Buprenorphine analgesia: Impacts on opioid burden and clinical trajectory in acute trauma care

BACKGROUND: Schedule II opioids are widely used for trauma analgesia but carry dose-dependent risks of respiratory depression, tolerance, hyperalgesia, and addiction. Buprenorphine, a Schedule III opioid, is a potent analgesic with a more favorable safety profile; however, its integration into trauma care remains uncharacterized. METHODS: A single-center observational study included adult trauma patients admitted to a Level I trauma center from January 2021 to June 2024. The trauma service formalized buprenorphine analgesia in June 2023. Outcomes were assessed by (1) an unadjusted pre/post June 2023 analysis (pre-BΔ vs. post-BΔ) and (2) a 1:1 nearest-neighbor propensity score-matched comparison of post-BΔ patients who received (Bup+) or did not receive (Bup-) buprenorphine. Bup+ and Bup- groups were matched by demographics and injury characteristics. Sublingual/buccal and parenteral buprenorphine were assigned morphine milligram equivalents (MME) conversion factors of 30 and 100, respectively. Incidence rate ratios (IRRs) with 95% CI were calculated; significance was set at p <0.05. RESULTS: Unadjusted analysis included 3,935 patients (2,777 pre-BΔ; 1,158 post-BΔ). Increased buprenorphine use was associated with reduced MME (median, 138 pre-BΔ vs. 75 post-BΔ; p < 0.001; IRR, 0.70; 95% CI, 0.69-0.71), lower intensive care unit (ICU) admission rates (IRR, 0.78; 95% CI, 0.73-0.83), and shortened ICU length of stay (IRR, 0.87; 95% CI, 0.80-0.94). In the matched post-BΔ cohort (n = 544) buprenorphine use was associated with lower ICU admission (IRR, 0.63; 95% CI, 0.54-0.73) and shorter ICU length of stay (IRR, 0.67; 95% CI, 0.59-0.75); median MME did not differ (114 vs. 91, p = 0.187), though IRR analyses demonstrated lower opioid exposure (IRR, 0.82; 95% CI, 0.81-0.83). Across analyses, no differences were observed in survival or adverse events. CONCLUSIONS: In trauma patients, Schedule III buprenorphine analgesia was associated with reduced inpatient opioid exposure and ICU escalation. Further validation may establish buprenorphine as an advance in opioid stewardship for vulnerable trauma populations. (J Trauma Acute Care Surg 2026;00:000-000. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.). LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.