New Dosing Guide Will Maximize Buprenorphine Benefit Without Putting Patients at High Risk of Addiction

Amy Case, MD, FAAHPM

A team at Roswell Park Comprehensive Cancer Center have developed clinical recommendations to help clinicians appropriately prescribe buprenorphine, a schedule III opioid, for chronic pain associated with cancer or cancer treatments.¹ The resource, which was compiled after researchers conducted a comprehensive literature review, was recently published in Current Treatment Options in Oncology.²

Currently, there is little standardized guidance regarding buprenorphine use for chronic pain management. However, the review article presents clinicians with appropriate dosing conversions to help patients switch to buprenorphine from traditional opioid.

“In the age of the opioid epidemic, there is demand for an analgesic that has less abuse potential and adverse side effects compared with other opioids,” explained Amy Case, MD, FAAHPM, the Lee Foundation Endowed Chair of Palliative and Supportive Care and Palliative Care Program Chief at Roswell Park, in a press release. “Buprenorphine is an opioid with less potential for abuse and a lower risk of adverse effects such as sedation or cognitive impairment, but few palliative care providers are well versed in this drug.”

The conversion chart outlines appropriate buprenorphine dosing compared with the oral morphine equivalent (OME) per 24 hours. The chart also outlines whether the opioid should be administered via transdermal (TD) patch, buccal patch, or sublingual (SL) tabs, and when the change in administration strategy becomes appropriate.

Notably, buprenorphine has become a favorable first-line opioid option in recent years due to its association with less cognitive impairment, falls, sexual dysfunction, and sarcopenia compared with schedule II opioids. While the agent is effective in improving mood and euphoria, the drug is also believed to be less likely to induce misuse.

Furthermore, opioids are a common method of treating cancer-related pain, but they are also associated with a high risk of misuse disorders. This has become especially apparent in New York, where opioid overdose has been identified as the leading cause of accidental death.³ The development of this guide is intended to help practitioners navigate the unique challenges that managing chronic pain presents.

Buprenorphine has been an available pain management treatment in the United States since 1981, when it was available as an injectable schedule pain reliever in accordance with the Controlled Substances Act. By 2002, the drug was approved as a sublingual (applied under the tongue) and reclassified as a schedule III drug.

A transdermal buprenorphine patch was approved in 2010 and by 2019, the US Department of Health and Human Services developed a new set of pain guidelines that support the use of buprenorphine as the preferred first-line opioid option.

Buprenorphine is an approved treatment in over 40 countries, and currently, it is typically selected as a second- or third-line treatment option. In addition, the agent is often chosen as a maintenance or discontinuation therapy among patients who need assistance with opioid misuse disorder. Yet while a limited number of patients receive this treatment as a frontline option, 85% of patients who received it reported good or very good pain control, highlighting its potential efficacy.

“The drug’s unique pharmacological properties make it an attractive first-line opioid for chronic pain, especially in older patients, as it results in less sedation or cognitive impairment when compared with other opioids, reducing the risk of confusion or falls,” Case concluded. “The popularity of using buprenorphine for analgesia continues to grow over time and with practice; This drug should be considered as an excellent and safe option for the management of acute and chronic pain.”

References

1. Roswell Park experts highlight evidence on a safe, effective, less-addictive opioid: buprenorphine. Roswell Park. News release. February 1, 2022. Accessed February 7, 2022. https://bit.ly/3oSA7oj
2. Case AA, Kullgren J, Anwar S, et al. Treating chronic pain with buprenorphine—the practical guide. Curr Treat Options in Oncol. 2021;22(116). doi:10.1007/s11864-021-00910-8.
3. Prevent Overdose. NYC Health. Accessed February 10, 2022. https://on.nyc.gov/3LnxTqo