PRACTICE PARTNER
R
ates of overdose and addiction
are increasing rapidly in Ontario.
Buprenorphine, a medication used to
treat opioid use disorder, is an important
tool for combatting this crisis. Physicians working in
ED, hospital, and primary care settings are encouraged
to know how to prescribe buprenorphine.
Buprenorphine is a sublingual partial opioid agonist
with a slow onset and long duration of action. In the
appropriate dose, it relieves cravings and withdrawal
symptoms for 24 hours without causing sedation or
euphoria. It is combined in a 4:1 ratio with naloxone
as an abuse deterrent. Buprenorphine is far more effec-
tive than abstinence-based treatment at retaining pa-
tients in treatment, reducing opioid use and prevent-
ing overdose and other harms of illicit opioid use (1) .
Buprenorphine has a ceiling effect and therefore has a
much lower risk of overdose than other potent opioids
such as morphine, oxycodone or hydromorphone (2, 3) .
Unlike methadone, the CPSO does not audit bu-
prenorphine prescribing. This reflects the vastly differ-
ent safety profiles of methadone and buprenorphine.
The CPSO recommends that physicians have an
appropriate level of knowledge when prescribing bu-
prenorphine, as they should with any medication. The
CPSO also recommends physicians be familiar with
the expectations articulated in its Prescribing Drugs
policy.
Buprenorphine in the ED and Hospital
CASE: A 35-year-old man has an overdose after injecting
heroin laced with fentanyl; he is resuscitated in the ED. On
discharge, he states he needs something for withdrawal or
he will start using again. The ED doctor calls the psychia-
trist on call, who recommends transfer to the withdrawal
management service. The patient refuses. A month later, he
dies of an overdose.
Patients in the ED or hospital with an opioid-related
problem, such as overdose or sepsis, should be offe red
a buprenorphine prescription prior to discharge (4) .
Without this intervention, they are at high risk
of relapse; those who have been abstinent while
in hospital are at especially high risk for acciden-
tal overdose due to loss of tolerance. The prescription
should last for at least 3–5 days, or long enough for
the patient to be seen in an addiction medicine clinic
that provides urgent assessment and treatment. Patients
should also be advised to get a naloxone kit for overdose
prevention, which can be obtained without a prescrip-
tion and free of charge at most Ontario pharmacies.
Buprenorphine in Primary Care
CASE: You have been prescribing oxycocet 10/day to a
40-year-old woman with fibromyalgia. She has requested
early refills of her prescription several times in the last
year. Her husband tells you she is buying medications from
the street, and her health is deteriorating; she is depressed
and unwell. When you confront her, she states she has to
buy from the street because the oxycocet no longer con-
trols her pain.
Family physicians are encouraged to become comfort-
able with prescribing buprenorphine. There are not
enough addiction specialists in Ontario to provide
opioid substitution treatment to all who would benefit
from it, and smaller communities often lack special-
ized methadone clinics. While the drug itself is safe
and easy to prescribe, it is recommended that family
physicians take an online course or workshop (see
resources at end of article) in order to become familiar
with the components of opioid agonist treatment (eg,
take-home doses, regular urine drug screens).
Diagnosing Opioid Use Disorder in a Pain
Patient
It can be very challenging to discern the features of an
opioid use disorder in patients who also have chronic
pain. Opioids have both analgesic and psychoactive
effects. Tolerance to the analgesic effects develops
slowly, and patients without an opioid use disorder
can often remain on the same low to moderate dose
rivastava A, Kahan M, Nader M. Primary care management of opioid use disorders: Abstinence, methadone, or buprenorphine-naloxone? Canadian family
S
physician Medecin de famille canadien. 2017;63:200-5.
2.
Kahan M, Srivastava A, Ordean A, Cirone S. Buprenorphine: new treatment of opioid addiction in primary care. Canadian family physician Medecin de famille
canadien. 2011;57(3):281-9.
3.
Ducharme S, Fraser R, Gill K. Update on the clinical use of buprenorphine in opioid-related disorders. Canadian family physician Medecin de famille cana-
dien. 2012;58(1):37-41.
4.
D'Onofrio G, O'Connor PG, Pantalon MV, Chawarski M, Busch SH, Owens PH, et al. Emergency Department–Initiated Buprenorphine/Naloxone Treatment for
Opioid Dependence: A Randomized Clinical Trial. Jama. 2015;313(16):1636-44.
1.
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