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.