Double Successful Buprenorphine/Naloxone Induction to Facilitate Cardiac Transplantation in an Iatrogenically Opiate-Dependent Patient

Rodgman, Christopher; Pletsch, Gayle

doi:10.1097/adm.0b013e3182486e44

Cited by 13 publications

(8 citation statements)

References 4 publications

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“…Our search identified 324 unique articles, of which 12 articles 11,13,14,[23][24][25][26][27][28][29][30][31] met our inclusion criteria (Fig. 1).…”

Section: Resultsmentioning

confidence: 99%

“…All studies were retrospective (3 studies with a control group and 9 without): 4 studies examined patients with OUD taking buprenorphine, 14,24,28,30 5 examined those taking methadone, 11,[25][26][27]31 1 examined a patient taking naltrexone, 29 and 2 examined a mixed group of medications. 13,23 Four studies examined those with emergency conditions, 14, 24-26 7 examined those undergoing planned surgery, 13,23,[27][28][29][30][31] and 1 examined a mixed group of emergency and surgical patients. 11 Study size ranged from 1 to 134 participants, and studies were conducted in hospitals/tertiary care centers, specialized pain centers, and outpatient addiction treatment clinics.…”

Section: Resultsmentioning

confidence: 99%

“…Additional evidence from 9 observational studies that lacked control groups 14,[24][25][26][27][28][29][30][31] (Table 3) address some gaps in evidence, as they looked at additional causes of acute pain (especially emergency conditions), examined naltrexone, and provided more detailed descriptions of the timing, dosage, and sequence of acute pain management strategies. The most notable finding among these studies is that tramadol adequately managed pain in a patient on extended-release naltrexone undergoing a planned surgery.…”

Section: Studies Without Comparison Groupsmentioning

confidence: 99%

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Managing Acute Pain in Patients Taking Medication for Opioid Use Disorder: a Rapid Review

et al. 2020

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BACKGROUND: Managing acute pain in patients with opioid use disorder (OUD) on medication (methadone, buprenorphine, or naltrexone) can be complicated by patients' higher baseline pain sensitivity and need for higher opioid doses to achieve pain relief. This review aims to evaluate the benefits and harms of acute pain management strategies for patients taking OUD medications and whether strategies vary by OUD medication type or cause of acute pain. METHODS: We systematically searched multiple bibliographic sources until April 2020. One reviewer used prespecified criteria to assess articles for inclusion, extract data, rate study quality, and grade our confidence in the body of evidence, all with second reviewer checking. RESULTS: We identified 12 observational studies-3 with control groups and 9 without. Two of the studies with control groups suggest that continuing buprenorphine and methadone in OUD patients after surgery may reduce the need for additional opioids and that ineffective pain management in patients taking methadone can result in disengagement in care. A third controlled study found that patients taking OUD medications may need higher doses of additional opioids for pain control, but provided insufficient detail to apply results to clinic practice. The only case study examining naltrexone reported that postoperative pain was managed using tramadol. We have low confidence in these findings as no studies directly addressed our question by comparing pain management strategies and few provided adequate descriptions of the dosage, timing, or rationale for clinical decisions. DISCUSSION: We lack rigorous evidence on acute pain management in patients taking medication for OUD; however, evidence supports the practice of continuing methadone or buprenorphine for most patients during acute pain episodes. Well-described, prospective studies of adjuvant pain management strategies when OUD medications are continued would add to the existing literature base. Studies on nonopioid treatments are also needed for patients taking naltrexone.

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“…Our search identified 324 unique articles, of which 12 articles 11,13,14,[23][24][25][26][27][28][29][30][31] met our inclusion criteria (Fig. 1).…”

Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Section: Studies Without Comparison Groupsmentioning

confidence: 99%

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Managing Acute Pain in Patients Taking Medication for Opioid Use Disorder: a Rapid Review

et al. 2020

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“…Rationale for recommendation: existing scientific literature suggests that mu-opioid receptor binding affinity and oil-water partition coefficients are important in determining the ability of competing mu agonists to overcome the buprenorphine-mu-opioid receptor complex. 23 However, given that these ranges are broad and overlapping with those of buprenorphine, the panel did not feel that recommendations on a particular full mu agonist were appropriate. Furthermore, there was a lack of consensus on the use of sufentanil to overcome the binding effects of buprenorphine given the lack of familiarity with this full mu agonist.…”

Section: Section 4 Postoperative Paindopioid Selectionmentioning

confidence: 99%

Perioperative Pain and Addiction Interdisciplinary Network (PAIN) clinical practice advisory for perioperative management of buprenorphine: results of a modified Delphi process

Goel

Azargive

Weissman

et al. 2019

British Journal of Anaesthesia

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Until recently, the belief that adequate pain management was not achievable while patients remained on buprenorphine was the impetus for the perioperative discontinuation of buprenorphine. We aimed to use an expert consensus Delphibased survey technique to 1) specify the need for perioperative guidelines in this context and 2) offer a set of recommendations for the perioperative management of these patients. The major recommendation of this practice advisory is to continue buprenorphine therapy in the perioperative period. It is rarely appropriate to reduce the buprenorphine dose irrespective of indication or formulation. If analgesia is inadequate after optimisation of adjunct analgesic therapies, we recommend initiating a full mu agonist while continuing buprenorphine at some dose. The panel believes that before operation, physicians must distinguish between buprenorphine use for chronic pain (weaning/conversion from longterm high-dose opioids) and opioid use disorder (OUD) as the primary indication for buprenorphine therapy. Patients should ideally be discharged on buprenorphine, although not necessarily at their preoperative dose. Depending on analgesic requirements, they may be discharged on a full mu agonist. Overall, long-term buprenorphine treatment retention and harm reduction must be considered during the perioperative period when OUD is a primary diagnosis. The authors recognise that inter-patient variability will require some individualisation of clinical practice advisories. Clinical practice advisories are largely based on lower classes of evidence (level 4, level 5). Further research is required in order to implement meaningful changes in practitioner behaviour for this patient group.

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“…They were maintained on doses of 6 mg per day. There is additionally one published case of buprenorphine‐naloxone used safely in the peri‐transplantation period for a heart transplant patient . Prior to transplantation, the patient was considered a poor candidate due to prescription opioid misuse, however she was successfully transitioned to buprenorphine‐naloxone and was listed for transplant.…”

mentioning

confidence: 99%

Personal viewpoint on opioid agonist therapy and transplantation

Ivkovic

Wakeman

2018

American Journal of Transplantation

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Opioid use disorder (OUD) is an increasing public health problem. Transplant centers worldwide are being confronted with increasing numbers of patients with opioid use disorder and end stage organ disease. Opioid agonist therapy (OAT; ie, methadone, buprenorphine, and buprenorphine/naloxone) is a scientifically proven, effective, physician-prescribed treatment for OUD. Although data in transplant populations remain limited, studies suggest that OAT does not appear to negatively affect graft or patient survival. Policies that require discontinuation of OAT for purposes of listing or transplantation contradict the evidence base for efficacy of OAT. Additional prospective outcomes studies on OAT and transplantation are needed. In the meantime, centers should not be asking patients to come off these effective treatments.

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Double Successful Buprenorphine/Naloxone Induction to Facilitate Cardiac Transplantation in an Iatrogenically Opiate-Dependent Patient

Cited by 13 publications

References 4 publications

Managing Acute Pain in Patients Taking Medication for Opioid Use Disorder: a Rapid Review

Managing Acute Pain in Patients Taking Medication for Opioid Use Disorder: a Rapid Review

Perioperative Pain and Addiction Interdisciplinary Network (PAIN) clinical practice advisory for perioperative management of buprenorphine: results of a modified Delphi process

Personal viewpoint on opioid agonist therapy and transplantation

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