Background & Aims
Buprenorphine/Naloxone is a potential substitute for full agonist opioids for treating chronic pain in sickle cell disease (SCD). Buprenorphine is a long-acting medication that can effectively provide pain relief with less risk of tolerance or dangerous overdose. A recent study conducted at Johns Hopkins Adults Sickle Cell Center (David-Carroll Protocol) demonstrated that when people with SCD are well managed, their pain can be treated with combination buprenorphine-naloxone, resulting in a significant reduction in acute care utilization with patients reporting less pain and better quality of life (1). Our goal is to replicate recent findings with people with SCD and chronic pain and its impact on healthcare utilization pre-and-post initiation of buprenorphine. Study outcomes included frequency of hospitalizations, emergency room visits, acute care visits for pain management and SCD related complications.
Methods
This is a retrospective report on 32 patients with SCD and chronic pain who were transitioned from chronic opioid therapy to buprenorphine. As per the David-Carroll protocol, most patients started buprenorphine therapy during an outpatient clinic visit with follow-up the following day either in person or by tele-health and weekly thereafter. Starting dosage was sublingually at 4mg/1mg BID to TID and the dosage was adjusted based on participants’ response to treatment, including pain ratings and withdrawal symptoms. Patients were monitored during the initial induction using a clinical opiate withdrawal scale (COWS) and also evaluated for pain, nausea, itching or other concerns. Healthcare utilization data was retrieved from the chart review and collected during medical encounters.
Results
The mean buprenorphine dosage for all participants was 10.20 (SD=4.96) at induction and 13.41 (SD=6.82) at 6-months post-induction. Following induction, there was a statistically significant reduction in the mean frequency of healthcare utilization (encounters), which included number of hospitalizations, ED visits and acute care visits at SCD center. Specifically, the mean 6-month total HCU from pre-induction to post induction reduced from 12.04 encounters to 10.73 (a statistical mean decrease of 1.30, p<.01). The number of hospitalizations at 6-months reduced from 1.61 visits to 0.30 visits (a statistical mean decrease of 1.30 visits). There was also a decrease in ED visit from a mean of 3.42 visits to a mean of 1.50 visit (a statistical mean decrease of 1.92 visits, p<.05). The mean 6-month acute care healthcare utilization visits decreased from 9.85 visits in the pre-induction phase to 4.65 visits post induction (a statistical mean decrease of 5.19 visits, p<.05).
Conclusions
This report details the adaptation of the David-Carroll buprenorphine protocol for real world use in people with SCD. The positive, safe use of this protocol at our SCD center is consistent with previous reports of buprenorphine treatment for chronic pain in SCD. However, these findings also highlight the importance of a future, larger dissemination, and implementation study to identify which individuals are most likely to be successful with this treatment regimen and how centers can implement this method in their own environments.
References
1. David, M. S., Jones, J., Lauriello, A., Nnake, I., Plazas Montana, M., Lasko, K., … & Carroll, C. P. (2022). Converting adults with sickle cell disease from full agonist opioids to buprenorphine: A reliable method with safety and early evidence of reduced acute care utilization. American journal of hematology, 97(11), 1435-1442.