Buprenorphine Micro-Dosing in Refractory Cancer Associated Pain

Outcomes 1. Critically evaluate and interpret relevant scientific literature related to buprenorphine micro-dosing initiation and utilize this knowledge to inform evidence-based decision-making in the treatment of cancer associated pain. 2. Analyze the efficacy and safety profile of buprenorphine in the treatment of cancer associated pain. Key Message Case series utilizing buprenorphine micro-dosing for refractory cancer-associated pain. We present two patients with severe, uncontrolled pain despite escalating pure mu opioid agonist doses. Both patients underwent buprenorphine induction and experienced improved pain control with lower pure mu opioid requirements, and no observed opioid withdrawal. Introduction Buprenorphine (BUP) therapy has been well studied in the realm of opioid use disorder and chronic pain but has less published evidence in the use for cancer associated pain. 1, 4,2 Despite the many purposed benefits of BUP, a prior barrier to the initiation specifically in the oncology patient, was the idea of required precipitation of opiate withdrawal. Multiple case reports have shown harnessing the idiosyncratic pharmacological profile of BUP one can initiate without precipitating withdrawl.3, 5 Objective Give examples of how buprenorphine can help in reducing pure-mu opioid agonists in cancer associated pain crisis. Methods BUP was initiated at 1mg sublingual (SL) daily, with continuing existing pure mu agonist opiates. BUP was titrated up daily by approximately 1mg until patients reported an improvement in pain, between 4-16 mg in split doses. As pain improved, pure mu opioid agonists were gradually weaned down. Results Patient A underwent BUP induction up to 4 mg SL daily. His daily pure mu agonist opioid requirement reduced from 408 mg morphine milliequivalent (MME) to 0 mg MME after 7 days. He also self-reported improved pain control and resolution of headaches attributed to pure-mu opioid agonist. Patient B underwent buprenorphine induction up to 16 mg SL daily. Her daily pure mu agonist opioid requirement reduced from 2200 mg morphine to 670 after 14 days. She self-reported improved pain and anxiety. Neither patient exhibited signs of opioid withdrawal. Conclusion Buprenorphine induction via the Bernese method resulted in decreased daily pure mu agonist opioid requirement and improved pain control which had not been achieved with pure mu agonist opioids alone. Neither patient experienced signs or symptoms of opioid withdrawal. Clinicians should consider use of buprenorphine in cases of refractory cancer-associated pain due to its unique properties and demonstrated safety and efficacy. Keywords Emergencies / Refractory Symptom Management / Managing Suffering and Distress