Case 1
Patient 1 is a 16-year-old male with Hemoglobin SC disease with no SCD complications prior to 2016. In 2016, he presented 13 times to local emergency departments (ED) for acute pain. Oxycodone immediate-release (IR) was prescribed to treat and prevent escalation of pain. In 2017, he presented to the ED 17 times and was hospitalized for 36 days leading to the addition of oxycodone extended-release (ER). On this regimen, his ED visits decreased, he did not require hospitalization, and he returned to school and extra-curricular activities.
He continued to do well, and in early 2019, oxycodone IR and ER were slowly tapered. This triggered multiple presentations to the ED for pain, where SCD and non-SCD etiologies were ruled out, and he was discharged to continue the oxycodone taper. Tapering efforts continued to be unsuccessful and he was transitioned from oxycodone ER to methadone, while increasing his oxycodone IR. Unfortunately, his high ED utilization continued, expanded to other hospital systems, and he faced discontinuation of his opioids due to controlled substance agreement violations.
In December 2019, the patient’s primary care was transitioned from a community pediatrician to a family medicine physician, co-boarded in addiction medicine. His daily regimen was methadone 12.5 mg and oxycodone IR 37.5 mg (approximately 106 morphine milligram equivalents (MME)). At this time, the patient did not meet criteria for an opioid use disorder, but showed signs of opioid dependence and risky use. The patient’s goal was to wean off opioids. The patient and his PCP discussed initiating buprenorphine-naloxone for persistent pain given its favorable side effect profile and long-acting nature. He was amenable, and in late December 2019 buprenorphine-naloxone was initiated using the Bernese Method of micro-dose induction, Table 1.11,12
The patient denied opioid withdrawal symptoms or side effects. He reported two migraines during induction, which were responsive to his standard migraine medications. The patient has been on buprenorphine for five months and is currently taking 1mg-0.25mg SL daily with the plan to discontinue the medication completely in two weeks. He reports improved pain control, has not utilized any ED or hospital services, and has not missed any school since induction. During visits with pediatric hematology and his PCP, he consistently reports feeling like a normal teenager, and plans to return to playing soccer.