Case presentation
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A 22-year-old woman with sickle cell disease (SCD) and chronic pain on oxycodone 160 mg every 6 hours (960 morphine mg equivalents) was admitted to the hospital from jail for a vaso-occlusive episode. Since childhood, she has experienced numerous SCD-related complications (i.e., vaso-occlusive episodes, acute chest syndrome, chronic pain). Opioid treatment started during adolescence, with doses escalating due to ineffectiveness for pain management, causing side effects (i.e., severe constipation and sedation) that impaired her ability to perform enjoyed activities. Attempts to taper opioids led to frequent hospitalizations for vaso-occlusive episodes after interrupted doses, leading to discharges on higher opioid doses. The patient did not readily engage with a multidisciplinary sickle cell disease team and was not receiving evidence-based treatments like hydroxyurea. The patient was incarcerated at age 20, where opioid prescribing was continued by Jail Health clinicians.
During this hospitalization, the patient was managed with intravenous (IV) hydromorphone 4 mg every 6 hours, as needed, in addition to her outpatient dose of oxycodone 160 mg every 6 hours. The patient stated a desire to discontinue opioids due to a lack of efficacy, perceived different treatment due to using high-dose opioids, and family history of substance use disorder. Due to the patient's inquiry in buprenorphine for chronic pain, the inpatient addiction consultation service was counseled on day 2 for a potential microdose buprenorphine transition.
On day 5, while the patient was still experiencing acute on chronic pain, buprenorphine was initiated with a gradual microdose, starting on a 20 mcg/hour patch while full agonist opioids were continued. Over the next 5 days, buprenorphine was slowly increased, and oxycodone was tapered. All dosing adjustments were made with shared decision-making with the clinicans and patient. The maximum Clinical Opioid Withdrawal Scale (COWS) score was 7 on day 10, which occurred after swallowing buprenorphine/naloxone tablets instead of taking them sublingually. The patient remained hospitalized for several days for symptom management and gradually titrated buprenorphine/naloxone to a dose of 40/10 mg per day (in four divided doses). Despite mild to moderate withdrawal symptoms, the patient tolerated the transition well with adjunctive therapy (i.e., loperamide, clonidine, diphenhydramine, acetaminophen, ibuprofen, trazodone) and non-pharmacological techniques (i.e., mind-body relaxation strategies, music, and coloring books).
On hospital day 16, the patient was discharged back to jail. She was briefly readmitted to the hospital due to acute worsening of pain after a missed dose of buprenorphine in the jail. During subsequent hospitalization, buprenorphine/naloxone was increased to 48/12 mg daily in four divided doses. After close coordination with Jail Health Services to ensure timely dosing, the patient experienced marked improvement in pain levels, reporting 0/10 pain levels at 4 months after starting buprenorphine, as well as improved mood and function.
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