Introduction
Sickle cell disease (SCD) is a hematologic disorder defined by presence of a mutation in the HBB gene that results in sickle-shaped red blood cells (RBC). These misshapen, rigid RBCs can occlude blood vessels causing tissue ischemia and intense pain. Although this vaso-occlusive pain best characterizes SCD pain, many patients have more complex pain manifestations including chronic, persistent pain. While opioids are the mainstay of treatment for pain in SCD, patients may become physically and emotionally dependent on opioids; with some developing opioid use disorder (OUD).
Buprenorphine is a mixed agonist-antagonist agent that exerts analgesic effects by binding to CNS opioid receptors. Buprenorphine-naloxone has been used to treat OUD since 2002.1 Buprenorphine has a high affinity to mu-opioid receptors, which can result in precipitated opioid withdrawal symptoms if given too soon after a full opioid agonist in opioid-dependent individuals. Historically, induction of buprenorphine in opioid-dependent individuals required mild to moderate opioid withdrawal and cessation of full opioid agonists for 24-48 hours.2 Case reports describe alternative approaches utilizing small, frequent doses of buprenorphine-naloxone to avoid withdrawal symptoms and rapidly transition patients off full agonist opioids.3–12 None of these case studies include adolescents or individuals with SCD.
Here we describe two adolescent patients with SCD who were safely transitioned to buprenorphine-naloxone using a micro-dose induction protocol (Bernese Method) 11,12 in an outpatient setting.