Buprenorphine, Pain, and Opioid Use in Patients Taking High-Dose Long-Term Opioids: A Randomized Clinical Trial.

Summary

In a 12-month pragmatic RCT of 207 patients on high-dose long-term opioids, offering a switch to buprenorphine did not improve pain or reduce opioid dose beyond usual collaborative care. Both arms achieved small pain improvements and substantial opioid dose reductions; only 26% in the option arm switched.

Key Findings

• No between-group difference in Brief Pain Inventory total score at 12 months (between-group AMD −0.09; 95% CI, −0.52 to 0.34).
• Both groups had substantial reductions in opioid dose (AMD −61.0 mg/d vs −58.5 mg/d MME within arms), with no between-group difference (AMD −2.5 mg/d; 95% CI, −21.1 to 16.0).
• Only 26% of participants in the buprenorphine option arm switched to buprenorphine.

Clinical Implications

Switching to buprenorphine may not provide additional benefit over collaborative pain care when offered optionally, given low uptake; focus may be placed on multimodal pain care and structured dose reduction irrespective of switching.

Limitations

• Low uptake of switching (26%) likely diluted potential treatment effects.
• Predominantly male VA population may limit generalizability.

Future Directions

Evaluate structured protocols to increase buprenorphine uptake, identify subgroups who benefit from switching, and integrate behavioral and interdisciplinary pain programs.