Transitioning to Buprenorphine From Other Opioids Howard Kornfeld

Transitioning to Buprenorphine From Other Opioids Howard Kornfeld, MD Medical Director, Recovery Without Walls Clinical Faculty, UCSF School of Medicine, Pain Fellowship Program Distinguished Fellow, American Society of Addiction Medicine (ASAM) Board Certified in Addiction Medicine, Pain Medicine, and Emergency Medicine Note: this talk will reference off-label use of buprenorphine

February 22, 2018 N Engl J Med 2018; 378: 691 -693 DOI: 10. 1056/NEJMp 1713159

American J Public Health, Feb 1; 108: 2: 182 -186. doi 10. 2105/AJPH. 2017. 304187

WAR ON PAIN WAR ON OPIOIDS BUPRENORPHINE

BUPRENORPHINE MU RECEPTOR Binds tightly & Pushes off other opioids Long duration of action, despite shorter duration of blood levels

ATTENUATED INTRINSIC ACTIVITY MU B Receptor Gi signaling pathway is DIFFERENT with BUP binding Preserved mu receptors on membranes attenuate tolerance Degree BUP-MU interaction is NOT equal to Degree response

Antagonist at KAPPA Opioid Receptor STIMULUS Dysphoria KAPPA Receptor B Dysphoria

Unique at Opioid-Like Receptor (ORL-1) ORL-1 B Receptor B Stimulates ANALGESIA Inhibits ANALGESIA SPINAL LEVEL Peripheral SUPRASPINAL LEVEL Central

BUPRENORPHINE Khanna, I. , & Pillarisetti, S. (2015). Buprenorphine-an attractive opioid with underutilized potential in treatment of chronic pain. J Pain Research, Dec 4; 8: 859 -70. doi: 10. 2147/JPR. S 85951

Budd, K & Raffa, R (Eds. ), Buprenorphine - the Unique Opioid Analgesic: Pharmacology and Clinical Application (p. 3 -21). George Thieme, 2005

DOSING PEARLS 10 mg IM morphine = 30 mg PO morphine 0. 3 mg IM buprenorphine = 10 mg IM morphine 0. 3 mg IM buprenorphine = 0. 6 mg SL buprenorphine 0. 6 mg SL bup = 30 mg PO morphine 20 mcg/hr buprenorphine transdermal = 480 mcg/day ~~ 500 mcg/d =0. 5 mg/day transdermal bup requires 1 mg SL bup tablet buprenorphine SL tablet Compounded BUP troches ~~ 50% better absorbed than manufactured BUP tablets. Swallowing bup tablets yields about a 10% absorption rate

Zurichese Method SMALL dose with MICROgram transdermal buprenorphine Micro gram Bup patch Bernese Method SMALL dose with sublingual buprenorphine 0. 125 -0. 5 mg Bup troche

HYBRID (Kornfeld) Method SMALL dose with transdermal and sublingual buprenorphine Micro gram Bup patch 1/8 film of 2 mg = 0. 25 mg Bup 0. 125 -0. 5 mg Bup troche

MEET ETHEL 85 y/o female with COPD and sleep disorder on opioids x 8 years for pain Chronic low back pain Remote lumbar reconstructions and L 4 -5 fusion On morphine SR 15 mg bid + oxycodone 10 mg q 4 h po (MME = 120 mg) Pain fluctuates and causes significant distress each day Nighttime awakenings due to pain

Buprenorphine 5 ug TD DAY 0 DAY 1 Oxycodone 10 mg po q 4 hr Morphine SR 15 m g bid Buprenorphine 5 ug TD DAY 1: Buprenorphine introduced as a transdermal 5 mcg/hr patch No change of other medications

DAY 2/3: ADDED: 2 more 5 mcg/hr TD BUP patches STOPPED: Long-acting Morphine Buprenorphine 5 ug TD DAY 2 Buprenorphine 5 ug TD Oxycodone 5 mg po q 4 hr Oxycodone 10 mg po q 4 hr CONTINUED Oxycodone 10 mg po q 4 hr continued ADDED: Oxycodone 5 mg po q 4 hr continued DAY 3: Ethel experiences a DECREASE in pain Morphine SR 15 m g bid DAY 3

0. 0625 mg BUP 1/2 troch Q 4 h SL Oxycodone 10 mg po q 4 hr 0. 125 mg BUP 1 troch Q 4 h SL Oxycodone 5 mg po q 4 hr DAY 4: ADDED: 0. 5 compounded buprenorphine troch SL q 4 hours DECREASED to Oxycodone 10 mg po q 4 hr, instead of 15 mg DAY 5: 5 mg 10 mg Oxy 5 mg 10 mg DAY 5 DAY 4 INCREASED: 1 compounded buprenorphine troch SL q 4 hours DECREASED to Oxycodone 5 mg po q 4 hr, instead of 10 mg

DAY 6: INCREASED: 2 compounded buprenorphine troch SL q 4 hours 0. 125 mg BUP 1 troch Q 4 h SL 2 mg BUP 0. 5 -1 tab sl qid STOPPED Oxycodone DAY 7: STOPPED: troch and transdermal patch ADDED: buprenorphine tabs 1 mg SL 4 times daily DAY 8: INCREASED: buprenorphine tabs 2 mg SL 4 times daily 5 mg Oxy Patch OFF 5 mg DAY 6 DAY 7

Micro-Buprenorphine Rotates the Opioid Pool Methadone to Buprenorphine California Health Care Foundation (October 2016). Buprenorphine: Everything You Need to Know

California Health Care Foundation (October 2016). Buprenorphine: Everything You Need to Know pp. 6