Chronic pain is highly prevalent in older adult cancer survivors, but the prevalence of nociplastic pain is ill-defined. This is important because nociplastic pain responds poorly to opioids, the cornerstone of cancer pain management. Moreover, older adults face high risk of respiratory depression, falls, and mortality from opioids. Given these risks, a better understanding of nociplastic pain prevalence is needed. This was a cross-sectional analysis study at a large, academic medical center. Patients ≥65 years of age with at least one outpatient visit between November 1, 2015 and December 23, 2021 were included. The primary outcome was the proportion of older adults, with and without cancer, with a chronic overlapping pain condition (COPC) diagnosis (a type of nociplastic pain). There were 320,727 older adults included and 15.5% carried at least one COPC diagnosis. Those with COPCs were more likely to be female, younger, and have a higher Elixhauser Comorbidity Index. Black Americans were less likely to carry a COPC diagnosis. The incidence rate of COPCs was 1.0333 times higher in older adults with cancer (95% CI [1.014, 1.053], p = 0.001). One in six older adults had a COPC diagnosis. Those with cancer were more likely to carry a COPC diagnosis than their peers without.

OBJECTIVE:To critically evaluate the available evidence for low-dose oral ketamine for analgesia and provide summary recommendations for clinicians on its use in practice. DATA SOURCES:A search of the primary literature was performed in PubMed from 2010 through 2025 using the following keywords: "Administration, oral," "Administration, sublingual," "ketamine," and "pain." STUDY SELECTION AND DATA EXTRACTION:All studies and case reports involving the use of oral or sublingual ketamine for analgesia as the primary focus were included. DATA SYNTHESIS:Oral ketamine was well tolerated in dose ranges from 25 to 300 mg/day, which were associated with reduced pain scores, improved quality of life, and decreased opioid requirements in line with low-dose infusions for pain management. Weight-based doses above 6 mg/kg corresponded with an increase in adverse effects. Optimal parenteral-to-oral dose conversions are not known; however, dose reductions by 75% from the daily infusion dose maintained analgesia in a small number of cases. Treatment durations ranged from single doses up to 12 years but were predominantly studied in less than 2 years of use. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE:There remains a dearth of safe and effective pharmacologic pain management options which serve as alternatives to opioids. Low-dose ketamine is an oft-overlooked analgesic with evidence dating back over 50 years, but clinical uptake is poor. Oral ketamine presents a pragmatic formulation, and this review uses the current evidence to address pertinent clinical queries raised by clinicians in practice. CONCLUSIONS:Subanesthetic oral ketamine is an analgesic with continually growing evidence investigating use in a variety of acute and chronic pain syndromes. Based on the current evidence, ketamine may be helpful for refractory pain, as a component of multimodal analgesia, or in patients with high opioid requirements. Adverse effects are typically mild, but the risks of long-term use ultimately remain unclear.

Disparities in care and management of pain among racial groups have been demonstrated in various studies. Chronic overlapping pain conditions (COPCs) have yet to be examined. This was an observational cohort study of Medicare beneficiaries from 2018-2020 analyzing COPC diagnosis rates and prescription claims. Nationally representative 20% sample of Medicare beneficiaries from 2018-2020. Medicare beneficiaries ≥ 66 years of age in 2019 were included if they had ≥ nine months of A/B/D coverage in 2018-2020. Beneficiaries were excluded if they had Medicare Advantage or end-stage renal disease. Prevalence of COPC diagnosis using validated ICD-10 codes in Medicare beneficiaries and disparities in diagnosis and management. In 2019, 2,573,165 patients were included in the analysis; 87% were White, 8% Black, and 1.7% Asian. COPC diagnosis prevalence in Medicare beneficiaries was more than 10% (n=273,996). Black (odds ratio [OR], 0.89 [95% CI, 0.88-0.91]) and Asian (OR, 0.68 [95% CI, 0.66-0.71]) patients were less likely to have a COPC diagnosis. The incidence of a new COPC diagnosis was 11.4% (n=31,281) among Medicare beneficiaries; only 24.1% (n=7541) received COPC-targeted prescriptions. Black (OR, 1.13 [95% CI, 1.02-1.26]), and Asian (OR, 1.32 [95% CI, 1.06-1.63]) beneficiaries were more likely to receive COPC-targeted prescriptions. Black (OR, 1.12 [95% CI, 1.01-1.25]) beneficiaries were more likely to receive opioids. Examination of associations, not causations or reasons underlying the identified disparities. The prevalence of COPC diagnosis in Medicare beneficiaries was 10%, but only one-quarter of those received COPC-targeted prescriptions. Disparities in COPCs persist into COPCs for Black beneficiaries. PERSPECTIVE: The study examines the prevalence and management of COPCs in older adults using Medicare data. It found racial disparities in diagnosis and prescriptions, with Black and Asian beneficiaries less likely to receive a diagnosis. Opioid use remains high despite known ineffectiveness, highlighting the need for better pain management strategies.

Outcomes1. Understand the role acetylcholine may have in acute and chronic pain.2. Consider potential mechanisms through which rivastigmine might impact pain in individuals with cognitive impairment.Key MessageRivastigmine has become one of the most commonly prescribed medications for multiple forms of dementia. We present a case of unexpected and rapid improvement in chronic pain upon rivastigmine initiation during a hospital admission for delirium. It is important to consider cholinergic mechanisms in addressing refractory pain as well as the interactions between chronic pain and cognitive impairment.BackgroundCholinergic deficit is a common component of both cognitive impairment and acute pain. Neostigmine has a well-documented history of use as adjunctive postoperative analgesia. Rivastigmine has become one of the most commonly prescribed medications for multiple forms of dementia. Little has been reported, however, about potential analgesic properties of rivastigmine, particularly in the setting of chronic pain.Case DescriptionWe present the case of a 76-year-old male with a history of cognitive impairment and chronic low back pain refractory to multiple therapeutic agents. After a traumatic fall with fracture, he experienced a significant decline in his cognitive function and worsening of his pain. After repeated episodes of delirium, aggression and suicidal ideation secondary to unremitting pain, the patient experienced an unexpected and rapid relief in pain and improved mentation upon initiation of a rivastigmine patch during his admission. In the 8 months following discharge, the patient demonstrated sustained improvement of his chronic low back pain with minimal additional pharmacotherapy and no further episodes of delirium requiring hospitalization.Learning objectives-Review the roles of acetylcholine in acute and chronic pain. -Consider potential mechanisms through which rivastigmine might impact pain in individuals with cognitive impairment.-Discuss recent literature regarding the interdependent relationship between chronic pain and cognitive impairment.KeywordsEmergencies / Refractory Symptom Management /Disease specific management

Outcomes 1. Describe the clinical challenges in treating acute and chronic pain in patients with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), and identify the potential benefits of buprenorphine use in patients with HIV/AIDS and complex pain.2. Understand the evidence for buprenorphine use in chronic, non-terminal pain in patients without a history of opioid use disorder (OUD). Key Message This is a case of a male veteran in his 50s with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) and disseminated mycobacterium avium-intracellulare infection with lumbar vertebral osteomyelitis and epidural abscess that experienced complex pain responsive to buprenorphine therapy, demonstrating the utility of buprenorphine in treating non-cancer pain in patients with HIV/AIDS who have failed traditional opioids. Background Patients living with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) can experience complex acute and chronic pain. Buprenorphine, a partial mu-agonist, inverse kappa-agonist, and delta-antagonist, has potential advantages. While it has classically been used to treat opioid use disorder (OUD), it has been increasingly used as an alternative to traditional full opioid agonists for management of acute and/or chronic pain in patients with cancer and other conditions, even in the absence of OUD. Less is known about the use of buprenorphine for complex pain in patients living with HIV/AIDS. Case Description A male veteran in his 50s with HIV/AIDS and disseminated mycobacterium avium-intracellulare infection with biopsy proven lumbar vertebral mycobacterial osteomyelitis was hospitalized after outside imaging showed worsening L2-L3 osteomyelitis with left epidural and possible intraosseous abscess. He experienced severe complex pain in his low back and left thigh radiating to the knee in the L2-L3 dermatomal distribution. He was not a surgical candidate due to significant disease burden and proximity to vascular structures. Pain was not responsive to titration of multiple full opioid agonists. Methadone was considered but contraindicated due to drug-drug interactions with his antiretrovirals. Adjuncts including duloxetine and gabapentin were trialed, but limited due to side effect burden. Buprenorphine was initiated and titrated to 4 mg three times daily, leading to significant reductions in all pain sites. He was able to ambulate comfortably. Use of hydromorphone for breakthrough pain was minimal after buprenorphine titration. Conclusion Buprenorphine is a useful medication for treating patients with pain who do not respond to traditional opioids. Despite its uptake in clinical use, more research is needed to determine place in therapy in patients living with HIV/AIDS. This case presentation demonstrates potential benefits of buprenorphine for acute and chronic non-cancer pain in patients living with HIV/AIDS who have failed traditional opioids. Keywords Disease specific management / Emergencies / Refractory Symptom Management

Naltrexone is a mu-opioid receptor antagonist increasingly used as an analgesic for chronic pain at low doses. This retrospective, observational cohort study was conducted at an academic medical center to evaluate low-dose naltrexone (LDN) efficacy and describe its use in routine clinical practice. Adults receiving LDN, doses <10 mg for >= 1 month, seen at an outpatient pain clinic from January 1, 2014 to April 1, 2022 were included. The primary outcome was change in the Pain, Enjoyment of Life, and General Activity (PEG) score after LDN. Thirty-one patients were included. Median age was 50 years and 71% were female. Median duration of pain at baseline was 5 years. Mean PEG scores were 7.27 +/- 1.39 and 6.62 +/- 2.04 at baseline and follow-up, respectively. Mean difference was 0.66 (95% CI [0.10-1.21], p = 0.022). Eighty-seven percent (27) of patients discontinued LDN, 52% (16) for lack of benefit, 23% (7) for loss of benefit, 10% (3) for side effects, and 3% (1) for other reasons. Seven (23%) reported side effects. LDN was associated with a statistically significant reduction in PEG in adult chronic pain patients, however the clinical significance is unclear as over 75% of patients discontinued LDN due to lack of benefit.

self-reported improved pain control and resolution of headaches attributed to pure-mu opioid agonist.Patient B underwent buprenorphine induction up to 16 mg SL daily.Her daily pure mu agonist opioid requirement reduced from 2200 mg morphine to 670 after 14 days.She self-reported improved pain and anxiety.Neither patient exhibited signs of opioid withdrawal.Conclusion.Buprenorphine induction via the Bernese method resulted in decreased daily pure mu agonist opioid requirement and improved pain control which had not been achieved with pure mu agonist opioids alone.Neither patient experienced signs or symptoms of opioid withdrawal.Clinicians should consider use of buprenorphine in cases of refractory cancer-associated pain due to its unique properties and demonstrated safety and efficacy.

Abstract The intersection of insomnia and pain with age has been broadly studied but has not been evaluated specifically in centralized pain. The objective of this study was to estimate the effect of age on rates of centralized pain and insomnia in older adults. This was a single center, retrospective, observational cohort study consisting of older adults (≥55 years old) with a diagnosis of centralized pain, insomnia, or both seen at University of Michigan Health from January 1, 2016 – January 1, 2022. The primary outcome was the proportion of older adults with both insomnia and centralized pain, defined as least one centralized pain diagnosis coded in the subject’s electronic health record within one year of insomnia diagnosis. A total of 26,804 patients were included in the analysis. Mean age was 66.84 years (SD 8.79); 66% of patients (n=17,687) were female. Overall, 92.1% of patients (n=24,683) carried ≥1 centralized pain diagnosis, 5.6% of patients (n=1,505) carried a diagnosis of insomnia, and 2.3% (n=616) had both [95% CI 2.1,2.5]. Of older adults with insomnia, 29% (95% CI 27, 31) also carried a centralized pain diagnosis. Of older adults with centralized pain, 2.4% (95% CI 2.3, 2.6) also carried an insomnia diagnosis. Compared to older adults with insomnia alone, those with both insomnia and centralized pain were more likely to be female (p=< 0.001) and older (p=0.014). Insomnia and centralized pain are highly prevalent in older adults and co-occur frequently in those with insomnia. Older adults with insomnia should be screened for centralized pain.

Despite being an essential part of whole-person care, patients with cancer often experience complex and under-treated pain. Managing cancer-related pain in patients who are also pregnant compounds the challenge for adequate pain management, as studies have largely excluded this population. Therapy for pain management should be guided by the cause and mechanism of pain. The objective of this review is to provide clinicians with an understanding of pain experienced by pregnant patients with cancer and medications that may be used to help manage cancer-related pain. Nociceptive pain results from damage to somatic or visceral tissues that may be directly caused by cancer. This type of pain can be managed in pregnant patients using acetaminophen and/or nonsteroidal antiinflammatory drugs as first-line agents. In nociceptive pain not managed by non-opioid analgesics, buprenorphine is recommended for those requiring chronic opioids to help manage their pain. Neuropathic pain that results from damage to the peripheral or central nervous system may also be directly caused by cancer, particularly chemotherapy. In pregnant patients, duloxetine and gabapentin should be considered first. Venlafaxine, pregabalin, tricyclic antidepressants, and sodium channel blockers should be avoided, if possible. Nociplastic pain is not directly caused by cancer but may be caused by ongoing peripheral nociceptive input or a condition that predates the cancer diagnosis. Duloxetine and gabapentin are reasonable agents to consider for treatment of nociceptive pain in pregnant patients. Cyclobenzaprine may also be helpful for nociplastic pain.

Capsaicin is a topical pain reliever that has been evaluated by randomized controlled trials (RCTs) as a potential adjunctive therapy for treating unmitigated fibromyalgia. Therefore, a review of English articles using PubMed and Embase was conducted from January 1, 1990 to February 9, 2022 in order to evaluate the utility of capsaicin for improvement of sleep quality and fatigue associated with fibromyalgia. The search terms included: “fibromyalgia” and “capsaicin”. Articles included were RCTs evaluating capsaicin in adult patients with fibromyalgia. Two studies met criteria and included 175 patients that received either capsaicin or placebo for an average total treatment length of 5 weeks. The treatment outcomes assessed were changes in quality of sleep and fatigue by several standardized modalities. These include visual analog scale (VAS) of sleep quality and fatigue, fatigue severity scale, Pittsburgh Sleep Quality Index (PSQI), and global subjective improvement. Both studies demonstrated no changes in sleep quality, but one study did find a significant difference in global subjective improvement. This same study also found a significant improvement in fatigue. Consequently, this existing evidence is insufficient to warrant recommending capsaicin as adjunctive therapy for improvement in sleep quality and fatigue. Future studies regarding capsaicin therapy for fibromyalgia are needed.

Key Points Question How often are opioid prescriptions from US surgeons and dentists dispensed more than 30 days after writing (delayed dispensing)? Findings In this cross-sectional analysis of a national pharmacy database representing 63% of US prescriptions, 194 452 opioid prescriptions (0.9%) from surgeons and dentists in 2019 were dispensed more than 30 days after writing. The prevalence of delayed dispensing decreased after a Minnesota law was enacted to preclude dispensing of opioid prescriptions more than 30 days after writing. Meaning These findings raise concerns that opioids prescribed by surgeons and dentists may sometimes be used for reasons or during a time frame other than that intended by the prescriber.

Ketamine use has increased recently for the management of acute and chronic pain. Ketamine can cause a variety of neuropsychiatric adverse effects, such as hallucinations, dysphoria, and nightmares. The objective of this study was to explore risk factors for the development of neuropsychiatric adverse effects in ketamine-treated pain. This was a retrospective, single-center cohort study of hospitalized patients who received low dose intravenous (IV) ketamine or oral ketamine for pain. Patients who had a neuropsychiatric adverse effect were compared to those who did not. One hundred and seventy-one patients were included, with 155 receiving IV ketamine and 16 receiving oral ketamine. Overall, 50 (29.2%) had a neuropsychiatric adverse effect and 26 (15.2%) required treatment discontinuation. No significant differences were found between patients who tolerated ketamine and those who did not. Patients who had an adverse effect were numerically less likely to receive benzodiazepines (28% vs 39.7%, p = 0.153), as were patients who required discontinuation of ketamine (23.1% vs. 41.4%, p = 0.08). In patients receiving ketamine for pain, predicting who may be more likely to experience neuropsychiatric adverse effects remains difficult. Further research is warranted to determine whether benzodiazepines are safe and effective for mitigating these adverse effects in this setting.

Buprenorphine possesses many unique attributes that make it a practical agent for adults and adolescents with opioid use disorder (OUD) and/or acute or chronic pain. Sublingual buprenorphine has been the standard of care for treating OUD, but its use in pain management is not as clearly defined. Current practice guidelines recommend a period of mild‐to‐moderate withdrawal from opioids before transitioning to buprenorphine due to its ability to displace full agonists from the μ‐opioid receptor. However, this strategy can lead to negative physical and psychological outcomes for patients. Novel initiation strategies suggest that concomitant administration of small doses of buprenorphine with opioids can avoid the unwanted withdrawal associated with buprenorphine initiation. We aim to systematically review the buprenorphine initiation strategies that have emerged in the last decade. Embase, PubMed, and Cochrane Databases were searched for relevant literature. Studies were included if they were published in the English language and described the transition to buprenorphine from opioids. Data were collected from each study and synthesized using descriptive statistics. This review included 7 observational studies, 1 feasibility study, and 39 case reports/series which included 924 patients. The strategies utilized between the literature included traditional initiation (47.9%), microdosing with various buprenorphine formulations (16%), and miscellaneous methods (36.1%). Traditional initiation and microdosing initiation were compared in the data synthesis and analysis; miscellaneous methods were omitted given the high variability between methods. Overall, 95.6% of patients in the traditional initiation group and 96% of patients in the microdosing group successfully rotated to sublingual buprenorphine. Initiation regimens can vary widely depending on patient‐specific factors and buprenorphine formulation. A variety of buprenorphine transition strategies are published in the literature, many of which were effective for patients with OUD, pain, or both.

Methadone is a long-acting synthetic opioid with wide interpatient variability in pharmacokinetic and pharmacodynamic parameters, which make it complicated to utilize. 1 McPherson ML Walker KA Davis MP et al. Safe and appropriate use of methadone in hospice and palliative care: expert consensus white paper. J Pain Sympt Manage. 2019; 57 (e4): 635-645https://doi.org/10.1016/j.jpainsymman.2018.12.001 Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar ,2 Smith MA Quirk KC Saul DC Rodgers PE Silveira MJ Comparing methadone rotation to consensus opinion. J Pain Symptom Manag. 2020; 59: 116-120https://doi.org/10.1016/j.jpainsymman.2019.09.014 Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar The problem of interpatient variability in drug response is not unique to methadone; in fact, interest in pharmacogenetics research to address variability in response to a number of different medications has been growing. 3 Relling MV Klein TE Gammal RS et al. The clinical pharmacogenetics implementation consortium: 10 years later. Clin Pharmacol Ther. 2020; 107: 171-175https://doi.org/10.1002/cpt.1651 Crossref PubMed Scopus (88) Google Scholar A recent Clinical Pharmacogenetics Implementation Consortium guideline for select opioid therapy found insufficient evidence to recommend routine use of genotype to guide methadone use at present. 4 Crews KR, Monte AA, Huddart R, et al. Clinical pharmacogenetics implementation consortium guideline for CYP2D6, OPRM1, and COMT genotypes and select opioid therapy. Clin Pharmacol Ther. 2021:110:888–896 doi:10.1002/cpt.2149. Google Scholar

Opioid tapering is an essential clinical tool to utilize for a variety of reasons, including safety and analgesic optimization. The need for individualized regimens reveals a corresponding need for healthcare providers who can actively manage patients throughout the process. Pharmacists have taken on an integral role for achieving success in opioid tapering. This survey was conducted to describe the current opioid tapering practices of pain and palliative care pharmacists. A Qualtrics survey was offered to the Society of Pain and Palliative Care Pharmacist members. The majority (87%) indicated they specialized in pain management. Almost all respondents (98%) reported providing tapering recommendations and 82% reported being involved with patient monitoring throughout the taper. The majority (multiple responses could be chosen) noted that the indication for initiating an opioid taper was due to abuse/misuse (91%), reduced overall efficacy (89%), and adverse drug reactions (78%). The most common follow-up intervals during tapering were weekly (15%), every 2 weeks (22%), and every 4 weeks (44%). This practice-based survey, though small, showed that pharmacists in pain management and palliative care are actively involved in opioid tapering. This survey will hopefully serve as a foundation for continuing research into opioid tapering and the pharmacist's role therein.

To improve the management of cancer related pain, the National Comprehensive Cancer Network (NCCN) publishes the Adult Cancer Pain guideline on an annual basis. However, a large majority of oncology patients still report inadequate pain control. Single-center, retrospective cohort study of adult patients admitted for uncontrolled pain or pain crisis between 3/1/19 and 06/30/20 were assigned to cohorts of either adherent or non-adherent to NCCN guideline recommendations for management of pain crises based on their initial opioid orders. Patients must have reported a pain score >/= 4 and received at least one dose of opioids within 24 hours upon admission. The length of stay (LOS), pain scores, and naloxone administration were compared between both groups. Patients in the adherent group had a shorter median LOS (3.7 days [range: 1 to 18.93] vs 5.4 days [range: 1.45 to 19.64 days], p = 0.04). Patients that received lower doses than recommended had longer LOS compared to adherent group (6.1 vs. 3.7 days; p = 0.009). When adjusted for confounders, this significance did not remain. The lowest reported pain score within 24 hours of admission was lower in the adherent group (median 3 vs 4, p = 0.04). Predictors of LOS included opioid tolerance and a pain or palliative care consult. Adherence to NCCN guidelines for acute pain crisis management in adult patients with cancer remains poor. Patients who received guideline adherent initial opioid regimens demonstrated a trend toward a shorter LOS. Opioid-tolerant patient outcomes remain inadequate; appropriate pain management for these patients need to improve.

Chronic overlapping pain conditions (COPCs) are a collection of chronic pain syndromes that often co-occur and are thought to share underlying nociplastic pathophysiology. Since they can manifest as seemingly unrelated syndromes they have historically been studied in isolation. Use of International Classification of Diseases (ICD) codes in medical records has been proposed as a means to identify and study trends in COPCs at the population level, however validated code sets are needed. Recently, a code set comprising ICD-10 codes as proxies for 11 COPCs was validated. The goal of this project was to validate a code set composed of ICD-9 codes for the identification of COPCs in administrative datasets. Data was extracted using the Electronic Medical Record Search Engine at the University of Michigan Health System from January 1st, 2011 to January 1st, 2015. The source population were patients with one of the candidate ICD-9 codes corresponding to various COPCs. Natural language searches were used as a reference standard. If code sets met a pre-specified threshold of agreement between ICD-9 codes and natural language searches (>= 70%), they were retained and diagnostic accuracy statistics were calculated for each code set. Validated ICD-9 code sets were generated for 10 of the 11 COPCs evaluated. The majority had high levels of diagnostic accuracy, with all but one code set achieving >= 80% specificity, sensitivity, and predictive values. This code set may be used by pain researchers to identify COPCs using ICD-9 codes in administrative datasets.

Abstract Purpose: Pain is experienced by over half of patients with cancer. Despite effective treatments being available, many patients with cancer related pain remain undertreated. Chronic overlapping pain conditions (COPCs) are recognized as a set of disorders in varying combinations. Cancer pain can effectively be treated with opioids; however, COPCs do not respond well to this treatment. The purpose of this study is to describe the prevalence of COPCs in adult patients with cancer. Methods: Patients with any new cancer diagnosis of any stage from 1/1/2020 to 11/1/2021 were included. All patients included were seen at Michigan Medicine and were over 18 years of age. The primary outcome was a diagnosis of a COPC, which were captured using validated ICD-10 codes and date of diagnosis. All data was collected through Data Direct and EMERSE and analyzed using descriptive statistics.Results: The final analysis included 2638 patients. Most patients had stage I cancer (44.3%), while 19.6% had metastatic disease. A COPC was diagnosed in 501 patients (19%). Of patients with COPCs, 69% were diagnosed before cancer, while 20% were diagnosed after cancer. Low back pain was the most common COPC (55.5%) followed by migraine (13.8%).Conclusion: We identified that 19% of patients with cancer also had COPCs, the majority were diagnosed before cancer. By identifying the prevalence of COPCs in patients with cancer we can develop studies evaluating if these patients have difference in quality-of-life outcomes related to pain or require different treatment pathways to optimize their pain management.

Sickle-cell disease (SCD) is an inherited hematologic disorder characterized by the presence of sickle-shaped red blood cells. 1 Brandow AM Carroll CP Creary S et al. American society of hematology 2020 guidelines for sickle cell disease: management of acute and chronic pain. Blood Adv. 2020; 4: 2656-2701https://doi.org/10.1182/bloodadvances.2020001851 Crossref PubMed Scopus (37) Google Scholar Misshapen red blood cells are rigid, which leads to occlusion of blood vessels resulting in tissue ischemia and pain. Pain can manifest as acute, intermittent episodes (vaso-occlusive crises [VOC]), chronic pain, or acute-on-chronic pain. 1 Brandow AM Carroll CP Creary S et al. American society of hematology 2020 guidelines for sickle cell disease: management of acute and chronic pain. Blood Adv. 2020; 4: 2656-2701https://doi.org/10.1182/bloodadvances.2020001851 Crossref PubMed Scopus (37) Google Scholar Buprenorphine is a semisynthetic opioid that has historically been used for opioid use disorder. Due to a unique receptor binding profile and favorable safety profile, including lower risk of tolerance and hyperalgesia, buprenorphine is increasingly recognized for its utility in chronic pain management, especially in complex cases. 2 Pergolizzi JV Raffa RB Safety and efficacy of the unique opioid buprenorphine for the treatment of chronic pain. J Pain Res. 2019; 12: 3299-3317https://doi.org/10.2147/JPR.S231948 Crossref PubMed Scopus (15) Google Scholar ,3 Irwin M Petersen KS Smith MA Rapid buprenorphine induction for cancer pain in pregnancy. J Palliat Med. 2020; (Published online December 4jpm.2020.0524)https://doi.org/10.1089/jpm.2020.0524 Crossref PubMed Scopus (3) Google Scholar Two small studies reported decreased healthcare utilization and daily opioid requirements in adults with chronic SCD pain transitioned from full opioid agonists to buprenorphine. 4 David M Carroll C Lauriello A Salzberg B Lanzkron S Assessing the safety and efficacy of converting adults with sickle cell disease from full agonist opioids to buprenorphine. Blood. 2018; 132: 856https://doi.org/10.1182/blood-2018-99-111435 Crossref Google Scholar ,5 Osunkwo (ify), I Veeramreddy P Arnall J et al. Use of buprenorphine/naloxone in ameliorating acute care utilization and chronic opioid use in adults with sickle cell disease. Blood. 2019; 134: 790https://doi.org/10.1182/blood-2019-126589 Crossref Google Scholar Another case series of two adolescents with chronic SCD pain described rotation to buprenorphine with improved functionality and decreased opioid requirements. 6 Buchheit BM Joslin T Turner HN Wong TE Ambulatory microdose induction of buprenorphine-naloxone in two adolescent patients with sickle cell disease. Pediatr Blood Cancer. 2020; (Published online October 27)https://doi.org/10.1002/pbc.28766 Crossref PubMed Scopus (4) Google Scholar Literature on buprenorphine for pain in pediatric patients is sparse in general and practically nonexistent for pediatric chronic SCD pain. 7 Quirk K Wright J Marks A Smith MA. Sublingual buprenorphine for pediatric cancer pain: a case report and review of the literature. J Pain Symptom Manage. 2020; 60: 1055-1058https://doi.org/10.1016/j.jpainsymman.2020.07.029 Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar Here, we report buprenorphine induction for chronic pain in a pediatric patient with SCD.