Low-Dose Buprenorphine Initiation Strategies for Pain

OBJECTIVE: The purpose of this review is to describe the common benefits and pitfalls of various low-dose buprenorphine initiation strategies for patients experiencing long-term pain without opioid use disorder (OUD). DATA SOURCES: A search of the primary literature was performed in PubMed using the following keywords: "Buprenorphine OR Buprenorphine-naloxone OR Belbuca OR Suboxone, Primary care OR Outpatient, Pain OR Pain management," from January 1980 to August 2, 2026. STUDY SELECTION AND DATA EXTRACTION: Case reports involving the use of sublingual/buccal buprenorphine in outpatients for pain without OUD were included. DATA SYNTHESIS: Three low-dose buprenorphine initiation methods were evaluated, titrating buprenorphine from once to thrice-daily up to a total of 7 days. Two studies abruptly discontinued full μ-agonists prior to initiating buprenorphine, whereas 1 study tapered full μ-agonists by 25% weekly after day 7. Tapering full-agonist opioids after attainment of target buprenorphine dosing was well tolerated and potentially unneeded after steady-state levels were achieved; bridging analgesia with sufficient pharmacokinetic overlap between buprenorphine and full μ-agonist opioids appears tantamount to mitigating withdrawal symptoms. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE: The ideal buprenorphine initiation method considers desired duration, whether to perform cross-titration, product pharmacokinetics, patient-specific factors, and goals of care. CONCLUSIONS: No data exist to support one low-dose buprenorphine initiation method over another. All methods discussed were highly successful at rotating patients to buprenorphine, that is, with equivalent or improved pain control with minimal to no withdrawal symptoms and may be used to build a methodology for starting buprenorphine in outpatients with sub-optimal pain regimens.