The role of buprenorphine in patients with opioid use disorder in need of acute or chronic pain management

Tanya J Uritsky; Benjamin A Miskle; Lee A Kral

doi:10.1093/ajhp/zxaf293

The purpose of this review is to summarize and apply existing literature to acute and chronic pain management for patients using buprenorphine for opioid use disorder (OUD).PURPOSEThe purpose of this review is to summarize and apply existing literature to acute and chronic pain management for patients using buprenorphine for opioid use disorder (OUD).Pain management in patients taking buprenorphine for OUD presents many challenges for clinicians. Buprenorphine has unique pharmacological properties compared to full μ-opioid receptor agonists, including a strong affinity for and slow dissociation from the μ opioid receptor. Patients using buprenorphine have more pain than those not utilizing chronic opioid therapy, as occurs with most chronic opioid use. This may be due to the development of tolerance or hyperalgesia or may be part of the OUD process. Management of chronic pain should be approached the same as with any patient, focusing on nonpharmacological and nonopioid therapies, as opioid therapies have been shown to have very little efficacy for chronic pain. Management of acute pain is based on maintaining a stable dose of buprenorphine and supplementing with full μ-opioid receptor agonists, nonopioid analgesics, and nonpharmacological therapies. Transitioning to buprenorphine, in either the inpatient or outpatient setting, can be done with standard, low-dose, or high-dose induction based on the clinical situation. Transitions to and from the acute care setting require extensive communication and are enhanced by multidisciplinary teams.SUMMARYPain management in patients taking buprenorphine for OUD presents many challenges for clinicians. Buprenorphine has unique pharmacological properties compared to full μ-opioid receptor agonists, including a strong affinity for and slow dissociation from the μ opioid receptor. Patients using buprenorphine have more pain than those not utilizing chronic opioid therapy, as occurs with most chronic opioid use. This may be due to the development of tolerance or hyperalgesia or may be part of the OUD process. Management of chronic pain should be approached the same as with any patient, focusing on nonpharmacological and nonopioid therapies, as opioid therapies have been shown to have very little efficacy for chronic pain. Management of acute pain is based on maintaining a stable dose of buprenorphine and supplementing with full μ-opioid receptor agonists, nonopioid analgesics, and nonpharmacological therapies. Transitioning to buprenorphine, in either the inpatient or outpatient setting, can be done with standard, low-dose, or high-dose induction based on the clinical situation. Transitions to and from the acute care setting require extensive communication and are enhanced by multidisciplinary teams.It is imperative that providers be knowledgeable about buprenorphine and how to optimize it for OUD as well as pain. Pain management with buprenorphine can be tailored to the patient and clinical situation, but any therapeutic plan must contain a holistic approach and involve extensive communication that includes the patient and all relevant providers to achieve safe and effective care.CONCLUSIONIt is imperative that providers be knowledgeable about buprenorphine and how to optimize it for OUD as well as pain. Pain management with buprenorphine can be tailored to the patient and clinical situation, but any therapeutic plan must contain a holistic approach and involve extensive communication that includes the patient and all relevant providers to achieve safe and effective care.

The role of buprenorphine in patients with opioid use disorder in need of acute or chronic pain management

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