Disclosures: Leonard B. Kamen, DO: Indivior Pharma (Products/Services: Yes) (Speaker/Honoraria includes speakers bureau, symposia, and expert witness)

Case Description: Chronic pain patients meeting criteria for OUD who have been successfully transitioned to stable doses of buprenorphine (OUD-B) are prone to exacerbations of pain perception. In this case series OUD-B patients with episodic pain exacerbations were managed with adjunctive therapies while maintained on buprenorphine. Pain education in the self-recognition of anxiety, fear avoidance and catastrophizing, using behavioral desensitization was employed. Adjustments of buprenorphine dosing (no > 24mg) to suppress pain followed by use of alternative analgesics were employed. Tramadol, tapentadol and levorphanol may be considered after failure of agents from AEDs and psychotropic therapies. Ketamine nasal spray, trigger point and spheno-palentine ganglion (SPG) blocks with lidocaine/bupivacaine and topical agents were utilized. Electronic desensitization techniques, heart rate variability training, CBT and FAB counseling along with physical skills training were incorporated.

Setting: Hospital based outpatient PMR clinic.

Patient: Chronic pain patients on buprenorphine therapy for pain and opioid use disorder (OUD). Assessment/

Results: In this case series there were 70 buprenorphine prescriptions in a 30 day cycle. During this cycle there were no discontinuations of buprenorphine therapy or OUD relapses. No individual requested return to prescription opioid use alone for treatment of pain. Dosing spectrum was inclusive of buprenorphine from 300 mcg(s) to 24 mg(s) daily.

Discussion: Buprenorphine MAT in patients with acute on chronic pain requires integration of knowledge re the pharmacology of buprenorphine and individual characteristics of OUD-B. There are currently a plethora of pharmacologic, non-invasive physical medicine and cognitive –behavioral skill sets available to effectively address episodic pain that can present while on MAT.

Conclusion: Medical and non-medical strategies during buprenorphine MAT of OUD in chronic pain patients may prevent relapse and return to non-sustainable opioid use, escalation and substance abuse in this vulnerable population.

Level of Evidence: Level IV

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/management-of-acute-on-chronic-pain-in-patients-on-buprenorphine-therapy/