Buprenorphine for Chronic Pain

Cost, limited supply and availability, and provider bias are all documented barriers to the fair and effective implementation of widespread buprenorphine use for chronic pain across different populations.

Buprenorphine for Chronic Pain — Evidence Rating: Moderate Quality

Buprenorphine is an FDA-approved medication for the treatment of chronic pain that can be prescribed from a clinician’s office and filled at a pharmacy. Research data supporting the effectiveness of buprenorphine come from multiple randomized clinical trials and observational studies demonstrating that buprenorphine can reduce pain comparable to full agonist opioids, and offers a safer alternative to full agonist opioids with notably reduced likelihood of severe adverse events, including fatal overdose. While short-term analgesic efficacy is well documented, evidence for benefit beyond 16 weeks of treatment is lacking, as most trials do not extend past 16 weeks. Buprenorphine remains underutilized in the chronic pain management world largely due to a lack of comfort around prescribing and management practices for both care recipients and providers. Several considerations to bolster appropriate buprenorphine utilization for chronic pain are discussed in this evidence-based practice guide.

Evidence-based Scale

Individuals who are uninsured or underinsured can benefit from the use of lower-cost generic medications, which are less available for buprenorphine relative to other full agonist opioids. Further, Medicaid coverage and insurance policy variation create an uneven landscape for financial access geographically.

Pharmacies and providers can also limit the scaling up of buprenorphine due to stigma, fear of DEA intervention, and inadequate prescriber training. Pharmacies are subject to wholesaler limits on the amount of buprenorphine they can keep in stock, which can especially impact those in low-income or rural areas. DEA audits can be triggered by pharmacies or prescribers increasing amounts of buprenorphine ordered or distributed, disincentivizing switching individuals from higher-risk opioids to buprenorphine.

Finally, providers can perpetuate unequal access to buprenorphine via differential treatment of certain minority populations inaccurately perceived to be experiencing lesser degrees of pain or being at higher risk for opioid misuse. Improving the objectivity of pain assessment and treatment can further fair access to buprenorphine across marginalized populations.