Converting adults with sickle cell disease from full agonist opioids to buprenorphine: A reliable method with safety and early evidence of reduced acute care utilization

Abstract

Buprenorphine, a novel opioid with complex pharmacology, is effective for treating pain and is qualitatively safer than high-dose full agonist opioid therapy; but transitioning to buprenorphine can be technically complex and carries some risk of precipitated withdrawal. We report our clinic's experience converting 36 patients with sickle cell disease (SCD) from full agonist opioids to buprenorphine using a method developed in the past 10 years. Thirty of these patients were induced using a standard outpatient protocol and six were induced during medical admissions. Typically, patients were on high-dose chronic opioid therapy (COT) with inadequate response, and often with very high acute care utilization. Unlike prior case series, the method of induction, dosing, and management of withdrawal are detailed, as are postinduction adverse events. There were seven adverse events in the first 3 days following standard induction, and two of which were judged to be definitely related to the induction but none with any lasting sequelae. At 6 months follow-up, five participants had discontinued buprenorphine (16.67%), and overall acute care visits dropped from a mean of 10.50 (SD 11.35) in the 6 months pre-induction to 2.89 (SD 3.40) in the 6 months post-induction. In an appropriately interdisciplinary care setting, buprenorphine shows promise as a safe alternative to COT with early evidence of benefit for high-utilizing patients with SCD. | INTRODUCTIONSickle cell disease (SCD) is a genetic hematologic disorder that affects between 80 000 and 100 000 individuals in the United States and leads to severe morbidity and early mortality. [1][2][3][4][5][6] Acute painful crises are the most common complications of SCD and drive a large number of acute care visits and hospitalizations. [7][8][9][10] In addition, SCD pain can evolve into a chronic pain condition with poorly understood physiology. [11][12][13][14][15][16] Half or more of adult SCD patients in the United States likely meet criteria for chronic pain. 11,17 People living with SCD consistently describe pain as the greatest detriment to their quality of life, and an optimal pain management strategy remains unclear. 18 Numerous studies show that patients and healthcare providers are dissatisfied with the quality of SCD pain management. [18][19][20] Disease-modifying therapies that prevent acute crises have little effect on chronic SCD pain. 16,21 The evidence base for management of chronic pain in SCD is sparse, 22 but chronic opioid therapy (COT) is one major modality. Clinical trials of opioids for chronic non-cancer pain (CNCP) support efficacy relative to placebo, but also frequently fail to produce clinically significant improvements. Risks emerge with

A Challenging Case of Severe Sickle Cell Crisis With Multiorgan Involvement: A Case Report

“…While previous studies have focused on classical manifestations, there is a lack of literature addressing atypical presentations and their unique features, including the absence of acute pain and the development of complications such as thrombotic events and acute chest syndrome [ 9 , 10 ]. Understanding the heterogeneous nature of sickle cell disease is crucial, as it presents a wide range of clinical manifestations [ 11 , 12 ]. Diagnostic challenges are encountered in identifying atypical sickle cell crises, as evidenced by the delayed diagnosis in this patient.…”

Roles of Pharmacists in the Management of Sickle Cell Disease in Adults: A Narrative Review

“…50 A study by David and colleagues reported that patients on chronic, high-dose opioid therapy with inadequate response had successful transition to sublingual buprenorphine. 51 The conversion strategy was done through a multidisciplinary team and performed under careful monitoring for the risk of withdrawal symptoms; the converted patients experienced minimal adverse effects. 51 According to the researchers, only a few patients reverted back to using strong opioids.…”

“…51 The conversion strategy was done through a multidisciplinary team and performed under careful monitoring for the risk of withdrawal symptoms; the converted patients experienced minimal adverse effects. 51 According to the researchers, only a few patients reverted back to using strong opioids. 51…”

Psychiatric comorbidities in adults with sickle cell disease: A narrative review

“…[149][150][151] Dose reductions in such patients are often well-tolerated, sometimes even improving pain severity; in some patients transition to partial agonist therapy with buprenorphine can both reduce risks and improve symptom control. 152,153…”

“…The risks of opioid therapy, principally incurred by patients on prolonged therapy at high doses, can then be compared to benefits 149–151 . Dose reductions in such patients are often well‐tolerated, sometimes even improving pain severity; in some patients transition to partial agonist therapy with buprenorphine can both reduce risks and improve symptom control 152,153 …”