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.