Non-opioid medications in combination with non-pharmacologic interventions are preferred for treatment of chronic pain. However, when treatment with opioids is indicated, buprenorphine may be preferred over full agonist opioids (i.e. heroin, fentanyl, oxycodone, hydrocodone, morphine) due to a unique mechanism of action and safety profile. Buprenorphine is an opioid partial-agonist, meaning it can be used to treat pain but has lower risk of causing euphoria, respiratory depression, or accidental overdose than other opioids. This is because buprenorphine has a ceiling effect, which means that after a certain point taking more medicine will not increase the effects. Buprenorphine can also be used to treat opioid use disorder (OUD).
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Buprenorphine comes in many different formulations. It can be used in the cheek (buccal), as a skin patch (transdermal), under the tongue (sublingual) or by injection. Some formulations are indicated for the treatment of chronic pain and others are for treatment of OUD. Naloxone is combined with buprenorphine to discourage misuse by injection in formulations that are taken daily to treat OUD.
Buprenorphine buccal film (Belbuca®):
• Used for chronic pain
• Apply film to check mucosa every 12 hours
• Lick inside of cheek or rinse with water if mouth is dry to moisten the area
• Avoid eating, drinking acidic beverages, and using toothpaste or mouthwash 30 minutes before, during, or 30 minutes after application
Buprenorphine transdermal patch (Butrans®):
• Used for chronic pain
• Change patch and rotate site every 7 days
• Apply to clean, dry, nearly hairless skin on upper chest, upper back, side of chest, upper outer arm
• Do not cut patch
Buprenorphine/naloxone sublingual tablets or films (Suboxone®) :
• Used to treat OUD, concomitant OUD and pain, or off-label for just pain
• Avoid swallowing because that results in less medication being absorbed
• Buprenorphine can cause opioid withdrawal if used too soon after taking a full agonist opioid (i.e. heroin, fentanyl, oxycodone, hydrocodone, morphine), so it is important to wait and start buprenorphine once withdrawal symptoms have begun
Buprenorphine long acting injection (Sublocade®) :
• Used to treat OUD
• Can be used after using sublingual buprenorphine 8-24 mg/day for at least 7 days
• Used when daily dosing is difficult or risky, or if there is concern for misuse or insufficient response to sublingual formulation
If chronic pain is severe and warrants opioid therapy, buprenorphine may be the preferred medication. If you or someone you care about has opioid use disorder know that medications, like buprenorphine, are the gold-standard treatment for patients with OUD. Buprenorphine saves lives, reduces illicit opioid use and opioid cravings, and improves engagement in treatment and well-being. Talk to your doctor about the risks and benefits of buprenorphine products.
Sources:
- Substance Abuse and Mental Health Services Administration https://www.samhsa.gov/medication-assisted-treatment/medications-counseling-related-conditions/buprenorphine
- Webster L, Gudin J, Raffa RB, et al. Understanding Buprenorphine for Use in Chronic Pain: Expert Opinion. Pain Medicine. 2020;21(4):714-72
- American Society of Addiction Medicine. The ASAM national practice guideline for the treatment of opioid use disorder: 2020 focused update. Rockville, MD: American Society of Addiction Medicine;2020.
- VA/DoD clinical practice guideline for opioid therapy for chronic pain. VA/DoD. 2017;Version 3.0:1-19
