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PHARMACIST ROUNDS Background Buprenorphine and naloxone (Suboxone) is a mu-opioid receptor partial agonist and a kappa-opioid receptor antagonist used to treat opioid dependence. Its use has skyrocketed in the United States, surpassing Viagra and Adderall. The US government helped in the devel- opment of the drug and promoted it as a safer, less stigmatizing alter- native to methadone. In addition to its legally prescribed use, however, it has now become a street drug. With the increasing number of patients using buprenorphine and naloxone being admitted to the hospital, how should hospital pharmacy staff best handle pain management in the acute setting for these patients? General Principles • Inform the patient of your awareness of his or her addiction and provide reassur- ance that a history of opioid addiction will not be an obstacle to acute pain manage- ment. • Include the patient in the decision-making process to allay anxi- ety about relapse. Offer addiction counseling as needed. Patients who are opioid dependent should not be denied pain treatment with opioids when medically indicated. • Maintenance opioids should not be expected to adequately treat new onset acute pain, and discontinuation of buprenorphine and naloxone therapy in patients experiencing acute pain will increase the patient's requirement for acute analgesic relief. The conversion process involves several steps: • Determine when the last dose of buprenorphine and naloxone was ingested, and temporarily stop use of the drug. • Consider regional anesthesia or a high-potency opioid, such as fen- tanyl, for pain management. • Provide adequate opioid analge- sia, and titrate to effect. It is good practice to know the usual doses needed for patients with a history of opioid addic- tion. Discuss with your colleagues and remem- ber that patients who are opioid dependent and who have recently received buprenorphine and naloxone therapy will likely need higher- than-usual doses of opioid analgesics due to their physical tolerance and/or narcotic blockade from recent doses of buprenorphine and naloxone. • Monitor/caution patients regard- ing the potential for oversedation during the frst 72 hours after the last buprenorphine and naloxone dose. Although the initial effect of a full agonist may be blocked by buprenorphine, the full agonist effect may become clinically evi- dent as this blockade fades. • Do not provide buprenorphine and naloxone while patient is receiving opioid analgesia. • Discontinue opioid analgesia once pain has remitted or can be man- aged with nonopioid analgesia. • Allow the patient to experience mild-to-moderate opioid with- drawal for safe re-initiation of buprenorphine and naloxone therapy. • Re-induce the patient onto buprenorphine and naloxone therapy as per the usual induction procedure by the authorized phy- sician. Communication between the institution and the authorized prescriber is essential. n Acute Pain Management for Patients Maintained on Buprenorphine and Naloxone Therapy Ed Sredzienski, MSPharm Would you like to submit a case study to the Pharmacy Times Health-System Edition? Please contact Stephen F. Eckel, PharmD, MHA, BSPS, FASHP, FAPhA, at SEckel@unch.unc.edu. Share Your Case Studies Ed Sredzienski, MSPharm, is a clinical specialist in the surgical intensive care unit/trauma intensive care unit at UNC Hospitals. Maintenance opioids should not be expected to adequately treat new onset acute pain. H16 www.PharmacyTimes.com September 2015 MORE @ WWW. PHARMACY TIMES.COM For a list of resources, go to www.pharmacytimes.com/ publications/health-system- edition. HEALTH SYSTEMS