Buprenorphine is an opioid used to treat opioid use disorder, acute pain, and chronic pain. It is administered under the tongue, in the cheek, by injection (intravenous or subcutaneous), or as a skin patch or implant. Maximum pain relief generally occurs within an hour and lasts up to 24 hours. In the United States, buprenorphine/naloxone (Suboxone) is usually prescribed to discourage injection misuse. Both formulations are Schedule III controlled substances.
Buprenorphine acts as an agonist, partial agonist, or antagonist at different opioid receptors. It relieves opioid withdrawal and reduces the effects of other opioids. Unlike full agonists such as heroin and methadone, it has a ceiling effect for some effects, including respiratory depression, but retains misuse potential.
Side effects include respiratory depression, sleepiness, adrenal insufficiency, QT prolongation, low blood pressure, allergic reactions, constipation, and opioid addiction. It may increase seizure risk in susceptible people; opioid withdrawal after discontinuation is generally less severe than with other opioids. Safety during pregnancy is unclear, but use while breastfeeding is probably safe: infants receive approximately 1–2% of the maternal weight-adjusted dose.
Buprenorphine was patented in 1965, FDA approved for medical use as an analgesic in 1981, and FDA approved for treating opioid use disorder in 2002. It is on the World Health Organization's List of Essential Medicines. Despite originally being marketed as an analgesic it is far more commonly prescribed and used to treat opioid use disorders, such as addiction to heroin. In 2020, it was the 186th most commonly prescribed medication in the United States, with more than 2.8million prescriptions.
Medical uses Opioid use disorder Buprenorphine is used to treat people with opioid use disorder. In the U.S., the combination formulation of buprenorphine/naloxone is generally prescribed to deter injection, since naloxone, an opioid antagonist, is believed to cause acute withdrawal if the formulation is crushed and injected. Taken orally, the naloxone has virtually no effect, due to the drug's extremely high first-pass metabolism and low bioavailability (2%).
Before starting buprenorphine, individuals with opioid dependence are generally advised to wait after their last dose of opioid, often 24–72 hours, because if taken too soon buprenorphine can displace other opioids bound to the receptors and precipitate an acute withdrawal. The dose of buprenorphine is then adjusted until symptoms improve, and individuals remain on a maintenance dose, often 8–16 mg.
Because withdrawal is uncomfortable and a deterrent for many patients, users have called for different means of treatment initiation. The Bernese method, also known as microdose induction, was described in 2016, where very small doses of buprenorphine (0.2 to 0.5 mg) are given while patients are still using street opioids, with medicine levels slowly titrated upward without precipitating withdrawal. This method has been used by some providers as of the 2020s. Many of the publications on the Bernese method are case reports, case series, or clinical guidance rather than large randomized controlled trials (RCTs). For example, a CMAJ article noted that only two case reports and one small case series existed at the time of writing, and guidance documents typically state that micro-dosing is not yet a fully evidence-based alternative compared with standard induction. Furthermore, the phrase "without precipitating withdrawal" should be understood as "typically less likely to precipitate withdrawal" rather than guaranteed to avoid it. Clinicians adopting this method must do so with caution, informed consent, and close monitoring — particularly because many of the studies are small, heterogeneous, and variable in protocol.
Buprenorphine versus methadone Both buprenorphine and methadone are medications used for detoxification and opioid replacement therapy, and appear to have similar effectiveness based on limited data. Both are safe for pregnant women with opioid use disorder, although preliminary evidence suggests that methadone is more likely to cause neonatal abstinence syndrome. In the US and European Union, only designated clinics can prescribe buprenorphine or methadone for opioid use disorder, requiring patients to travel to the clinic daily. If patients are drug-free for a period they may be permitted to receive "take-home doses," reducing their visits to as little as once a week. Alternatively, up to a month's supply of buprenorphine has been able to be prescribed by clinicians in the US or Europe who have completed basic training (8–24 hours in the US) and received a waiver/licence allowing the prescription of the medicine. In France, buprenorphine prescription for opioid use disorder has been permitted without any special training or restrictions since 1995, resulting in treatment of approximately ten times more patients per year with buprenorphine than with methadone in the following decade. In 2021, seeking to address record levels of opioid overdose, the United States also removed the requirement for a special waiver (X-waiver) for prescribing physicians. In the years that have followed, statistics reveal a significant improvement in accessibility for the treatment of opioid use disorder.
Buprenorphine versus naltrexone
Naltrexone is a full antagonist to the mu-opioid receptor, while buprenorphine is a partial-agonist. Naltrexone is not to be confused with naloxone, a compound paired with buprenorphine to provide relief from (and regular maintenance for) opioid withdrawal and opioid dependence.
Chronic pain
A transdermal patch is available for the treatment of chronic pain. These patches are not indicated for use in acute pain, pain that is expected to last only for a short period, or pain after surgery, nor are they recommended for opioid addiction.
Potency For equianalgesic dosing, when used sublingually, the potency of buprenorphine is about 40 to 70 times more potent than morphine." When used as a transdermal patch, the potency of buprenorphine may be 100 to 115 times greater than that of morphine.
Adverse effects
Common adverse drug reactions associated with the use of buprenorphine, similar to those of other opioids, include nausea and vomiting, drowsiness, dizziness, headache, memory loss, cognitive and neural inhibition, perspiration, itchiness, dry mouth, shrinking of the pupils of the eyes (miosis), orthostatic hypotension, male ejaculatory difficulty, decreased libido, and urinary retention. Constipation and central nervous system (CNS) effects are seen less frequently than with morphine.Budd K, Raffa RB. (eds.) Buprenorphine – The unique opioid analgesic. Thieme, 200, Central sleep apnea has also been reported as a side effect of long-term buprenorphine use.
Respiratory effects The most severe side effect associated with buprenorphine is respiratory depression (insufficient breathing). It occurs more often in those who are also taking benzodiazepines or alcohol, or have underlying lung disease. The usual reversal agents for opioids, such as naloxone, may be only partially effective, and additional efforts to support breathing may be required. Respiratory depression may be less than with other opioids, particularly with chronic use. In the setting of acute pain management, though, buprenorphine appears to cause the same rate of respiratory depression as other opioids such as morphine. Central sleep apnea is possible with long-term use, possibly resolving with dose reduction.
Buprenorphine dependence Buprenorphine treatment carries the risk of causing psychological or physiological (physical) dependencies. It has a slow onset of activity, with a long duration of action, and a long half-life of 24 to 60 hours. Once a patient has stabilised on the (buprenorphine) medication and programme, three options remain: continual use (buprenorphine-only medication), switching to a buprenorphine/naloxone combination, or a medically supervised withdrawal.
Pain management Achieving acute opioid analgesia is difficult in persons using buprenorphine for pain management. However, a systematic review found no clear benefit to bridging or stopping buprenorphine when used in opioid substitution therapy to facilitate perioperative pain management, but failure to restart it was found to pose concerns for relapse. Therefore, it is recommended that buprenorphine opioid substitution therapy is continued in the perioperative period when possible. In addition, preoperative pain management in patients taking buprenorphine should use an interdisciplinary approach with multimodal analgesia.Disha Mehta, Vinod Thomas, Jacinta Johnson, Brooke Scott, Sandra Cortina, Landon Berger. 2020 Continuation of Buprenorphine to Facilitate Postoperative Pain Management for Patients on Buprenorphine Opioid Agonist Therapy. 23;E163-E174. https://www.painphysicianjournal.com/current/pdf?article=NzAzMQ%3D%3D&journal=125
Pharmacology Pharmacodynamics + Buprenorphine Site Ki (nM) Action SpeciesStimulation Ref 0.2~0.90.081 Partial agonist HumanMonkey48%±5% 2.9–6.10.82 Antagonist HumanMonkey0 0.62–2.50.44 Antagonist/functional antagonism HumanMonkey9%±5 77.4 Partial agonist Human~50%±10% (8 mg≥) σ1 >100,000 σ2 >10,000 Agonist Human >100,000 Rat >100,000 Rat 33,000 (IC50) Inhibitor Rodent Values are Ki (nM), unless otherwise noted. The smallerthe value, the more strongly the drug binds to the site.
Opioid receptor modulator Buprenorphine has been reported to possess these following pharmacological activities:
μ-Opioid receptor (MOR): extremely high affinity partial agonist: at low doses, the MOR-mediated effects of buprenorphine are comparable to those of other narcotics, but these effects reach a "ceiling" as the receptor population is saturated. This behavior is responsible for several unique properties: buprenorphine greatly reduces the effect of most other MOR agonists, can cause precipitated withdrawal when used in actively opioid dependent persons, and has a lower incidence of respiratory depression relative to full MOR agonists. κ-Opioid receptor (KOR): High affinity antagonist/weak partial agonist —this activity is hypothesized to underlie some of the effects of buprenorphine on mood disorders and addiction. δ-Opioid receptor (DOR): High affinity antagonist Nociceptin receptor (NOP, ORL-1): Weak affinity, very weak partial agonist
In simplified terms, buprenorphine can essentially be thought of as a nonselective, mixed agonist–antagonist opioid receptor modulator, acting as an unusually high affinity, weak partial agonist of the MOR, a high affinity antagonist of the KOR and DOR, and a relatively low affinity, very weak partial agonist of the ORL-1/NOP.
Although buprenorphine is a partial agonist of the MOR, human studies have found that it acts like a full agonist with respect to analgesia in opioid-intolerant individuals. Conversely, buprenorphine behaves like a partial agonist of the MOR with respect to respiratory depression.
Buprenorphine is also known to have high binding affinity with antagonistic activity at the putative ε-opioid receptor.
Full analgesic efficacy of buprenorphine requires both exon 11- and exon 1-associated μ-opioid receptor splice variants.Grinnell S et al. (2014): Buprenorphine analgesia requires exon 11-associated mu opioid receptor splice variants. The FASEB Journal
The active metabolites of buprenorphine are not thought to be clinically important in its CNS effects.
In positron emission tomography (PET) imaging studies, buprenorphine was found to decrease whole-brain MOR availability due to receptor occupancy by 41% (i.e., 59% availability) at 2 mg, 80% (i.e., 20% availability) at 16 mg, and 84% (i.e., 16% availability) at 32 mg.
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