Patients taking buprenorphine for opioid substitution

Buprenorphine is used in opioid substitution programs to reduce craving and suppress withdrawal symptoms. When used for opioid substitution, buprenorphine is administered as a long-acting injection or as a sublingual tablet in coformulation with naloxone (an opioid antagonist). The coformulation with naloxone aims to reduce parenteral abuse of buprenorphine because naloxone has little clinical effect when used sublingually, but when injected it can precipitate opioid withdrawal; however, parenteral abuse still occurs.

Acute pain in patients taking buprenorphine for opioid substitution should be managed similarly to opioid-tolerant patients, see here for management advice.

If a patient on buprenorphine presents with acute pain, contact the patient’s buprenorphine provider or dispensing pharmacist to verify the dose and discuss management plans. Patients on opioid substitution programs may be concerned about relapse if additional opioids are administered. Effective communication and planning are essential. Consider early consultation with an acute pain service for patients in hospital.

If additional opioids are required to manage moderate or severe acute pain, continue the patient’s usual buprenorphine dose and add an immediate-release opioid on an ‘as-required’ basis—patient-controlled analgesia (PCA) may be useful. Buprenorphine does not negate the effect of other opioids used for acute pain management; it may even reduce the doses of additional opioid required. Liaise with the patient’s buprenorphine provider regarding resumption of dosing on discharge.