Buprenorphine for Chronic Pain

Buprenorphine can be initiated as an initial therapy or can be switched from another form of long-term opioid therapy for individuals with chronic pain that cannot be managed by non-opioid medications.

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

Buprenorphine is recommended as an initial therapy for chronic pain that is inadequately managed by non-opioid medications. Buprenorphine for chronic pain is appropriate for individuals who have never been on opioids and those who are already on other forms of long-term opioid therapy. Buprenorphine formulations approved for the treatment of pain are not recommended for individuals with co-occurring chronic pain and OUD.

Determining when to initiate buprenorphine is an important factor to consider when transitioning patients from full agonist opioids. The American Society of Addiction Medicine (ASAM) clinical guidelines recommend patients should be in mild to moderate withdrawal (as assessed using the Clinical Opiate Withdrawal Scale) from full agonist opioids before their initial buprenorphine dose. This typically occurs 8-12 hours after the last dose of short-acting full agonist opioids or 12-24 hours after the last dose of long-acting opioids.

An alternative transitioning method is emerging in more recent research: low-dose initiation for individuals currently on full agonist long-term opioid therapy. The goal of low-dose initiation is to minimize withdrawals while providing adequate pain relief. In a case series study reporting the switch from high-dose, long-term opioid therapy to buprenorphine among patients experiencing chronic pain, clinician researchers describe a dosing regimen where full agonist opioids are used in conjunction with buprenorphine to ultimately pivot patients to only buprenorphine over the course of several days. Case reports demonstrate that individuals successfully made the switch to buprenorphine from other opioids in outpatient settings using this method. These findings align with a growing body of literature that diverges from the ASAM guidelines in favor of patient-centered “overlapping” dosing strategies.