PRACTICE PARTNER
for pain control for years. In contrast, patients with
opioid use disorders are particularly sensitive to the
psychoactive effects of the opioids. Tolerance to these
effects develops rapidly, causing patients to escalate
their dose. Soon, they begin to experience distressing
withdrawal symptoms, which causes them to escalate
the dose further.
This explains the clinical features of opioid use
disorder in pain patients. They are often on a higher
dose than is generally needed for their pain condition
(although opioid use disorders can also occur at lower
doses). They often run out of medication early, request
frequent dose increases, request specific opioids, and
are resistant to tapering. They may access opioids
from other sources (e.g., other physicians, friends, the
street) and/or chew, snort, or crush tablets to intensify
the effect. They often have a current, past, or strong
family history of misuse of other substances, and of
mood and anxiety disorders.
Reluctant Patients
Patients with opioid use disorder are often reluctant
to disclose their drug-taking behaviours for fear that
the physician will ‘cut them off’. A careful history and
discussion may reveal that the patient is experiencing
significant withdrawal between doses, anxiolytic and
psychoactive effects, and may be supplementing their
opioids from other sources. Frequently, they are very
reluctant to enter treatment, fearing that their pain
will intensify if their opioid medication is stopped.
Physicians should inform reluctant patients that
buprenorphine will markedly improve their mood,
function, and withdrawal symptoms, and their pain
will remain the same or improve (5) .
Prescribing Buprenorphine
Buprenorphine binds tightly to the endorphin recep-
tors, displacing other opioids from opioid receptors
in the brain. This can cause precipitated withdrawal,
the abrupt onset of opioid withdrawal symptoms that
manifest within 30–90 minutes after the first dose
of buprenorphine. To avoid precipitated withdrawal,
the first dose of buprenorphine should be taken at
least 12 hours after the last opioid dose, when the
patient is experiencing mild to moderate withdrawal
symptoms. The first dose should be observed in the
office if possible; however, patients who are unable to
attend the office while in withdrawal should be given
a one-day prescription for buprenorphine to take
at home, with instructions to wait at least 12 hours
after their last opioid use so as to avoid precipitated
withdrawal (6) .
Buprenorphine is taken sublingually, as it has poor
oral bioavailability. The first dose is usually 4 mg,
with another 4 mg dose two hours later if necessary.
The maximum dose on Day 1 is 12 mg. Lower doses
should be used for patients who are elderly, on benzo-
diazepines or other sedating drugs, or who may have
lower tolerance (e.g., codeine users, non-daily binge
users). The dose may be increased by 4 mg every 3–7
days, until it achieves cessation of opioid use and
24-hour relief of withdrawal symptoms and cravings,
without causing sedation or major side effects. The
optimal dose for most patients is 8–16 mg, taken as
a single morning dose. The maximum dose is 24 mg.
Patients continuing to use opioids despite an optim