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Teachable Moment
July 29, 2019

Acute Pain Management in Patients Treated With Buprenorphine: A Teachable Moment

Author Affiliations
  • 1Department of Medicine, Warren Alpert Medical School, Brown University, Providence, Rhode Island
  • 2Division of General Internal Medicine, Warren Alpert Medical School, Brown University, Providence, Rhode Island
  • 3Thundermist Health Center, West Warwick, Rhode Island
JAMA Intern Med. 2019;179(10):1415-1416. doi:10.1001/jamainternmed.2019.3103

A man in his 40s with a history of opioid use disorder (OUD) in remission taking buprenorphine/naloxone, 16mg/4mg, presented to the hospital with a fifth distal phalanx fracture and was scheduled for surgery. He was told to stop taking buprenorphine/naloxone starting 2 days prior to surgery and was discharged hours after surgery with a prescription for oxycodone.

The patient presented for follow-up at the surgery clinic 4 days later reporting continued pain. He had finished the oxycodone and was instructed to restart buprenorphine/naloxone treatment. However, the surgeon was unable to write a prescription because buprenorphine (including the buprenorphine/naloxone formulation) can only be prescribed in the outpatient setting for treatment of OUD by physicians, nurse practitioners, and physician assistants who have completed a buprenorphine waiver training and received a special “X” number issued by the Drug Enforcement Agency. The patient’s primary care physician (PCP), who holds a buprenorphine waiver and had prescribed him buprenorphine/naloxone for years, was not contacted. Without a clear plan for how to restart buprenorphine/naloxone treatment, and concerned that withdrawal was imminent, the patient experienced OUD relapse. Two months later he presented to the hospital with chest pain after snorting heroin. The patient was reconnected with his PCP, who prescribed buprenorphine/naloxone and explained that, in accordance with recent guidelines, her practice was generally not to stop buprenorphine/naloxone treatment prior to surgery, but rather to transition patients to every-8-hour dosing.

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