Remark: Some OTPs may be able to offer a split-dose methadone regimen for patients.
Alternatively, the medical provider may need to prescribe the remaining daily doses: 5%–10%
of the current methadone dose should be added, usually as an afternoon and evening dose for a
total 10%–20% increase over the regular dose for the treatment of opioid use disorder (OUD)
(S-VL).
➤ If prescribing additional methadone is not possible, (e.g., OTP policy, high
baseline methadone dose, prolonged QTc intervals, high risk of diversion,
the patient is new to or poorly adherent to the OTP), then the addition
of an additional medication may be recommended for chronic pain
management depending upon the etiology of the pain (e.g., gabapentin
for neuropathic pain, NSAIDs for musculoskeletal pain, or an additional
opioid) (W-L).
➤ Acute exacerbations in pain or "breakthrough pain" should be treated
with small amounts of short-acting opioid analgesics in patients at low-
risk for opioid misuse (S-L).
Remark: Providers and patients should agree upon the number of pills that will be dispensed
for breakthrough pain, their frequency of use, and the expected duration of this treatment.
Buprenorphine
➤ Clinicians should utilize adjuvant therapy appropriate to the pain
syndrome for mild-moderate breakthrough pain (S-M).
Remark: These adjuvants include, but are not limited to, non-pharmacologic treatments,
steroids, non-opioid analgesics, and topical agents [See section on "non-opioids" for treatment
of chronic neuropathic and non-neuropathic pain].
➤ Based on expert opinion, the clinician should increase the dosage of
buprenorphine in divided doses as an initial step in the management of
chronic pain (S-VL).
Remark: Dosing ranges of 4–16 mg divided into 8 hour doses have shown benefit in patients
with chronic non-cancer pain.
➤ Based on expert opinion, clinician's might switch from buprenorphine/
naloxone to buprenorphine transdermal formulation alone (W-VL).
➤ The IDSA recommends, if a maximal dose of buprenorphine is reached,
an additional long-acting potent opioid such as fentanyl, morphine, or
hydromorphone should be tried (S-L).
➤ If usual doses of an additional opioid are ineffective for improving chronic
pain, the IDSA recommends a closely monitored trial of higher doses of an
additional opioid (S-M).
Remark: Buprenorphine's high binding affinity for the mu-opioid receptor may be preventing
the lower doses of other opioids from accessing the mu-opioid receptor.
➤ For patients on buprenorphine maintenance with inadequate analgesia
despite the above-mentioned strategies, the IDSA recommends
transitioning the patient from buprenorphine to methadone maintenance
(S-VL).
Treatment
