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Morrissey PJ, Quinn M, Mikolasko B, Fadale PD. Optimizing Safe Opioid Prescribing: A Paradigm Shift in Buprenorphine Management for Orthopaedic Surgery. J Arthroplasty 2024:S0883-5403(24)00652-1. [PMID: 38914144 DOI: 10.1016/j.arth.2024.06.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Revised: 06/17/2024] [Accepted: 06/19/2024] [Indexed: 06/26/2024] Open
Abstract
The worsening opioid epidemic in the United States, exacerbated by the COVID-19 pandemic, necessitates innovative approaches to pain management. Buprenorphine, a long-acting opioid, has gained popularity due to its safety profile and accessibility. Orthopaedic surgeons, encountering an increasing number of patients on buprenorphine, face challenges in perioperative management. This article will update orthopaedic surgeons on new developments in the understanding of buprenorphine as a pain reliever and share evidence-based practice guidelines for buprenorphine management. For patients on buprenorphine for opioid use disorder or chronic pain, the updated recommendation is to continue their home dose of buprenorphine through the perioperative period. The patient's buprenorphine prescriber should be contacted and notified of any impending surgery. The continuation of buprenorphine should be accompanied by a multimodal approach to analgesia, including a preoperative discussion about expectations of pain and pain control, regional anesthesia, standing acetaminophen, Nonsteroidal anti-inflammatory drugs when possible, gabapentinoids at night for patients under 65 years, cryotherapy, elevation, and early mobilization. Patients can also be prescribed short-acting, immediate-release opioids for breakthrough pain. Transdermal buprenorphine is emerging as an excellent option for the management of acute perioperative pain in both elective and nonelective orthopaedic patients. A single patch can provide a steady dose of pain medication for up to 1 week during the postoperative period. A patch delivery method can help combat patient nonadherence and ultimately provide better overall pain control. In the future, transdermal buprenorphine patches could be applied in virtually all fracture surgery, spinal surgery, total joint arthroplasty, ligament reconstructions with bony drilling, etc. As the stigma surrounding buprenorphine decreases, further opportunities for perioperative use may develop.
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Affiliation(s)
- Patrick J Morrissey
- Department of Orthopedics, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Matthew Quinn
- Department of Orthopedics, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Brian Mikolasko
- Department of Palliative Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Paul D Fadale
- Department of Orthopedics, Warren Alpert Medical School of Brown University, Providence, Rhode Island
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Muñoz D, Orozco S, Jaramillo S, Herrera Torres AM. Multimodal postoperative analgesia with transdermal buprenorphine is a safe option in arthroscopic rotator cuff repair. J Perioper Pract 2023:17504589231185052. [PMID: 37646407 DOI: 10.1177/17504589231185052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
BACKGROUND Arthroscopic rotator cuff repairs are associated with moderate-to-severe pain. Opioids are not the first line for postsurgical pain control due to their potential misuse and side effects. Transdermal buprenorphine represents an alternative for multimodal postoperative pain control. METHODS This was a single-centre, prospective longitudinal exploratory study of patients undergoing arthroscopic rotator cuff repairs managed with multimodal analgesia with transdermal buprenorphine. Patients were followed-up by telephone at eight time points, assessing pain levels, rescue analgesics requirement and side effects. FINDINGS Twenty-five patients with an average age of 63.4 ± 8.2 were included. Fourteen patients were ⩾65 years. Pain levels were similar among age groups at all time points, with no pain or mild pain (visual analogue scale 1-4) in most patients. The most frequent side effects were dizziness and somnolence. CONCLUSION Transdermal buprenorphine provided a sustained analgesic effect after an arthroscopic rotator cuff repair during the acute postsurgical period. It showed a similar safety profile among younger and older patients.
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Affiliation(s)
- David Muñoz
- Anesthesia and Analgesic Intervention Group, Department of Anesthesia, Clínica del Campestre, Medellín, Colombia
| | - Sergio Orozco
- Anesthesia and Analgesic Intervention Group, Department of Anesthesia, Clínica del Campestre, Medellín, Colombia
| | - Santiago Jaramillo
- Anesthesia and Analgesic Intervention Group, Department of Anesthesia, Clínica del Campestre, Medellín, Colombia
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Khodaverdi E, Hadizadeh F, Hoseini N, Eisvand F, Tayebi M, Kamali H, Oroojalian F. In-vitro and in-vivo evaluation of sustained-release buprenorphine using in-situ forming lipid-liquid crystal gels. Life Sci 2023; 314:121324. [PMID: 36574944 DOI: 10.1016/j.lfs.2022.121324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 12/15/2022] [Accepted: 12/20/2022] [Indexed: 12/25/2022]
Abstract
AIMS Sustained-release systems reduce the incidence of drug side effects and the need for frequent drug consumption, thus increasing patient compliance with treatment. In this study, we aimed to produce sustained-release buprenorphine (BP) using lipid-liquid crystal gels. MAIN METHODS The three experimental groups in this study included: group I: lipid-liquid crystal formulation 5 (F5) containing BP, group II: BP-free F5, group III: BP solution in NMP, and group IV: control (no treatment). The formulations were injected subcutaneously into the rabbits' back neck. KEY FINDINGS The results showed that the time required to reach the drug's maximum concentration (Tmax) was longer in group I than in group III. The maximum BP concentration (Cmax) and the constants of the drug removal rate and drug absorption rate (Ka) were significantly higher in group III compared to group I. The half-life (t1/2) of the drug in blood circulation was significantly longer in group I than in group III. Histopathological analysis revealed no histological abnormalities in the skin and heart in group I (BP-containing F5); however, mild hyperemia was observed in interstitial vessels in group III (BP-containing NMP). The kidney and liver tissues showed normal structure in the control group, as well as groups I and II. However, in the group receiving BP-containing NMP, significant congestion, tissue damage, necrosis, and fibrosis were observed in the kidney and liver. SIGNIFICANCE The results showed that the lipid-liquid crystal system can be used to design slow-release platforms for BP, minimizing the side effects associated with the use of its conventional forms.
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Affiliation(s)
- Elham Khodaverdi
- Targeted Drug Delivery Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran; Department of Pharmaceutics, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Farzin Hadizadeh
- Department of Medicinal Chemistry, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran; Biotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Nilofarsadat Hoseini
- Targeted Drug Delivery Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran; Department of Pharmaceutics, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Farhad Eisvand
- Department of Pharmacodynamics and Toxicology, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mohadeseh Tayebi
- Targeted Drug Delivery Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran; Department of Pharmaceutics, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Hossein Kamali
- Targeted Drug Delivery Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran; Department of Pharmaceutics, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran.
| | - Fatemeh Oroojalian
- Department of Advanced Technologies, School of Medicine, North Khorasan University of Medical Sciences, Bojnurd, Iran; Natural Products and Medicinal Plants Research Center, North Khorasan University of Medical Sciences, Bojnurd, Iran.
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Neale KJ, Weimer MB, Davis MP, Jones KF, Kullgren JG, Kale SS, Childers J, Broglio K, Merlin JS, Peck S, Francis SY, Bango J, Jones CA, Sager Z, Ho JJ. Top Ten Tips Palliative Care Clinicians Should Know About Buprenorphine. J Palliat Med 2023; 26:120-130. [PMID: 36067137 DOI: 10.1089/jpm.2022.0399] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Pain management in palliative care (PC) is becoming more complex as patients survive longer with life-limiting illnesses and population-wide trends involving opioid misuse become more common in serious illness. Buprenorphine, a generally safe partial mu-opioid receptor agonist, has been shown to be effective for both pain management and opioid use disorder. It is critical that PC clinicians become comfortable with indications for its use, strategies for initiation while understanding risks and benefits. This article, written by a team of PC and addiction-trained specialists, including physicians, nurse practitioners, social workers, and a pharmacist, offers 10 tips to demystify buprenorphine use in serious illness.
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Affiliation(s)
- Kyle J Neale
- The Lois U and Harry R Horvitz Palliative Medicine Program, Department of Palliative Medicine and Supportive Care, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Melissa B Weimer
- Program in Addiction Medicine, Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Mellar P Davis
- Department of Palliative Care, Geisinger Medical Center, Danville, Pennsylvania, USA
| | | | - Justin G Kullgren
- Palliative Medicine Clinical Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Sachin S Kale
- Division of Palliative Medicine, Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Julie Childers
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Kathleen Broglio
- Section of Palliative Medicine, Geisel School of Medicine at Dartmouth, Collaboratory for Implementation Sciences at Dartmouth, Lebanon, New Hampshire, USA
| | - Jessica S Merlin
- Section of Palliative Care and Medical Ethics and Palliative Research Center, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Sarah Peck
- Division of Palliative Medicine, Emory University Healthcare Midtown, Atlanta, Georgia, USA
| | - Sheria Y Francis
- Collaborative Care Management, University of Pittsburgh Medical Center Presbyterian Shadyside, Pittsburgh, Pennsylvania, USA
| | | | - Christopher A Jones
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Zachary Sager
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - J Janet Ho
- Division of Palliative Medicine, University of California San Francisco, San Francisco, California, USA
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Poliwoda S, Noor N, Jenkins JS, Stark CW, Steib M, Hasoon J, Varrassi G, Urits I, Viswanath O, Kaye AM, Kaye AD. Buprenorphine and its formulations: a comprehensive review. Health Psychol Res 2022; 10:37517. [PMID: 35999975 PMCID: PMC9392838 DOI: 10.52965/001c.37517] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2023] Open
Abstract
Buprenorphine, a novel long-acting analgesic, was developed with the intention of two purposes: analgesia and opioid use disorder. Regarding its pharmacodynamics, it is a partial agonist at mu receptors, an inverse agonist at kappa receptors, and an antagonist at delta receptors. For the purpose of analgesia, three formulations of buprenorphine were developed: IV/IM injectable formulation (Buprenex®), transdermal patch formulation (Butrans®), and buccal film formulation (Belbuca®). Related to opioid dependence, the formulations developed were subcutaneous extended release (Sublocade®), subdermal implant (Probuphine®), and sublingual tablets (Subutex®). Lastly, in order to avoid misuse of buprenorphine for opioid dependence, two combination formulations paired with naloxone were developed: film formulation (Suboxone®) and tablet formulation (Zubsolv®). In this review, we present details of each formulation along with their similarities and differences between each other and clinical considerations.
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Affiliation(s)
| | - Nazir Noor
- Department of Anesthesiology, Mount Sinai Medical Center
| | | | - Cain W Stark
- Medical College of Wisconsin, 8701 West Watertown Plank Road, Wauwatosa, WI 53226
| | - Mattie Steib
- Louisiana State University Health Shreveport School of Medicine
| | - Jamal Hasoon
- Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA, Beth Israel Deaconess Medical Center
| | | | - Ivan Urits
- Department of Anesthesiology, 1501 Kings Hwy, Shreveport, LA 71103, Louisiana State University Health Shreveport
| | - Omar Viswanath
- Clinical Professor of Anesthesiology, LSU Health Sciences Center School of Medicine, Creighton University School of Medicine, Innovative Pain and Wellness
| | - Adam M Kaye
- Department of Pharmacy Practice, Stockton, CA, 95211,, Thomas J. Long School of Pharmacy and Health Sciences, University of the Pacific
| | - Alan D Kaye
- Department of Anesthesiology, Shreveport, LA, Louisiana State University Health Sciences Center - Shreveport
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Effectiveness of Transdermal Buprenorphine for Pain Control in the ICU After Major Surgical Procedures. Crit Care Explor 2022; 4:e0665. [PMID: 35372846 PMCID: PMC8963835 DOI: 10.1097/cce.0000000000000665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Transdermal buprenorphine (TBUP) may be useful for postoperative pain after major surgery, when pain is expected to be severe and sustained. The objective of this study was to compare pain control and opioid consumption in critically ill postoperative patients who were treated with TBUP or not during ICU admission.
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Influences of Gender on Intravenous Nalbuphine Actions After Major Abdominal Surgery: A Multicenter Study. Pain Ther 2021; 10:1215-1233. [PMID: 34110603 PMCID: PMC8586316 DOI: 10.1007/s40122-021-00277-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 05/27/2021] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Nalbuphine, a synthetic kappa-opioid receptor (KOR) agonist and a partial µ-opioid receptor (MOR) antagonist, has been used for years as an effective analgesic. It has been shown to have a better safety profile than morphine. Considering the long history of use of this drug, it is interesting that only a limited amount of information exists on how gender differences influence nalbuphine responses. In this randomized double-blind comparative trial after major abdominal surgery, the analgesic effects of two doses of continuous intravenous infusion of nalbuphine were evaluated based on gender. METHODS Enrolled patients were divided into four groups (two females and two males with 32 patients in each group). Two of them (groups A1 and A2), one male and one female, received postoperative continuous intravenous infusions of nalbuphine at 2 mg/h via patient-controlled analgesia (PCA). Each patient had the potential of receiving a rescue bolus of 1 mg of nalbuphine with a lock out time of 15 min. The other two groups (groups B1 and B2) received half the infusion dose, 1 mg/h, and half the nalbuphine rescue dose with the PCA pump, 0.5 mg maximum every 15 min as needed. Patients' vital signs, numerical pain rating scores, rescue nalbuphine, and incidence of side effects were assessed immediately after the operation, and every 3 h during the first 12 h. RESULTS Nalbuphine 2 mg/h dosing led to significantly lower pain scores amongst females compared to males at 6, 9, and 12 h; while the 1 mg/h infusion pain scores were only lower at the 9-h time period. Females receiving the nalbuphine 2 mg dose at 6 h, and the 1 mg dose at 6, 9, and 12-h measurements needed significantly lower doses of rescue nalbuphine. Females on the 1 mg dose experienced significantly more nausea, vomiting, and sedation at the 6-, 9-, and 12-h measurement times. In the multivariate analysis, female gender was a negative predictor at all measurement times. CONCLUSIONS The current study supports the hypothesis that although nalbuphine was found to be an effective and well-tolerated analgesic after major abdominal surgery, females were statistically more responsive than males. TRIAL REGISTRATION The study was registered at the Pan African Clinical trials Registry PACTR201304000486309, and approved for the Ethical aspects.
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