Case Presentation: 46 yo man with chronic pain due to T8-T10 compression fractures from renal osteodystrophy related to tertiary hyperparathyroidism in the setting of end-stage renal disease from sickle cell nephropathy had recurrent prolonged admissions due to uncontrolled pain to the point where the patient was unable to perform his activities of daily living. Traditional opioid therapy was unsuccessful as the patient required more narcotics than could be safely prescribed out of the hospital and multiple pain adjuvants including gabapentin, methocarbamol, baclofen, and ketamine were not tolerated due to adverse effects. Buprenorphine-naloxone (Suboxone) was successfully initiated inpatient according to a microdosing schedule with the patient tolerating bathing, showering, and walking short distances at the time of discharge.
Discussion: Suboxone is a partial opioid agonist currently approved by the FDA for opiate use disorder, but has been used off-label for the management of chronic pain. Because of its partial mu agonist with kappa antagonism, Suboxone has analgesic properties without the respiratory depression and development of tolerance seen in full opioid agonists, making Suboxone a possible option for chronic pain management. Traditionally, suboxone is initiated according to the Clinical Opiate Withdrawal Scale (COWS) after voluntary cessation of opiates, however, microdosing is a technique for suboxone initiation that is gaining popularity as it obviates the need for the patient to go through opiate withdrawal, but may require additional days of hospital admission in order to titrate the medication to adequate pain control. Suboxone is an attractive option for sickle cell patients with chronic pain related to complications of their disease as it is safer than full opiate agonists and may carry less stigma. One issue is that suboxone has a maximum dose of about 32 mg/day ( equal to approximately 960 morphine milligram equivalents) which places a theoretical ceiling on possible pain control. Additionally in the setting of acute pain, Suboxone’s partial antagonism may reduce the effectiveness of full opiate agonists. Typically, this issue is circumvented by giving buprenorphine intravenously (preferred) or by reducing the dose of Suboxone by half if intravenous full opiate agonists are needed. Microdosing may require provider expertise but can be learned by any hospitalist and used successfully to improve pain management in the acute setting.
Conclusions: Suboxone is an effective option for sickle cell patients with chronic pain related to complications of their disease. Microdosing can be done to avoid opioid withdrawal during Suboxone initiation and serves as an alternative when full opioid agonists are not tolerated due to side effects. Our patient experienced improved pain, resolution of opioid related side effects, and improved functional status with Suboxone