Consider Buprenorphine for Chronic Pain in Some Patients

You’ll see growing interest in buprenorphine (Belbuca, Butrans, etc) for chronic pain...partly to reduce opioid risks.

Buprenorphine is a partial agonist at mu-opioid receptors...and an ANTagonist at other opioid receptors.

That’s why it seems to hit a ceiling that limits respiratory depression...may cause less euphoria compared to full opioid agonists (morphine, etc)...and may have less potential for misuse.

Plus buprenorphine seems similarly effective to other opioids.

But buprenorphine can still be misused...or lead to overdose.

For chronic noncancer pain, continue to emphasize NON-opioids, physical therapy, etc. See our toolbox, Appropriate Opioid Use.

If an opioid is needed, consider starting with or switching to buprenorphine when a full opioid agonist may not be a good fit.

For example, think of buprenorphine for a patient with chronic pain at risk of respiratory depression due to COPD...or a patient with chronic pain AND opioid use disorder.

Carefully choose products in your e-Rx pick list to avoid mix-ups.

Belbuca BID buccal films or Butrans weekly patches are dosed in MICROgrams. Lean toward these for patients who are opioid-naive or on lower opioid doses.

Sublingual buprenorphine/naloxone (Suboxone, etc) combos are dosed in MILLIgrams. Reserve these for cases where a higher opioid dose is needed...such as patients who also have opioid use disorder.

Also weigh cost and payer coverage. Belbuca or Butrans costs about $400/month or more versus about $200 for generic buprenorphine/naloxone.

When switching to Belbuca or Butrans, product labels say to taper the current avoid precipitating withdrawal.

If that’s not practical, consider stopping the current opioid in the PM and starting buprenorphine the next AM. Think of adding meds to manage withdrawal (clonidine, etc) for a few days when switching.

Keep in mind, you don’t need an “X” DEA number to prescribe buprenorphine for pain alone...only when using it for opioid use disorder. Consider adding the ICD-10 code to the limit pharmacy callbacks.

Continue to provide rescue naloxone.

Use our FAQ, Buprenorphine for Chronic Pain, for more dosing and switching guidance...and how to manage acute or breakthrough pain.

Key References
  • Pain Med. 2020 Apr 1;21(4):714-723
  • Pain Med. 2021 May 21;22(5):1109-1115
  • Pain Med. 2020 Dec 25;21(12):3691-3699
  • JAMA. 2016 Apr 19;315(15):1624-45
  • Medication pricing by Elsevier, accessed Oct 2021
Prescriber's Letter. November 2021, No. 371106

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