Case Report: A Perioperative Buprenorphine/Naloxone Microinduction to Reduce the Harms Associated With Long-Term High-Dose Intravenous Opioid Infusion

Background: Patients with complex chronic bowel conditions and Hypermobile Ehlers–Danlos syndrome requiring multimodal analgesia regimens often require significant doses of opioids. Prolonged exposure to opioids can lead to opioid dependence and opioid misuse, requiring its own management. While the role of buprenorphine/naloxone as part of a multimodal pain management and opioid harm reduction strategy has been well described, its application following cardiac surgery in patients who also have Ehlers–Danlos disease remains limited. Historically, buprenorphine/naloxone induction has required patients to experience withdrawal symptoms and can result in patients experiencing emotional distress. Aims: Our aim was to review the outcomes of using a modified Bernese method microinduction strategy to help transition a patient from intravenous hydromorphone to buprenorphine/naloxone. This transition took place during hospitalization, approximately 2 weeks following cardiac surgery in a patient with significant opioid dependence, a relevant medical history of scoliosis, chronic pain of the, back, and abdomen, and significant gastric dysmotility requiring gastric tube feeding. The patient required a wheelchair for mobility. Before hospital discharge, the patient was successfully transitioned from approximately 1,300 mg oral morphine equivalents per 24-hour period to a stable dose of buprenorphine and naloxone and remained on the latter in the long term. Methods: Retrospective chart review was used for data collection to understand outcomes of the microinduction strategy. This case was undertaken on an inpatient cardiovascular surgical recovery ward in a Quaternary Care Facility in Ontario. The patient provided consent for chart review and publication of the case report as well as inclusion of her reported experience. Results: Review of the clinical records suggests that using the microinduction strategy of buprenorphine/naloxone to gradually transition from high-dose intravenous opioid to a stable dose of buprenorphine/naloxone was successful and sustained in the long term. Conclusions: Microinduction of sublingual buprenorphine/naloxone was successful in a patient who was clinically stable postoperatively, presented with significant psychological distress given pending discharge on high-dose opioids and wanting to change the recovery trajectory related to opioid requirement. Precipitated withdrawal with buprenorphine/naloxone could have worsened psychological distress, and thus, a microinduction technique was successful.