Intervention
Barriers and facilitators (sometimes called "contextual determinants") are factors that make it harder or easier to implement buprenorphine for chronic pain. These factors span multiple levels. Click the buttons on the left to read more about common barriers and facilitators for buprenorphine for chronic pain. In addition, view the RASC guides on Contextual Determinants Affecting Implementation and the Inventory of Factors Affecting Successful Implementation and Sustainment (IFASIS) to learn practical ways to assess these constructs.
Lack of awareness around the efficacy and use of buprenorphine for chronic pain creates barriers to the use of the intervention, but increased provider awareness can help mitigate these barriers.
Barriers
Although strong evidence supports buprenorphine’s use as a pain-reliever, it is often perceived by both providers and care recipients as weaker than other opioids (e.g., oxycodone, morphine). This misperception may stem from its partial agonist status (seen as inferior), its ceiling effect (misunderstood as meaning “limited pain relief”), and its association with OUD treatment and not pain.
In addition to its high opioid receptor affinity that can precipitate withdrawals, there are challenges in transitioning individuals to buprenorphine from other forms of long-term opioid therapy. These methods involve careful opioid tapering or overlapping dosing between buprenorphine and other opioids, which not all providers are adequately trained in.
Few buprenorphine formulations are officially FDA-approved for pain (e.g., Butrans, Belbuca). Others, like Suboxone or generics, are labeled for OUD only, even though they provide pain relief. Off-label use of OUD formulations for pain may create legal or regulatory concerns for providers.
Pain formulations of buprenorphine have fixed-dose increments, slow titration schedules, and limitations for acute or breakthrough pain. Skin patches have a delayed onset, can be difficult to titrate, and can lead to skin irritation. The dissovable films require careful placement and patient adherence to strict dosing schedules. Finally, there are no rapid-onset or “as needed” versions, limiting the use of buprenorphine in managing fluctuating or breakthrough pain.
Facilitators
Consistent high-quality evidence demonstrates that buprenorphine offers pain relief that is as effective as other, full agonist opioids such as morphine, fentanyl, and oxycodone. Some studies have even demonstrated greater pain reductions in individuals receiving buprenorphine relative to other opioids. Low-quality evidence also suggests that successful transition to buprenorphine from full agonist opioids is associated with improved pain.
Providers who view buprenorphine as an effective alternative to other opioid therapies for chronic pain management were more likely to plan to prescribe buprenorphine for pain in the future.
Though transitioning to buprenorphine from other opioids may be challenging for some providers to manage, there are several methods that have documented successes in the literature that providers can use to achieve a safe transition. These options include discontinuing current opioids altogether and waiting for mild withdrawals prior to initiating buprenorphine, a low-dose initiation method that allows for the introduction of buprenorphine alongside the existing opioid regimen, and a bridging method that tapers the current opioid regimen down prior to introducing buprenorphine. The existence of several well-documented methods may allow provider adherence to a strategy that best fits their care setting and the needs of the individual care recipient.