Background & Aims
The effective treatment of moderate to severe cancer pain (CP) often requires the combination of short-acting full agonist opioids (FAO) along with long-acting opioids (1). Buprenorphine (Bup) has many benefits over traditional opioids (2,3,4). However, there is limited data surrounding the use of Bup in combination with short-acting FAO for CP (5,6). In the US, the FDA guidance for transdermal (TD) and transmucosal (TM) Bup recommends that patients be tapered to 30 mg oral morphine equivalents (OME) before initiation to prevent possible opioid withdrawal (OW). At Fox Chase Cancer Center (FCCC), the Supportive Oncology & Palliative Care Program (SOPCP) has been using Bup in combination with short-acting FAO for CP (7). Our primary aim of the retrospective chart review was to assess safety regarding OW in patients treated with the combination of Bup and FAOs by the SOPC team for CP. We also examined the perceived efficacy and doses of Bup and FAO in combination therapy for CP.
Methods
This retrospective chart review consisted of 50 SOPCP patients seen at the outpatient supportive oncology clinic at FCCC in 2022 who had been prescribed concomitant Bup and FAO by SOPCP clinicians. TD Bup (Butrans ®) and TM Bup (Belbuca ®) were used. Oxycodone, morphine, hydromorphone, and combination products of hydrocodone/acetaminophen and oxycodone/acetaminophen were used as FAO. All data forms were created in REDCap. Patients were on a minimum dose of greater than 30 mg OME per day of short-acting FAO and were concomitantly treated with long-acting Bup formulation – either TD or TM. Charts were searched for symptoms listed in the Clinical Opiate Withdrawal Scale (COWS), along with any mention of withdrawal. Additionally, the concomitant doses of buprenorphine and FAO were documented and compared. Dose conversions to OME were based on the available opioid conversion tables.
Results
This cohort had an average age of 58.9, and 32 (64%) were female. The most common sites of malignancy were gastrointestinal, followed by breast, and head and neck. 29 patients (58%) had stage IV disease, and 39 patients (78%) were receiving cancer treatment. No OW signs were noted. All patients were taking FAOs at a dose greater than 30 mg OME per day in addition to a formulation of Bup. The OME dose of FAOs ranged from 37.5mg to 270 mg (average 97 mg); the dose of TD Bup (Butrans patch®) ranged from 5-20 mcg/hr q 7 days or TM Bup (Belbucca®) from 150-750 mcg q 12 hrs. The highest recorded total daily dose of FAO was 270 OME used in combination with TM Bup at 750 mcg q 12 hrs. The average OME dose of oxycodone in combination with Bup was 97 OME; whereas the average OME dose for hydromorphone was 70 OME.
Conclusions
Bup, combined with FAOs, appears to be an effective and well-tolerated regimen for treating CP. Additionally, the current recommendation by the FDA to taper the OME of FAO to less than 30 mg per day seems unnecessary. It may be a barrier to Bup introduction in patients with CP. Additionally, consistent with studies examining the use of Bup in the perioperative period, hydromorphone may be the preferred agent to be used in combination with Bup given its higher affinity for the mu opioid receptor compared with oxycodone (8,9,10). Additional research is needed to confirm the results in prospective studies and compare the effectiveness of Bup in combination with FAO to standard treatments for CP (7,15).
References
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Presenting Author
Marcin Chwistek
Poster Authors
Topics
- Specific Pain Conditions/Pain in Specific Populations: Cancer Pain & Palliative Care