What is the recommended use and dosage of buprenorphine for opioid use disorder and chronic pain management?

Buprenorphine Dosage and Use for Opioid Use Disorder and Chronic Pain Management

For opioid use disorder, buprenorphine should be dosed at 16 mg daily as the target dose (range 4-24 mg), while for chronic pain management, dosing ranges of 4-16 mg divided into 8-hour doses (every 6-8 hours) have shown benefit in patients with chronic noncancer pain. 1, 2

Buprenorphine for Opioid Use Disorder

Formulations and Induction

• Buprenorphine is available as sublingual tablets, sublingual films, and 6-month implants approved for treating opioid use disorder; transdermal patches are approved for chronic pain 1
• Induction should begin only when objective signs of moderate opioid withdrawal appear:
  • For short-acting opioids (e.g., heroin): not less than 4 hours after last opioid use 2
  • For long-acting opioids (e.g., methadone): generally not less than 24 hours after last use 2
• Initial dosing on day 1 can be given in 2-4 mg increments, with studies showing 8 mg on day 1 and 16 mg on day 2 2

Maintenance Dosing for OUD

• The recommended target dosage is 16 mg as a single daily dose 2
• Maintenance dose range is generally 4-24 mg daily depending on individual patient needs 2
• Higher doses up to 32 mg/day have shown improved outcomes in recent research, including:
  • Decreased opioid use (68.5% at 24 mg vs 59.5% at 32 mg)
  • Reduced frequency of use per week
  • Fewer physiologic triggers for use
  • Better treatment retention (78.7% at 32 mg vs 50.0% at 24 mg) 3
• There is no maximum recommended duration of maintenance treatment; patients may require treatment indefinitely 2

Buprenorphine for Chronic Pain Management

Dosing Strategy

• For chronic pain, buprenorphine should be dosed in divided doses (every 6-8 hours) 1
• Dosing ranges of 4-16 mg divided into 8-hour doses have shown benefit in chronic noncancer pain 1
• In a study of 95 individuals with chronic noncancer pain, patients experienced moderate to substantial relief with improved functioning and mood using daily sublingual buprenorphine ranging from 4-16 mg (mean 8 mg) in divided doses 1

Management Options for Inadequate Pain Control

1. First step: Increase the dosage of buprenorphine in divided doses 1
2. Consider switching from buprenorphine/naloxone to buprenorphine transdermal formulation alone 1
   • Transdermal formulation bypasses 90% first-pass hepatic metabolism of sublingual forms 1
   • May provide better analgesia compared to tablet or film formulation 1
3. If maximal dose of buprenorphine is reached, add an additional long-acting potent opioid (fentanyl, morphine, or hydromorphone) 1
4. For inadequate response to usual doses of additional opioids, consider higher doses of the additional opioid 1
   • Note: Buprenorphine's high binding affinity for μ-opioid receptors may prevent lower doses of other opioids from accessing the receptor 1
5. For patients on buprenorphine maintenance with persistently inadequate analgesia despite the above strategies, consider transitioning from buprenorphine to methadone maintenance 1

Unique Properties of Buprenorphine

• Partial opioid agonist with high binding affinity for μ-opioid receptors 1
• Ceiling effect on respiratory depression but not necessarily on analgesia, making it safer than full opioid agonists 1, 4
• High affinity and slow dissociation provide analgesia over a long period 1
• May be associated with less cognitive impairment, falls, sexual dysfunction, and sarcopenia compared to schedule II opioids, making it potentially preferable for elderly patients 4
• Lower risk of misuse and euphoria compared to full opioid agonists 4

Important Considerations and Caveats

• Buprenorphine sublingual tablets without naloxone are preferred only for induction; buprenorphine/naloxone combinations are preferred for maintenance due to lower abuse potential 2
• Buprenorphine may pose challenges during acute pain episodes due to its blocking effect on other opioids 1
• When managing acute pain in patients on buprenorphine, a multidisciplinary approach and multimodal analgesic strategies are essential 5
• Side effects (headache, constipation) may be more pronounced at higher doses 1
• Prescription of buprenorphine for opioid use disorder requires providers to meet qualifying requirements under the Drug Addiction Treatment Act 2