Watch for Confusion With Buprenorphine Rxs for Chronic Pain

You may see more patients get buprenorphine (Belbuca, Butrans, etc) to treat chronic pain.

That's because buprenorphine seems to relieve chronic pain similarly to other opioids (oxycodone, etc)...but may be less risky.

For example, buprenorphine may limit the chance of dangerously slow breathing...cause less euphoria...and have less potential for misuse.

If an opioid is needed for chronic pain, expect buprenorphine to be an option when other opioids may not be a good fit...such as in patients at higher risk of dangerously slow breathing.

In these cases, you may see Belbuca buccal films or Butrans patches prescribed for patients who aren't already using opioids.

These products are dosed in MICROgrams...partly because patients who haven't used opioids before need a low dose to start.

Stay alert for med and dosing mix-ups.

Butrans is applied WEEKLY...and comes in five strengths.

Belbuca is usually taken BID...and comes in seven strengths.

Watch especially for mishaps with the 75 mcg and 750 mcg strengths of Belbuca...confusing the two can lead to a 10-fold dosing error.

Inform patients that Belbuca or Butrans costs about $400/month or more. If cost is a problem, help expedite prior auths or med switches.

Also be aware that buprenorphine/naloxone combos (Suboxone, etc) may be prescribed "off-label" for chronic pain. Expect to see these if a higher opioid dose is needed...such as patients who also have opioid use disorder. Generics cost about $200/month.

Pay close attention to sigs and strengths. Sublingual buprenorphine/naloxone products are dosed in MILLIgrams...and may be taken 3 to 4 times daily for chronic pain.

Remember that an "X" DEA number is NOT needed when buprenorphine is prescribed for pain alone. It's only needed when buprenorphine is prescribed for opioid use disorder.

Keep in mind that buprenorphine is a C-III and can still be misused...or lead to overdose. Verify that patients have rescue naloxone...and work with your pharmacist to provide it if needed.

Compare products in our FAQ, Buprenorphine for Chronic Pain.

Key References

  • Pain Med. 2020 Apr 1;21(4):714-723
  • Pain Med. 2021 May 21;22(5):1109-1115
  • Pain Med. 2020 Dec 25;21(12):3691-3699
  • JAMA. 2016 Apr 19;315(15):1624-45
  • Medication pricing by Elsevier, accessed Oct 2021
Pharmacy Technician's Letter. November 2021, No. 371106



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