How to manage acute pain in a patient on buprenorphine (partial opioid agonist) at home?

Managing Acute Pain in Patients on Buprenorphine at Home

Continue the patient's buprenorphine at the current dose and add short-acting full opioid agonists at higher-than-usual doses with scheduled (not as-needed) dosing, combined with aggressive multimodal non-opioid analgesia. 1, 2

Core Management Strategy

Continue Buprenorphine Maintenance

• Do not discontinue buprenorphine for patients on home therapy, as this places them at high risk for relapse to opioid use disorder and creates difficulty transitioning back after acute pain resolves 2
• Verify the patient's current buprenorphine dose with their prescribing physician or treatment program 1
• Reassure the patient explicitly that their maintenance therapy will not be interrupted and that adequate pain control will be achieved 1, 3

Add Full Opioid Agonists for Breakthrough Pain

• Use short-acting opioids (morphine, oxycodone, hydromorphone) in addition to—not instead of—the buprenorphine maintenance dose 1
• Prescribe significantly higher doses than for opioid-naive patients due to cross-tolerance and buprenorphine's high receptor affinity 1, 4
• Write orders for scheduled continuous dosing rather than as-needed to prevent pain recurrence and reduce patient anxiety 1, 3
• Avoid mixed agonist-antagonist opioids (pentazocine, nalbuphine, butorphanol) as they may precipitate acute withdrawal 1, 5

Alternative Approach: Divided Buprenorphine Dosing

For mild-to-moderate pain, consider dividing the daily buprenorphine dose into every 6-8 hour administration to leverage its analgesic properties 1, 5

• Example: If taking 16 mg daily, give 4 mg every 6 hours 1
• May need to add 5-10% to afternoon/evening doses (10-20% total daily increase) 3, 5
• This approach takes advantage of buprenorphine's shorter analgesic duration (6-8 hours) compared to its longer half-life for preventing withdrawal 3, 5
• Additional short-acting opioids may still be required even with divided dosing 1

Multimodal Non-Opioid Analgesia (Essential Component)

• NSAIDs and acetaminophen should be maximized as first-line adjuncts 1, 3
• Consider adjuvant analgesics such as gabapentinoids or tricyclic antidepressants 3
• Avoid fixed-dose acetaminophen/opioid combinations in patients requiring high opioid doses due to hepatotoxicity risk 3, 5

Critical Safety Monitoring

• Have naloxone immediately available at home or in the treatment setting 1
• Monitor level of consciousness and respiratory rate frequently, especially when initiating or escalating opioid doses 1, 3, 5
• Be aware that if buprenorphine is discontinued, patients become acutely sensitive to full agonist opioids with increased risk of respiratory depression for at least 72 hours 4

Coordination and Communication

• Notify the patient's buprenorphine prescriber or treatment program about the acute pain episode and any controlled substances prescribed 1
• Inform them that additional opioids may appear on routine urine drug screening 1
• Establish clear agreements about pill quantities, frequency of use, and expected treatment duration 5

Common Pitfalls to Avoid

• Do not under-treat pain due to fear of addiction relapse or "drug-seeking" behavior—patients on buprenorphine legitimately require higher opioid doses 1, 3
• Do not confuse pseudo-addiction (pain-driven drug-seeking) with true addiction 1
• Do not allow pain to recur before the next scheduled dose, as this increases suffering and erodes the therapeutic relationship 3
• Do not wait for buprenorphine "washout" in the outpatient setting—this is impractical and dangerous for relapse risk 6, 2

When Hospitalization May Be Needed

For severe acute pain (trauma, major injury) that cannot be adequately controlled at home despite the above measures, hospitalization allows for:

• Patient-controlled analgesia (PCA) with higher opioid doses 6, 4
• Regional anesthesia techniques (nerve blocks, catheters) 1, 6
• Temporary conversion to methadone (30-40 mg daily) which binds less tightly to receptors and allows better response to additional opioids 1
• Intensive monitoring for respiratory depression 1