Presentations for CME Review

Buprenorphine: Not Just Another Opioid – Understanding the World’s Most Interesting Opioid

Andrea Rubinstein, MD

In this talk we will delve deep into the pharmacology of this drug and how its receptor interactions are unique and then we will take that understanding and apply it to clinical usage to see how this drug behaves in a variety of situations.

Buprenorphine has recently been recommended by the Department of Veterans Affairs and the Department of Defense for use in place of traditional, full agonist opioids. Because of this shift in the recommendations, it is vitally important that providers fully understand this drug. There remains a lot of misconceptions and misunderstanding about how this drug works and this talk aims to address this.

Specifically we will look at the safety profile of this drug, including it’s ceiling effect on respiratory depression. Then we will look at efficacy, how well does this drug work in the treatment of pain. We will look at analgesia, tolerance and anti-hyperalgesic properties of buprenorphine. We will discus why this drug is so versatile anyhow versatility is a key asset when it comes to using buprenorphine for the treatment of pain.

The last section of this talk will look at the specific area of preoperative use of buprenorphine and why buprenorphine should be continued throughout the preoperative period.

CME and CPE credits are available for this presentation.

Presentation Slide Handouts: Click Here for Presentation Handouts

DOI: 10.5055/bupe.24.rp.1035

Impact of an Education Module on the Knowledge and Attitudes of EM Physicians Towards Prescribing Buprenorphine / Naloxone for Opioid Use Disorder

Amy Zosel, MD, MSCS; Jennifer Hernandez-Meier, PhD, MSW; Julie Owen, MD, MBA

This presentation describes an Education Program/Module, including the rationale for opioid use disorder(OUD) treatment for patients with buprenorphine, an evidence-based ED buprenorphine induction pathway, and electronic medical record tools, and how it changed the attitudes of emergency physicians towards buprenorphine treatment and demonstrated an increase in willingness and confidence to prescribe it for patients with OUD.

CME and CPE credits are available for this presentation.

Presentation Slide Handouts: Presentation Handouts

DOI: 10.5055/bupe.24.rp.1095

Buprenorphine for Cancer Pain: Results from a Systematic Review

Maria Silveira MD MA MPH, Victoria Powell MD, University of Michigan – VA, Ann Arbor MI

This study identified, evaluated, and synthesized the literature examining the efficacy and tolerability of buprenorphine for pain in patients with active cancer.

We conducted an updated systematic review of buprenorphine’s effect on cancer-related pain, including both new studies and additional study designs.

Buprenorphine may be safer and better tolerated than full mu-opioid receptor (MOR) agonists. Whether it effectively controls cancer-related pain is unclear. A prior review (Cochrane 2015) did not support prioritizing buprenorphine over full MOR agonists for cancer-associated pain.

CME and CPE credits are available for this presentation.

Presentation Slide Handouts: Presentation Handouts

DOI: 10.5055/bupe.24.rp.1075

Buprenorphine: Opioid Agonist-Antagonist Benefits for Opioid Resistant Pain Uncontrolled By Full-Agonist Opioids during Hematopoietic Stem Cell Transplant for Sickle Cell Disease

Mayuko Sakae, MD, Assistant Clinical Professor, City of Hope National Medical Center, Los Angeles, CA

Bone marrow transplant (BMT) offers potential cure for otherwise incurable diseases. However, BMT brings about multisystemic pain and management challenges in patients with pre-existing opioid tolerance. Buprenorphine-based pilot prospective clinical trial showed more effective pain control in sickle cell disease patients’ refractory BMT-related pain while minimizing opioid dose escalation and opioid adverse effects.

CME and CPE credits are available for this presentation.

Presentation Slide Handouts: Presentation Handouts

DOI: 10.5055/bupe.24.rp.1065

Conversion of CII Opioid Medications to Buprenorphine in the Chronic Pain Population – Insights and Clinical Pearls

Amanda Zimmerman, PA-C, West Forsyth Pain Management, Winston Salem, NC

There is a great deal of confusion associated with conversion from CII opioids to buprenorphine products. The data presented supports that patients can be converted from high-dose opioid medication to buprenorphine products safely and effectively. This presentation will provide a road map to help guide practitioners interested in applying this to their clinical practice.

The purpose of the research was not only to discover if conversion to a partial agonist CIII medication from full agonist CII medications would be achievable without sacrificing analgesia but also to provide guidance to providers interested in pursuing this option in clinical practice.

Patients who met inclusion criteria were stratified into subgroups based on their pre-conversion morphine milligram equivalents, whether they remained on opioids for breakthrough pain post-conversion, and their pre-and post-conversion numerical rating scale pain scores. Outcomes of interest included the differences between pre-and post-conversion numerical rating scale pain scores and daily morphine milligram equivalents for each subgroup.

Of 157 patients reviewed, 87.9% were successfully converted to buprenorphine buccal film. Overall, numerical rating scale pain scores were stable after conversion. Statistically significant reductions were demonstrated in the <90 daily morphine milligram equivalent subgroup. Postconversion daily morphine milligram equivalents decreased by 85.4% from baseline. Change in daily morphine milligram equivalents is representative of patients who remained on breakthrough pain medication.

Results demonstrate continued analgesia after conversion to buprenorphine buccal film despite reductions in daily morphine milligram equivalents. Most patients were able to convert directly from their long-acting opioid to buprenorphine buccal film and stabilized without the use of concurrent opioids for breakthrough pain. Aggressive titration strategies were associated with greater success.

This data proves that conversion from full agonist CII medications is possible without sacrificing analgesia while reducing the risk of adverse events associated with full agonist CII medications.

CME and CPE credits are available for this presentation.

Presentation Slide Handouts: Presentation Handouts

DOI: 10.5055/bupe.24.rp.1060

Clinical Pharmacist with DEA License: Efforts to Increase Access to Buprenorphine in a Veteran Population

Shelley Stevens, PharmD, BCPS, Pain Clinical Pharmacist Practitioner (CPP), North Florida/South Georgia Veterans Health System (NF/SG VHS)

DEA licensed pharmacists are often seen in the VA system, but it is not a universal practice. I became the first DEA licensed CPP in VISN 8 and now provide independent OUD and complex pain care. I aim to describe how a DEA licensed CPP can impact the current opioid epidemic.

Opioid overdoses continue to rise in the United States. In 2021, a record 80,411 reported overdoses occurred in the US alone, nearly double that in 2017. Buprenorphine’s pharmacology is ideal for management of patients with opioid use disorder (OUD) with or without chronic pain.
Within the VA, clinical pharmacist practitioners (CPP) are uniquely equipped to operate with significant scope of practice to prescribe medications including controlled substances, an opportunity to vastly increase access to care for veterans suffering from OUD, complex opioid dependency or pain.

CME and CPE credits are available for this presentation.

Presentation Slide Handouts: Presentation Handouts

DOI: 10.5055/bupe.24.rp.1010

Emerging Trends in Perioperative Buprenorphine Management

Amanda L. Engle, PharmD, BCPS, Jacqueline Cleary, PharmD, BCACP, Amanda Winans, PharmD, BCPS, CACP

Complex pharmacology makes perioperative buprenorphine management (PBM) challenging. More clinicians are managing buprenorphine than ever before given the elimination of the X-waiver, however they must be well versed in PBM to optimize pain control and minimize relapse risk. This presentation will provide an update on emerging trends in PBM.

Historically, there has been limited evidence and no clear consensus suggesting best practices for perioperative buprenorphine management (PBM). Previously published PBM strategies included a wide variation in dosing, complexity, and clinical decision making points. Importantly, there are limited published algorithms reporting corresponding patient outcomes data.

CME and CPE credits are available for this presentation.

Keywords: perioperative buprenorphine management (PBM), buprenorphine, perioperative, pain

Presentation Slide Handouts: Presentation Handouts

DOI: 10.5055/bupe.24.rp.1000

Review Presentation Questions

Outpatient Cross-Titration to Buprenorphine for Chronic Pain

Katherin Peperzak, MD, Medical Director, Center for Pain Relief at UWMC-Roosevelt, Department of Anesthesiology & Pain Medicine, University of Washington

The University of Washington has developed a cross-titration protocol for conversion from full agonist opioids to buprenorphine for chronic pain. A retrospective analysis was performed to evaluate the effectiveness and safety of this protocol.

Various protocols for micro-induction of buprenorphine in patients with opioid use disorder have been published. There is a paucity of literature similarly describing micro-induction in patients converting from full agonist opioids to buprenorphine for chronic pain. As the prescription opioid epidemic continues to be problematic and more patients are being converted to buprenorphine, we are working to provide more guidance on goal dosages of buprenorphine and how to safely cross-titrate to that goal.

CME and CPE credits are available for this presentation.

Presentation Slide Handouts: Presentation Handouts

DOI: 10.5055/bupe.24.rp.1005

Partial Agonist, Full Barrier: A Case-Based Discussion on Challenges with Buprenorphine in Chronic Pain Management

Tonya S. Hershman,  PharmD, BCPS, Michelle Park, MD

Buprenorphine is becoming more popular in the palliative care field as more patients who were started on opioids for cancer-related pain are living longer, but there is not much formal training on buprenorphine, including various challenges in prescribing and managing this medication.

More patients are on chronic opioids, as patients who were initially started on full agonist opioids for cancer-related pain are living longer. Despite doing well from the cancer standpoint, some patients have difficulty tapering off their opioids because they have been taking them for years. Given the potential complications of chronic full agonist opioids, it is important to manage these patients in a safer way. However, there are various challenges including lack of education for patients and healthcare professionals and lack of product availability. Many healthcare providers do not have much formal training on initiating, maintaining, and tapering the various buprenorphine products. These providers may not be able to effectively educate patients given the lack of education. Also, patients research these products on their own and are hesitant to try them because of misinformation. Even if patients are informed thoroughly about buprenorphine, there are barriers to obtaining them including insurance denial and lack of product availability at pharmacies. Given the above challenges, easily accessible best practices as well as avenues for healthcare professionals to educate and guide each other are needed.

CME and CPE credits are available for this presentation.

Presentation Slide Handouts: Click Here for Park and Hershman Slides Handouts.

DOI: 10.5055/bupe.24.rp.1030

Buprenorphine Use in the Military Health System (MHS)

Nicole Cornish, PharmD

The 2022 DoD/VA Opioid Clinical Practice Guidelines (CPG) suggests the use of buprenorphine instead of full agonist opioids for patients receiving daily opioids for the treatment of chronic pain. This is part of an ongoing project to increase awareness of the CPG and aid clinician and patient decision making.

The CPG’s updated recommendation is supported by buprenorphine’s lower risk of overdose and misuse. In comparison to full mu-opioid agonists, buprenorphine possesses a superior safety profile with respect to respiratory depression, even in non-dependent individuals, and fatal overdose when not combined with other sedating medications.

CME and CPE credits are available for this presentation.

Presentation Slide Handouts: Contact us.

DOI: 10.5055/bupe.24.rp.1025