Can additional doses of buprenorphine (BID: twice a day) be given for breakthrough pain?

Can Additional Doses of Buprenorphine Be Given for Breakthrough Pain?

Yes, the initial approach for breakthrough pain in patients on BID buprenorphine is to increase the total daily dose and divide it into more frequent dosing intervals (every 6-8 hours) to leverage buprenorphine's analgesic properties. 1, 2

Primary Strategy: Divided Dosing of Buprenorphine

• Divide the existing daily buprenorphine dose into 6-8 hour intervals rather than BID dosing to provide continuous analgesic coverage 1, 2
• For example, if a patient takes 32 mg daily (16 mg BID), redistribute this as 8 mg every 6 hours 1
• Dosing ranges of 4-16 mg divided into 8-hour intervals have demonstrated benefit for chronic noncancer pain 1, 2
• This approach takes advantage of buprenorphine's analgesic properties while maintaining opioid use disorder treatment 1, 3

Stepwise Escalation for Inadequate Pain Control

Step 1: Increase Total Buprenorphine Dose

• If divided dosing alone is insufficient, increase the total daily buprenorphine dose (strong recommendation) 1, 2
• This is the first-line intervention before considering other opioids 1, 2

Step 2: Add Adjuvant Therapies

• For mild-to-moderate breakthrough pain, use adjuvant therapy appropriate to the pain syndrome (strong recommendation) 1, 2
• Options include NSAIDs, acetaminophen, gabapentinoids, topical agents, and non-pharmacologic treatments 1, 2, 4
• These should be used concurrently with optimized buprenorphine dosing 4

Step 3: Add Short-Acting Opioids (With Caution)

• For acute exacerbations or breakthrough pain in patients at low risk for opioid misuse, small amounts of short-acting opioid analgesics can be prescribed 1, 2
• Critical caveat: Higher than usual doses of full agonist opioids may be required due to buprenorphine's high binding affinity blocking μ-opioid receptors 1, 2
• Providers and patients should agree on the number of pills dispensed, frequency of use, and expected duration 1
• Continue baseline buprenorphine while adding the short-acting opioid 1, 3

Step 4: Consider Transdermal Formulation

• Switch from sublingual buprenorphine/naloxone to buprenorphine transdermal patch alone (weak recommendation) 1, 2
• The transdermal formulation provides steady-state analgesia and may be better tolerated 2, 4, 5

Step 5: Add Long-Acting Potent Opioids

• If maximal buprenorphine dose is reached with inadequate pain control, add a long-acting potent opioid such as fentanyl, morphine, or hydromorphone 1, 2
• If usual doses are ineffective, closely monitored trials of higher doses may be necessary due to receptor competition 1

Step 6: Transition to Methadone

• For patients with persistent inadequate analgesia despite all above strategies, transition from buprenorphine to methadone maintenance 1, 2
• This is the final step when all other options have failed 1, 2

Important Clinical Considerations

Monitoring and Safety

• Naloxone should be available and level of consciousness and respiration should be frequently monitored when combining buprenorphine with full agonist opioids 1
• Caution is required if buprenorphine is abruptly discontinued after adding full agonists, as increased sensitivity to sedation and respiratory depression can occur 1

Coordination of Care

• Contact the patient's buprenorphine prescriber before making changes to their regimen 3, 4
• Establish clear expectations about pain control and the analgesic plan 4

Common Pitfall to Avoid

• Do not discontinue buprenorphine for breakthrough pain management in patients with opioid use disorder, as this places them at high risk for relapse 3, 4
• The evidence supports continuation of buprenorphine with multimodal analgesia rather than cessation 3, 4