Case 2
Patient 2 is 19-year-old male with Hemoglobin SC disease complicated by
acute vascular necrosis of bilateral hips at age 7 and a one-week course
of extracorporeal membrane oxygenation (ECMO) in June 2018 for
multisystem organ failure due to a presumed fat embolus. He has a
history of acute and persistent pain since early childhood and was
taking up to 330 MME per day of oxycodone while finishing high school
and working part-time. For transition to an adult primary care provider
at age 18, his hematology team sought a provider with experience
managing patients with persistent pain.
Upon transitioning to a family medicine PCP, intermittent urine drug
screens and regular checks of the Prescription Drug Monitoring Program
showed no evidence of diversion. In preparation for college, in January
2020, he requested his opioid regimen be tapered and discontinued. After
multiple discussions, and despite a slow and controlled taper, he
experienced withdrawal symptoms (body aches, worsening pains, sweats)
that he attributed to SCD which halted the taper and led to return to
previous oxycodone doses. During this time, due to multiple admissions
for pain crises, his total opioid dose actually increased.
The idea of rapid, opioid taper using a buprenorphine-naloxone
micro-dose induction was discussed over several visits with the patient.
Prior to undergoing the micro-dose induction, the patient was taking
oxycodone ER 40mg three times daily and 60mg oxycodone IR daily (270
MME). In February 2020, using the micro-dose induction protocol, the
patient successfully transitioned to buprenorphine-naloxone, Table 2. He
reported only sweats during the micro-induction. After induction, he
reported yawning, chills and sweats relieved by taking additional
buprenorphine-naloxone as needed. His sweating resolved with changing
from the tablet to the film formulation. The patient’s current dose is
4mg-1mg twice daily. In the months since his micro-induction, he has had
brief episodes of pain managed with small doses of oxycodone IR and
administration of IV opioids in the hematology clinic. He has avoided
admission for pain since transitioning to buprenorphine-naloxone,
compared to the year prior in which he had six hospital admissions
(total 56 days).