dependence to buprenorphine. Sublingual administration of buprenorphine offers improved absorption (60%-70%) by eliminating first-pass hepatic metabolism required by the standard oral route. It peaks at 90 minutes post administration and possesses a half-life of four to five hours.
The Drug Addiction Treatment Act of 2000 approved the use of buprenorphine with or without naloxone (Suboxone® and Subutex®) as a Schedule III drug for office-based treatment of opioid dependence. The prescriber is required to have special training and must obtain a waiver from the requirement to register as a narcotic treatment program from the Center for Substance Abuse Treatment (CSAT), a division of the Substance Abuse and Mental Health Services Administration (SAMHSA).
A waiver is not necessary for the off-label use of sublingual buprenorphine for the treatment of pain, and the prescriber who uses this drug for this purpose should not place an "X" before his/her DEA registration number. Heit and Gourlay suggest that the prescriber write the words, "Chronic Pain Patient" and "Off-Label Use" on the prescription to avoid any confusion. The authors advise that an individualistic approach be used for devising treatment plans, since not all pain, or the patients' response to pain, is the same. Consistency with the Universal Precautions in Pain Medicine is also advised. Heit and Gourlay recommend the use of urine drug testing as part of the treatment regimen and provide guidance about their particular protocol.
The authors discuss several different types of pain and how buprenorphine can play a role in its management. For anticipated acute pain, such as the type experienced with elective surgery, sublingual buprenorphine may simply be titrated to effect (provided the patient is not NPO [nothing by mouth]). For true breakthrough pain, fentanyl buccal tablets or hydromorphone are suggested. Full mu opioid agonists can be added to buprenorphine maintained patients without precipitating withdrawal, whereas the reverse is not true.
For unanticipated acute pain, such as in a trauma situation, buprenorphine may be titrated to effect with breakthrough medications as mentioned above, if needed. If the patient is NPO, this drug may not be an appropriate choice. In the case of acute pain superimposed on chronic pain managed with buprenorphine, the authors recommend a rapid-onset, potent opioid such as fentanyl or hydromorphone. For chronic pain, the full dose of buprenorphine can generally be taken once per day. The dose can otherwise be divided and administered t.i.d. or q.i.d. and titrated to effect. The authors state that for optimal effect, buprenorphine should be given on a t.i.d. or q.i.d. schedule because of the drug's six to eight hour duration of action. Further details are given as to dosing and proper rotation to a full mu opioid agonist, if needed.
The authors close by stressing the need for long-term prospective studies for all of their recommendations, and that pain management is as much, if not more "art" than "science." With an understanding of the pharmacodynamics and pharmacokinetics of buprenorphine, it can be effectively used for the treatment of addiction, management of pain, and comorbid conditions.
The authors include a link to complete information needed to obtain a waiver for the use of sublingual buprenorphine for office-based treatments:
http://www.buprenorphine.samhsa.gov/fulllaw.html
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