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- Perioperative Pain Management for Patients on Chronic Buprenorphine: A Case Report. [JOURNAL ARTICLE]
- J Anesth Clin Res 2013 Oct 30; 3(250)
Here we present a patient with a Type I Chiari malformation who was receiving buprenorphine for chronic pain who underwent two separate urogynecologic procedures for removal of vaginal mesh with two different pain management regimens. For the first procedure at an outside hospital, the patient's usual dose of buprenorphine (8 mg sublingual every 8 hours) was continued up through her surgery and then a full opioid receptor agonist was used for postoperative pain management. The patient complained that this resulted in very poor pain control for her in the postoperative period. Prior to her second procedure, which was performed at our institution, buprenorphine was switched to a full opioid agonist (oral hydromorphone 4 mg every 4 to 6 hours, maximum 20 mg per day) for 5 days prior to surgery; postoperative pain was managed with full opioid receptor agonists. The patient again reported suboptimal pain control in spite of substantially increased doses of opioids. This case report highlights the difficulty of perioperative pain management for patients on chronic buprenorphine and emphasizes the need for additional investigation.
- Neonatal outcomes and their relationship to maternal buprenorphine dose during pregnancy. [JOURNAL ARTICLE]
- Drug Alcohol Depend 2013 Nov 16.
Buprenorphine pharmacotherapy for opioid-dependent pregnant women is associated with maternal and neonatal outcomes superior to untreated opioid dependence. However, the literature is inconsistent regarding the possible existence of a dose-response relationship between maternal buprenorphine dose and neonatal clinical outcomes.The present secondary analysis study (1) examined the relationship between maternal buprenorphine dose at delivery and neonatal abstinence syndrome (NAS) peak score, estimated gestational age at delivery, Apgar scores at 1 and 5min, neonatal head circumference, length, and weight at birth, amount of morphine needed to treat NAS, duration of NAS treatment, and duration of neonatal hospital stay and (2) compared neonates who required pharmacotherapy for NAS to neonates who did not require such pharmacotherapy on these same outcomes, in 58 opioid-dependent pregnant women receiving buprenorphine as participants in a randomized clinical trial.(1) Analyses failed to provide evidence of a relationship between maternal buprenorphine dose at delivery and any of the 10 outcomes (all p-values>.48) and (2) significant mean differences between the untreated (n=31) and treated (n=27) for NAS groups were found for duration of neonatal hospital stay and NAS peak score (both p-values<.001).(1) Findings failed to support the existence of a dose-response relationship between maternal buprenorphine dose at delivery and any of 10 neonatal clinical outcomes, including NAS severity and (2) that infants treated for NAS had a higher mean NAS peak score and, spent a longer time in the hospital than did the group not treated for NAS is unsurprising.
- Long-term Consequences of Acute Pain for Patients under Methadone or Buprenorphine Maintenance Treatment. [Journal Article]
- Pain Physician 2013 Nov-Dec; 16(6):E739-47.
Acute and chronic pains are reported to be highly prevalent in patients under opioid maintenance treatment (OMT). Lack of knowledge concerning the complex relationship between pain, opioid use, and their impact on OMT efficacy can account for the barriers encountered for pain management.To assess the impact of acute pain exposure on long-term OMT retention in a cohort of patients under buprenorphine or methadone followed up during 12 months.Prospective, multi-center observational cohort clinical study.Emergency departments, surgery departments, and specialized addiction care centers in an outpatient setting in south-western France (Midi-Pyrenees area), from April 2008 to January 2010.Patients aged 18 or more under OMT for at least 3 months, and followed up by a physician were recruited. Acute pain was assessed using the Visual Analog Scale (VAS) or the Verbal Rating Scale (VRS). Exposed patients were those with a pain score greater than 0 at the time of admission on any of the rating scales. The OMT rate after 12 months was compared among exposed and unexposed patients. OMT retention was also investigated after 3 and 6 months follow-up.A total of 151 patients, 81 exposed and 70 unexposed, were recruited; among them, respectively, 26 (32%) and 34 (49%) completed 12-months follow-up. Acute pain exposure appeared to be significantly and negatively associated with retention in treatment (crude OR: 0.44; 95% CI [0.22 - 0.87]; adjusted OR: 0.46; 95% CI [0.23 - 0.93]). Compared to methadone users, patients under buprenorphine were less likely to have their OMT maintained after 12 months (OR 0.37; 95% CI [0.18 - 0.75]; adjusted OR 0.38; 95% CI [0.18 - 0.80]).Follow-up rate was 40% (60/151).This study demonstrates the strong negative impact of acute pain on OMT in a population mainly composed of patients under buprenorphine, as well as differential response depending on the OMT medication. The findings highlight the need to consider the characteristics of pain in the population under OMT and to develop evidence-based guidelines for pain management.The study was registered at www.clinical.trials.gov with the study identifier: NCT00738036. Ethics Committee approval was received on February 11, 2008. Participants' written consent was not required.
- Allergic Contact Dermatitis from Buprenorphine and Oral Tolerance to Other Opioid Derivatives in Three Patients. [JOURNAL ARTICLE]
- Dermatology 2013 Nov 23.
Transdermal buprenorphine (TDB) is a widely used analgesic for moderate pain. TDB is generally well tolerated, but both irritant and allergic contact dermatitis occur at patch application sites. Oral opioid tolerance in patients with allergic contact dermatitis to TDB remains controversial. Here, we describe 3 patients with allergic contact dermatitis to TDB who subsequently used oral opioid derivatives without adverse reactions. Thus, oral intolerance to opioid derivatives is not a rule in patients with allergic contact dermatitis to TDB, but the possibility should be taken into consideration. © 2013 S. Karger AG, Basel.
- Association between gene variants and response to buprenorphine maintenance treatment. [JOURNAL ARTICLE]
- Psychiatry Res 2013 Nov 11.
A variety of studies were addressed to differentiate responders and non-responders to substitution treatment among heroin dependent patients, without conclusive findings. In particular, preliminary pharmacogenetic findings have been reported to predict treatment effectiveness in mental health and substance use disorders. Aim of the present study was to investigate the possible association of buprenorphine (BUP) treatment outcome with gene variants that may affect kappa-opioid receptors and dopamine system function. One hundred and seven heroin addicts (West European, Caucasians) who underwent buprenorphine maintenance treatment were genotyped and classified into two groups (A and B) on the basis of treatment outcome. Non-responders to buprenorphine (group B) have been identified taking into account early drop out, continuous use of heroin, severe behavioral or psychiatric problems, misbehavior and diversion during the 6 months treatment period. No difference was evidenced between responders and non-responders to BUP in the frequency of kappa opioid receptor (OPRK1) 36G>T SNP. The frequency of dopamine transporter (DAT) gene polymorphism (SLC6A3/DAT1), allele 10, was evidently much higher in "non-responder" than in "responder" individuals (64.9% vs. 55.93%) whereas the frequency of the category of other alleles (6, 7 and 11) was higher in responder than in non-responder individuals (11.02% vs. 2.13% respectively). On one hand, the hypothesis that possible gene-related changes in kappa-opioid receptor could consistently affect buprenorphine pharmacological action and clinical effectiveness was not confirmed in our study, at least in relation to the single nucleotide polymorphism 36G>T. On the other hand, the possibility that gene-related dopamine changes could have reduced BUP effectiveness and impaired maintenance treatment outcome was cautiously supported by our findings. DAT1 gene variants such as allele 10, previously reported in association with personality and behavioral problems, would have influenced the effects of BUP-induced dopamine release, modulated through mu and kappa opioid receptors, and probably the related reinforcing capacity of the drug.
- Withdrawal from Buprenorphine/Naloxone and Maintenance with a Natural Dopaminergic Agonist: A Cautionary Note. [JOURNAL ARTICLE]
- J Addict Res Ther 2013 Apr 23; 4(2)
While numerous studies support the efficacy of methadone and buprenorphine for the stabilization and maintenance of opioid dependence, clinically significant opioid withdrawal symptoms occur upon tapering and cessation of dosage.We present a case study of a 35 year old Caucasian female (Krissie) who was prescribed increasing dosages of prescription opioids after carpel tunnel surgery secondary to chronic pain from reflex sympathetic dystrophy and fibromyalgia. Over the next 5 years, daily dosage requirements increased to over 80 mg of Methadone and 300 ug/hr Fentanyl transdermal patches, along with combinations of 12-14 1600 mcg Actig lollipop and oral 100 mg Morphine and 30 mg oxycodone 1-2 tabs q4-6hr PRN for breakthrough pain. Total monthly prescription costs including supplemental benzodiazepines, hypnotics and stimulants exceeded $50,000. The patient was subsequently transferred to Suboxone® in 2008, and the dosage was gradually tapered until her admission for inpatient detoxification with KB220Z a natural dopaminergic agonist. We carefully documented her withdrawal symptoms when she precipitously stopped taking buprenorphine/naloxone and during follow-up while taking KB220Z daily. We also genotyped the patient using a reward gene panel including (9 genes 18 alleles): DRD 2,3,4; MOA-A; COMT; DAT1; 5HTTLLR; OPRM1; and GABRA3.At 432 days post Suboxone® withdrawal the patient is being maintained on KB220Z, has been urine tested and is opioid free. Genotyping data revealed a moderate genetic risk for addiction showing a hypodopaminergic trait. This preliminary case data suggest that the daily use of KB220Z could provide a cost effective alternative substitution adjunctive modality for Suboxone®. We encourage double-blind randomized -placebo controlled studies to test the proposition that KB220Z may act as a putative natural opioid substitution maintenance adjunct.
- [Is the availability of buprenorphine/naloxone therapy for opioid-dependent inmates a necessity?]. [English Abstract, Journal Article]
- Rev Esp Sanid Penit 2013 Feb; 15(3):105-13.
Agonist therapy (OAT) programs in combination with a psychosocial approach are the most effective way to prevent relapse in opioid-dependent patients. These programs reduce morbidity and risk behaviours for HIV transmission and other infections, improve quality of life and retention in treatment, and have a positive impact on antisocial behaviour. They are therefore very useful for prisoners with a history of opiate use. OATs based on buprenorphine/naloxone (B/N), along with others using methadone, are currently available in Spain. Diversified treatment offers an alternative treatment for opioid dependence that is more personalized and tailored to the patient's characteristics. As regards effectiveness, both drugs are very similar, but B/N shows a better safety profile and fewer drug-drug interactions and can be dispensed in pharmacies once the patient is released, which can assist with the patient' social reintegration. B/N treatment is more expensive than methadone. It is advisable to have different modes of OAT. These should be prescribed according to the characteristics and needs of each case, without incarceration impeding the right to drug treatment, which should be similar to that performed outside prison.
- "The chief of the service is very enthusiastic about it": A qualitative study of the adoption of buprenorphine for opioid addiction treatment. [JOURNAL ARTICLE]
- J Subst Abuse Treat 2013 Oct 23.
Qualified physicians may prescribe buprenorphine to treat opioid dependence, but medication use remains controversial. We examined adoption of buprenorphine in two not-for-profit integrated health plans, over time, completing 101 semi-structured interviews with clinicians and clinician-administrators from primary and specialty care. Transcripts were reviewed, coded, and analyzed. A strong leader championing the new treatment was critical for adoption in both health plans. Once clinicians began using buprenorphine, patients' and other clinicians' experiences affected decisions more than did the champion. With experience, protocols developed to manage unsuccessful patients and changed to support maintenance rather than detoxification. Diffusion outside addiction and mental health settings was nonexistent; primary care clinicians cited scope-of-practice issues and referred patients to specialty care. With greater diffusion came questions about long-term use and safety. Recognizing how implementation processes develop may suggest where, when, and how to best expend resources to increase adoption of such treatments.
- Influence of Uridine Diphosphate-Glucuronyltransferase 2B7 (UGT2B7) Variants on Postoperative Buprenorphine Analgesia. [JOURNAL ARTICLE]
- Pain Pract 2013 Nov 20.
Genetic factors are known to influence individual differences in pain and sensitivity to analgesics. Different genetic polymorphisms in opioid-metabolizing enzymes that can affect the analgesic response to opioids have been proposed. This study investigates a possible difference in the response to postoperative buprenorphine analgesia related to the presence of different isoforms (cytosine or thymine substitution at nucleotide 802) of UGT2B7 gene.Transdermal buprenorphine was administered to 91 patients who underwent muscle-sparing thoracotomy. UGT2B7 polymorphism at locus C802T (His268Tyr) was detected using a PCR Taqman-based procedure. The severity of postoperative pain at rest and during coughing or deep inspiration was assessed by visual analog scale score after surgery. Hospital stay and perioperative opioid consumption were collected.Genotype frequencies were 18.4% for UGT2B7*1/*1, 52.9% for UGT2B7*1/*2, and 28.7% for UGT2B7*2/*2. VAS pain scores at rest were statistically similar among the groups except at 24, 60, and 120 hours (UGT2B7*2/*2 genotype showing higher pain scores). Patients with the UGT2B7*2/*2 genotype showed higher VAS scores triggered by coughing after the 48 hours (P < 0.05). In addition, patients with this genotype reported a higher prevalence of severe pain after 48 postoperative hours (P < 0.05). Thirty-eight percent of patients carrying genotype UGT2B7*2/*2 experienced severe pain in a final survey vs. 17% in the group with UGT2B7*1/*1 (P = 0.36).The presence of the SNP 802C>T UGT2B7 (UGT2B7*2/*2) is associated with a worse analgesic response to transdermal buprenorphine in the postoperative period of thoracic surgery.