Buprenorphine Low-Dose Initiation to Decrease Total Opioid Use in Patients with Cancer and Non-Cancer-Related Pain

Outcomes 1. Identify patients who would benefit from a trial of buprenorphine low-dose initiation.2. Review approaches to performing a buprenorphine low-dose initiation to decrease total opioid use in patients with cancer and non-cancer-related pain. Key Message Buprenorphine low-dose initiation is a novel approach that harnesses the unique pharmacological profile of this partial-opioid agonist to reduce both risk of precipitated opioid withdrawal and need for prolonged opioid tapers in vulnerable patients. Background Buprenorphine low-dose initiation is a novel approach that harnesses the unique pharmacological profile of this partial-opioid agonist to reduce both risk of precipitated opioid withdrawal and need for prolonged opioid tapers in vulnerable patients (1). Case A 65-year-old man with metastatic bladder cancer and significant non-cancer-related orthopedic spine concerns is followed in the palliative care clinic for both cancer and non-cancer-related pain. He was being treated with a multimodal pharmacologic approach, involving opioid therapy (hydromorphone 8mg every 4 hours), neuropathic agents (amitriptyline and pregabalin), muscle relaxants (baclofen), and anti-inflammatory agents (celecoxib). With this, he had recently noted improvement in his pain level and had a desire to wean opioids due to bothersome side-effects of fatigue, cognitive fogging, and occasional myoclonus. Given his chronic opioid use, a rotation to buprenorphine was performed using a low-dose initiation protocol with subutex (buprenorphine tablets). The patient successfully weaned his opioid use from 48mg oral hydromorphone daily to 12mg oral subutex with resolution of his opioid side-effects. Conclusion Buprenorphine low-dose initiation involves adding increasing low-dose formulations of buprenorphine to an amount where the opioid receptors are nearly fully occupied, then reducing the frequency and dose of full-agonist opioids. In patients with both chronic non-cancer-related and cancer-related pain, this strategy can provide relief from opioid-related side effects, while still achieving good pain control. Evidence supports the use of buprenorphine rotation to reduce chronic pain, without precipitating opioid withdrawal or other serious adverse side effects (2). Keywords Managing Suffering and Distress / Pharmacotherapeutics / Pharmacopalliation