Buprenorphine for Chronic Pain

Buprenorphine can be used for individuals who experience chronic pain severe enough to require around-the-clock, long-term opioid treatment when alternative treatments are inadequate.

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

The FDA has approved certain buprenorphine formulations for chronic pain severe enough to require around-the-clock, long-term opioid treatment when alternative treatments are inadequate. Most evidence on the use of buprenorphine for chronic pain focuses on individuals aged 18 and older who experience chronic pain for more than six months. Buprenorphine has been investigated for the treatment of pain in individuals who have never used opioids to manage pain and those who have tried or are actively using long-term opioid treatment. Ideal candidates for buprenorphine include individuals with inadequate pain relief from non-opioid analgesic medication and/or one or more of the following criteria:

  • Inadequate pain relief with current opioid regimen
  • Complex persistent opioid dependence
  • History of opioid overdose
  • Accompanying use of other sedatives
  • Comorbid respiratory disease
  • Comorbid renal disease
  • Comorbid non-opioid substance use or substance use disorder

Buprenorphine is an attractive option among opioid therapies for individuals with renal disease, as there is less risk of accumulation in the renal system relative to other opioids. This lowers the risk for adverse events related to buprenorphine accumulation, including respiratory inhibition, central nervous system depression, seizures, hypotension, and death.

Buprenorphine is not recommended for use in pregnant individuals, but can be used if alternative therapies are not viable. Compared to methadone, buprenorphine use during the first trimester of pregnancy was associated with fewer congenital malformations overall. Buprenorphine is detected in the breast milk of nursing mothers on treatment, so infants should be monitored.