Prescribing Buprenorphine for Chronic Pain

I think that buprenorphine actually should be one of the first line opioids. Pharmacologically, it's really a different animal. It's in the same kingdom, but just a different animal. Buprenorphine is available in two products that are specifically FDA approved for pain. Belbuca, which is the buccal film, and Butrans, which is the seven-day transdermal patch. For primary care providers, sometimes you're kind of in a pickle. You have a patient that medically cannot take NSAIDs, or NSAIDs wouldn't be beneficial. They can't be on SNRIs and things like duloxetine either. They can't be on anticonvulsants, because they're really only useful for neuropathic pain. So you're kind of stuck with opioids in a patient that may have an elevated risk of adverse effects. Buprenorphine is a wonderful drug to use in those patients because it really doesn't cause a lot of euphoria. It's safer because if you were to over use it, it has a plateau; a ceiling effect in CO2. So you can keep taking and taking it, but you're not going to accumulate CO2 beyond a certain point. Then we get to patients that have to be on a benzodiazepine, which is a risky combination with opioids. If you have them on buprenorphine, the risk would be less, because although the benzodiazepines cause additional accumulation of CO2, you're only going to able to do that to a certain point if you're on buprenorphine, because it's a partial agonist/antagonist opioid. Let's say I've got a type two diabetic patient with some kidney dysfunction so we can't give them NSAIDs. Let's say they've got pretty severe COPD. I'm going to put them on buprenorphine. The go-to drug to start a patient on an opioid chronically should be buprenorphine. From a scientific perspective, I think the buprenorphine products should be used as first line. If you dot your I's and cross your T's, and it's determined that chronic opioid therapy is indicated, then start with buprenorphine.