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Case report
Acute pain service reduces barriers to buprenorphine/naloxone initiation by using regional anesthesia techniques
  1. Alice Seol1,
  2. John Chan2,
  3. Brittni Micham2,3,
  4. Ying Ye4,
  5. Edward R Mariano1,4,
  6. T Kyle Harrison1,4 and
  7. Oluwatobi O Hunter4
  1. 1Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
  2. 2Department of Physical Medicine and Rehabilitation, Stanford University School of Medicine, Stanford, California, USA
  3. 3Physical Medicine and Rehabilitation Service, VA Palo Alto Health Care System, Palo Alto, California, USA
  4. 4Anesthesiology and Perioperative Care Service, VA Palo Alto Health Care System, Palo Alto, California, USA
  1. Correspondence to Dr Oluwatobi O Hunter, Anesthesiology and Perioperative Care Service, VA Palo Alto Health Care System, Palo Alto, CA 94304, USA; oadeboyejowork{at}gmail.com

Abstract

Background Medications for opioid use disorder (MOUD) are a life-saving intervention; thus, it is important to address barriers to successful initiation. Spasticity affects many patients with spinal cord injury and can be painful and physically debilitating. Chronic painful conditions can lead to the illicit use of non-prescribed opioids, but fear of pain is a barrier to the initiation of MOUD. In this case report, we describe the novel use of botulinum toxin A injections to treat abdominal spasticity and facilitate Acute Pain Service-led buprenorphine/naloxone initiation in a patient with opioid use disorder and severe abdominal spasticity due to spinal cord injury.

Case presentation A patient with C4 incomplete tetraplegia and opioid use disorder complicated by abdominal spasticity refractory to oral antispasmodics and self-treating with intravenous heroin was referred to the Acute Pain Service for inpatient buprenorphine/naloxone initiation. The patient began to fail initiation of buprenorphine/naloxone secondary to increased pain from abdominal spasms. The patient was offered ultrasound-guided abdominal muscle chemodenervation with botulinum toxin A, which resulted in the resolution of abdominal spasticity and facilitated successful buprenorphine/naloxone initiation. At 6 months post-initiation, the patient remained abstinent from non-prescribed opioids and compliant with buprenorphine/naloxone 8 mg/2 mg three times a day.

Conclusions This case report demonstrates that inpatient buprenorphine/naloxone initiation by an Acute Pain Service can improve the success of treatment by addressing barriers to initiation. Acute Pain Service clinicians possess unique skills and knowledge, including ultrasound-guided interventions, that enable them to provide innovative and personalized approaches to care in the complex opioid use disorder population.

  • Opioid-Related Disorders
  • CHRONIC PAIN
  • REGIONAL ANESTHESIA
  • Analgesics, Opioid
  • Pain Management

https://doi.org/10.1136/rapm-2022-104317

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    Footnotes

    • Twitter @EMARIANOMD, @TobiHunterDNP

    • Contributors AS provided care to the patient, helped develop the idea for the report, drafted and revised the initial manuscript, and reviewed and approved the submitted manuscript. JC provided care to the patient, helped develop the idea for the report, drafted and revised the initial manuscript, and reviewed and approved the submitted manuscript. BM provided care to the patient, helped develop the idea for the report, revised the initial manuscript, and reviewed and approved the submitted manuscript. YY provided care to the patient, helped develop the idea for the report, revised the initial manuscript, and reviewed and approved the submitted manuscript. ERM helped develop the idea for the report, revised the initial manuscript, and reviewed and approved the submitted manuscript. TKH helped develop the idea for the report, revised the initial manuscript, and reviewed and approved the submitted manuscript. OOH provided care to the patient, helped develop the idea for the report, collected and analyzed data, drafted and revised the initial manuscript, and reviewed and approved the submitted manuscript.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Disclaimer The contents do not represent the views of the Department of Veterans Affairs or the US Government.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.