Sunday, May 7, 2017

Adult Guidelines for Managing Patients on Medication-Assisted Treatment Programs for Opioid Use Disorder

Authors: VanDerveer, Pandya, Oyler; Date Revised: 5/7/2017; Committee: Opioid Stewardship

Background:
The objective of these guidelines is to assist providers in managing acute and perioperative pain patients admitted to UK on medication-assisted treatment (MAT) for opioid use disorder.

General Principles:
·       Continue buprenorphine and methadone therapies as prescribed whenever safely possible since stopping these therapies may put long term recovery from opioid use disorder at risk.
·       Contact the patient’s primary prescriber of MAT to obtain the most recent dose and inform the provider that the patient is/may be hospitalized and therefore may miss appointments.  
·       Consider pre-operative or admission urine toxicology screen. If drugs of abuse are confirmed, consultation with the patient’s MAT prescriber is recommended prior to continuation of MAT.
·       Patients may require higher than normal doses of short-acting opioids as a result of chronic buprenorphine or methadone therapy. Acute opioids may be titrated to CPOT/VAS for adequate analgesia; long acting opioids should not be titrated to analgesia. As pain resolves, consider de-escalating doses and frequencies of adjunct opioids until they can safely be discontinued.
·       All patients are candidates for multi-modal pain management as clinically appropriate with agents such as:
o   Acetaminophen (APAP)
o   Non-steroidal anti-inflammatories (NSAIDs)
o   Membrane stabilizers (e.g., gabapentin, pregabalin)
o   Ketamine as clinically appropriate
o   Alpha 2 agonists (e.g., dexmedetomidine, clonidine)
o   Topical anesthestics (e.g., transdermal lidocaine)
o   Regional anesthesia
o   Neuraxial analgesia / spinal epidural

Pre-operative Planning:
During the pre-operative stages for planned procedures and admissions:
·       Have pain management plan prepared and discuss pain management expectations
·       Provide written instructions of this plan and document in the medical record
·       Ensure plans are available to inpatient care providers
·       If therapies for opioid use disorder are to be stopped, make sure the provider managing the patient’s opioid use disorder is aware to assist in developing a plan to resume therapy

Discharge Planning:
·       Attempt to limit concomitant opioid prescribing as possible depending on clinical status.
·       MAT is not a contraindication to prescription of analgesics on discharge, and additional analgesics may be prescribed as needed.
·       Unless patients have naloxone available, discharge prescription of naloxone is recommended in patients leaving on MAT.

Methadone:
·       Continue prior to admission dosing of methadone during perioperative and post-operative period
o   If patient NPO, convert to IV methadone. Consider acute pain service or clinical pharmacist consultation for dosing assistance.
·       Other opioids may be added for new acute pain and tapered off as pain resolves
o   If mild pain: consider APAP / NSAIDs for break through pain
o   If moderate pain: consider adding PRN opioids + acute pain service consult
o   If severe pain: consider consulting acute pain service
·       Monitoring:
o   EKG at baseline
§  Repeat EKG if concomitant agents that may prolong QTc are initiated or clinical suspicion of arrhythmia
o   BMP/CMP with magnesium level as clinically indicated
·       Pearls:
o   Equipotent dosing of methadone to other opioids is challenging – consider consult acute pain services for assistance in dosing.
o   If methadone is converted to equipotent doses of other analgesics, resuming the same home dose of methadone may not work the same. Contact the acute pain service or the patient’s outpatient clinic for guidance on how to resume methadone and to confirm outpatient dosing.
o   Methadone dosing should NOT be adjusted to treat acute pain
o   For ambulatory or elective procedures, any additional opioids should preferably be tapered/discontinued within 3-5 days post-operatively

Buprenorphine:
Converting from a patient’s dosage form to UK’s formulary agent can be challenging
Non-Formulary Product
Equipotent Suboxone® Dose
Zubsolv® SL tablet

0.7/0.18mg
1/0.25mg
1.4/0.36mg
2/0.5mg
2.9/0.71mg
4/1mg
5.7/1.4mg
8/2mg
8.6/2.1mg
12/3mg
11.4/2.9mg
16/4mg
Bunavail® buccal film

2.1/0.3mg
4/1mg
4.2/0.7mg
8/2mg
6.3/1mg
12/3mg
Buprenorphine is also available as a subdermal implant (PROBUPHINE®, total 74.2mg buprenorphine over up to 6 months). Removal of the buprenorphine implant during hospitalization or preoperatively is not recommended without explicit discussion with the prescriber. Consultation with the provider/clinic regarding date of implantation is recommended. Acute pain consultation may be beneficial.
·       Pearls:
o   Total daily buprenorphine doses can be divided and administered every 6-8 hours for pain management if needed
o   Additional opioids can be administered with buprenorphine.
o   On discharge, if patient’s buprenorphine has been held for > 5 days AND if they continue to require opioid therapy for acute pain, continue acute pain regimen of opioids until outpatient follow up with addiction specialist. This follow up appointment should be arranged as soon as possible after discharge to facilitate resuming buprenorphine therapy. Consult service line social worker for assistance with this.
o   In patients resuming buprenorphine therapy prior to discharge after a period of abstinence from buprenorphine, consult the guidelines for buprenorphine induction.

Naltrexone:
·       Dosage formulations:
o   50 mg tablets
o   390 mg IM depot injection (given every 4 weeks)
·       Pearls
o   Binds competitively to mu receptor but does not activate mu receptor, thereby blocking opioid analgesia
o   Discontinue use in the post-operative period
o   For non-emergent surgeries and procedures, attempt to schedule surgery at the END of the dosing cycle if patient is receiving the IM depot formulation of naltrexone
o   For non-emergent surgeries and procedures, attempt to wait 24 hours if patient is using oral tablet formulations
o   Restart naltrexone once abstinence from post-operative opioids is appropriate, generally 7-10 days after last short-acting full opioid agonist (consider active metabolites of opioids used to manage post-operative pain)
o   Optimize multi-modal analgesia whenever possible.

o   Acute pain service consultation is strongly recommended.