Sublingual buprenorphine can be a safe and effective therapy for chronic pain if used properly. The process of switching from the current therapy depends on its half-life.
Patient selection: long-acting opioid (fentanyl patch, methadone)
NOTE: If the following process is not done properly, then acute opioid withdrawal may occur. A person not trained in the process should seek guidance from someone who has been trained.
Step 1: Preparation
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Fentanyl Patch
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Action
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<= 75 µg/h
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proceed to bridging
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> 75 µg/h
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taper by 12 µg/h every 6-9 days
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Methadone
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Action
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<= 80 mg/day
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taper by 5 mg per week
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> 80 mg/day
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taper by 10 mg per week
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Step 2: Bridging
(1) Stop fentanyl or methadone on morning of day 1.
(2) Begin morphine IR 30 mg 4 to 5 times per day for 5 days (7 days if obese).
(3) On evening of the 5th day (or the 7th day if obese) stop the morphine IR.
Step 3: Transition
(1) Wait for 12 hours.
(2) Give a loading dose as follows:
(2a) Give 1 mg sublingual every 30 minutes for 4 doses.
(2b) If the patient has withdrawal symptoms or significant pain after the first 2 doses (at 1 hour), then combine the third and fourth doses for the third administration.
(3) After the loading dose, start the initial daily dosing (shown below).
Initial Daily Dosing
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MME per day
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Lower End of Initial Daily Dose
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Upper End of Initial Daily Dose
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0 to 49
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0.5 mg
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3 mg
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50 to 150
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3 mg
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6 mg
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151 to 180
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6 mg per day
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8 mg
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If the patient has opioid use disorder (OUD) then
(1) use a dose at the higher end of the dose range
(2) divide the total daily dose into 2 doses per day.
If opioid use disorder (OUD) is not a key issue, then
(1) use a dose at the lower end of the dose range
(2) divide the total daily dose into 3 or 4 doses per day.
Pearls:
(1) The abuse deterrent formulation (buprenorphine plus naloxone) is recommended.
(2) Prescription of buprenorphine for pain does not require an XDEA number.
(3) Buprenorphine has a higher cost and it may not be covered by insurance.
(4) The film can be cut for finer dose titration.
(5) The film should be held under the tongue for 5 minutes. A tablet should be held under the tongue for 10 minutes.
(6) The patient should not talk, eat or drink while the dose is being absorced.
(7) Avoid weekend calls for refills. The prescription should be written for 1, 2, 3 or 4 weeks (not 30 days) to coincide with a weekday.
(8) Write "for pain" on the prescription.
(9) Delay tapering of benzodiazepine until stable on buprenorphine.
(10) Peri-procedural buprenorphine management may require consultation.
