Dialogue Volume 13 Issue 4 2017 - Page 54

PRACTICE PARTNER for pain control for years. In contrast, patients with opioid use disorders are particularly sensitive to the psychoactive effects of the opioids. Tolerance to these effects develops rapidly, causing patients to escalate their dose. Soon, they begin to experience distressing withdrawal symptoms, which causes them to escalate the dose further. This explains the clinical features of opioid use disorder in pain patients. They are often on a higher dose than is generally needed for their pain condition (although opioid use disorders can also occur at lower doses). They often run out of medication early, request frequent dose increases, request specific opioids, and are resistant to tapering. They may access opioids from other sources (e.g., other physicians, friends, the street) and/or chew, snort, or crush tablets to intensify the effect. They often have a current, past, or strong family history of misuse of other substances, and of mood and anxiety disorders. Reluctant Patients Patients with opioid use disorder are often reluctant to disclose their drug-taking behaviours for fear that the physician will ‘cut them off’. A careful history and discussion may reveal that the patient is experiencing significant withdrawal between doses, anxiolytic and psychoactive effects, and may be supplementing their opioids from other sources. Frequently, they are very reluctant to enter treatment, fearing that their pain will intensify if their opioid medication is stopped. Physicians should inform reluctant patients that buprenorphine will markedly improve their mood, function, and withdrawal symptoms, and their pain will remain the same or improve (5) . Prescribing Buprenorphine Buprenorphine binds tightly to the endorphin recep- tors, displacing other opioids from opioid receptors in the brain. This can cause precipitated withdrawal, the abrupt onset of opioid withdrawal symptoms that manifest within 30–90 minutes after the first dose of buprenorphine. To avoid precipitated withdrawal, the first dose of buprenorphine should be taken at least 12 hours after the last opioid dose, when the patient is experiencing mild to moderate withdrawal symptoms. The first dose should be observed in the office if possible; however, patients who are unable to attend the office while in withdrawal should be given a one-day prescription for buprenorphine to take at home, with instructions to wait at least 12 hours after their last opioid use so as to avoid precipitated withdrawal (6) . Buprenorphine is taken sublingually, as it has poor oral bioavailability. The first dose is usually 4 mg, with another 4 mg dose two hours later if necessary. The maximum dose on Day 1 is 12 mg. Lower doses should be used for patients who are elderly, on benzo- diazepines or other sedating drugs, or who may have lower tolerance (e.g., codeine users, non-daily binge users). The dose may be increased by 4 mg every 3–7 days, until it achieves cessation of opioid use and 24-hour relief of withdrawal symptoms and cravings, without causing sedation or major side effects. The optimal dose for most patients is 8–16 mg, taken as a single morning dose. The maximum dose is 24 mg. Patients continuing to use opioids despite an optim