Use of Buprenorphine in Managing Cancer Pain and Transition to Survivorship

Abstract

The management of cancer-related pain can often be challenging because clinicians must balance comfort with the potential side effects of prescribed treatments. Buprenorphine, a partial mu-opioid receptor agonist, offers a lower side effect profile compared to full agonist opioid medications. This makes buprenorphine a viable option for treating cancer-related pain as well as facilitating opioid tapers. Particularly for patients with a history of opioid use disorder or medication misuse, buprenorphine is a strategy to manage cancer-related pain while supporting the transition to survivorship.

AT A GLANCE

• ■ Buprenorphine is a partial mu-opioid receptor agonist approved by the U.S. Food and Drug Administration for opioid dependence as well as acute and chronic pain management.

• ■ The side effect profile of buprenorphine is lower in comparison to traditional opioid medications.

• ■ Clinicians may prescribe buprenorphine for the management of cancer-related pain.

By 2040, projections estimate that 26 million individuals in the United States will be diagnosed with cancer (Tonorezos et al., 2024). As the demand for cancer treatment escalates, a concomitant need exists for comprehensive, long-term management of cancer-related sequelae. Cancer-related pain is a common symptom during active disease, as well as remission, and can prove challenging to manage, particularly when complicated by drug misuse and substance use disorders. Opioids are often used as an evidence-based pain treatment plan aimed at mitigating pain and improving function as well as overall quality of life for patients with cancer-related pain (National Cancer Institute, 2025). The Centers for Disease Control and Prevention (Dowell et al., 2022) published clinical practice guidelines for chronic opioid prescribing that provide recommendations to assess risk and address potential harms associated with opioid use. However, full agonist opioids may cause disruptive side effects such as sedation, constipation, and nausea, which may limit or prevent patient use.

Use of opioids poses risks such as development of dependence, opioid use disorder (OUD), overdose, and death. Patients with cancer may experience challenges when tapering off opioids (Hande et al., 2024). Discontinuing opioids may cause intense cravings and acute withdrawal, which may increase the risk of relapse, overdose, and death from overdose. Emerging evidence advises consideration of transitioning to buprenorphine when tapering opioids to manage withdrawal instead of abruptly discontinuing opioid use (American Society of Addiction Medicine, 2020; Dowell et al., 2022). In addition, National Comprehensive Cancer Network (2024) guidelines direct clinicians to consider buprenorphine as a first-line opioid in treating cancer-related pain for patients with a history of OUD.

Buprenorphine is a partial mu-opioid receptor agonist approved by the U.S. Food and Drug Administration for opioid dependence as well as acute and chronic pain management (Spreen et al., 2022). This mechanism of action allows buprenorphine to strongly bind to receptors, alleviating withdrawal symptoms as well as cravings without full opioid medication effects (Scott et al., 2024). Benefits of buprenorphine compared to traditional opioids include reduced risk of respiratory depression, lower risk of constipation, less frequent dosing, long-acting pain control, reduced risk of dependence, lower risk of diversion, easier discontinuation, and no complications in patients with renal dysfunction (Poliwoda et al., 2022). Formulations include buccal films, injectables, and transdermal patches, offering multiple options for patients (see Table 1). Initial dosing is dependent upon the patient’s exposure to opioid medications and overall morphine milligram equivalent (MME) (Kumar et al., 2024).

TABLE 1.

BUPRENORPHINE FORMULATION AND DOSING FOR CANCER PAIN MANAGEMENT

FORMULATION	INITIAL DOSING
Buprenorphine filmsa (75 mcg, 150 mcg, 300 mcg, 450 mcg, 600 mcg, 750 mcg, 900 mcg)	■ Opioid naive: 75 mcg daily ■ Less than 30 MME per day: 75 mcg BID ■ 30–89 MME per day: 150 mcg BID ■ 0–160 MME per day: 300 mcg BID
Buprenorphine patches (5 mcg per hour, 7.5 mcg per hour, 10 mcg per hour, 15 mcg per hour, 20 mcg per hour)	■ Opioid naive or less than 30 MME per day: 5 mcg per hour ■ 30–80 MME per day: 10 mcg per hour

^aFor patients with mucositis, reduce starting dose by 50%.

BID—twice per day; MME—morphine milligram equivalent

Methods

The Supportive and Palliative Oncology Clinic (SPOC) interprofessional team at Vanderbilt-Ingram Cancer Center in Nashville, Tennessee, prescribed buprenorphine films and patches to successfully taper survivors with chronic cancer-related pain from opioids. These patients demonstrated a high risk of medication misuse or had a pertinent medical history of OUD. Clinicians provided education to patients about the mechanism of action and utility of buprenorphine for pain management. Counseling included application of buccal formulations such as wetting the mouth prior to film placement, leaving in place until dissolved, and rinsing the mouth once fully dissolved. For transdermal application, clinicians advised patients to remove soaps or lotions by cleaning the site, apply the patch to fatty tissue, and avoid exposure to heat. Providers prescribed individualized plans of care based on the patient’s total MMEs. Providers implemented titrations every two to four weeks depending on the patient’s condition and the severity of pain. Final regimens prescribed the lowest effective dose, with continued surveillance every one to three months.

Results

Three case studies highlight the favorable properties and efficacy of buprenorphine for patients with cancer-related pain. Clinician decision-making and collaboration with the patients yielded reductions in opioid medications by implementing evidence-based, multimodal pain management care plans. These patient experiences demonstrate the utility of buprenorphine in treating cancer-related pain for patients at high risk for misuse, undergoing treatment for OUD, and in survivorship.

Case Study 1: High Risk of Misuse and Cancer Survivor

F.M. is a 61-year-old with a history of polycythemia vera and on maintenance ruxolitinib treatments. The care team managed F.M.’s cancer-related pain for 10 years on oxycodone 15 mg by mouth every three hours as needed (maximum of six tablets per day) and oxycodone extended-release 9 mg by mouth twice per day (BID). When F.M.’s care was transferred to the SPOC team, the nurse practitioner (NP) implemented a slow taper, with a goal of transitioning to non-opioid medications. F.M. misused oxycodone to treat unrelated heel pain and required early refills twice in two sequential months. In addition, F.M. reported illicit use of methadone confirmed by a urine drug screening test. Because of opioid misuse, the NP stopped all full agonist opioid medications and prescribed a buprenorphine film 300 mcg BID to manage the pain and prevent opioid misuse. At the one-month follow-up visit, because of increased pain, the NP increased the buprenorphine film to 450 mcg BID and adjusted adjuvant treatments, including duloxetine 120 mg at night, pregabalin 100 mg BID, and memantine 10 mg BID. One year later, F.M. successfully remains off opioid antagonists with well-controlled pain.

Case Study 2: Head and Neck Cancer With OUD

J.B. is a 35-year-old who presented to an ear, nose, and throat clinician for persistent ear and throat pain. Endoscopy revealed a concerning lesion that was subsequently confirmed as squamous cell carcinoma of the supraglottis. J.B.’s past medical history was significant for OUD postrehabilitation treatment and more than three years of abstinence from opioids. The oncologic treatment plan included curative therapy with combination chemotherapy and radiation therapy. Because chemotherapy and radiation therapy in head and neck cancers historically produce acute pain, J.B. was referred to SPOC for pain and symptom management. Initially, adjuvant analgesics were maximized to accommodate patient preference for avoidance of opioid medications. After cycle 3 of chemotherapy and radiation therapy, J.B. was admitted to the hospital for intolerable pain and difficulty swallowing. The team held cancer treatment during the admission, and pain improved with IV ketorolac, ketamine, and lidocaine. After discharge, the SPOC NP offered J.B. low-dose buprenorphine as an alternative to a full agonist opioid. Reluctantly, J.B. agreed to trial this pain management strategy. The low-dose buprenorphine films improved pain for one week, at which time J.B. presented with inadequate pain control. After a risk-and-benefit discussion of continuing with low-dose buprenorphine, returning to full agonist opioids, or increasing buprenorphine to the OUD formulations, J.B. agreed to escalate dosing. The combination of high-dose buprenorphine, adjuvant analgesics, and nonpharmacologic treatment allowed J.B. to complete chemotherapy and radiation therapy with minimal interruptions and no additional hospital admissions. After four months of recovery from cancer treatment, the SPOC NP tapered J.B. off buprenorphine during a six-month period. Buprenorphine films bridged J.B. to complete chemotherapy and radiation therapy treatment without a subsequent relapse of opioid misuse. J.B. is cancer-free and remains off all opioids.

Case Study 3: Cancer Survivor

T.A. is a 56-year-old patient with a history of right thalamic astrocytoma diagnosed in 1998. Radiation therapy to the tumor was implemented at the time of diagnosis without any additional treatment needed. For 23 years, T.A. reported a history of chronic headache pain managed with a 50 mcg per hour fentanyl patch applied every 72 hours and hydrocodone with acetaminophen 10–325 mg every three hours as needed (maximum of eight tablets per day). T.A. had shown no evidence of disease for 26 years, and the SPOC NP had great concern for hyperalgesia contributing to pain exacerbations. In response, the NP initiated a slow opioid taper. T.A. tolerated gradual reductions until the MMEs dropped below 90 mg. At that time, T.A. reported decreased functionality at home and poor quality of life. The NP transitioned T.A. to 10 mcg per hour of buprenorphine patches applied every seven days, discontinuing full agonist opioids. At the one-month follow-up, T.A. reported subjective improvement in pain from “severe” at previous visits to “well controlled” with buprenorphine patches. T.A. gained functional improvement at home and began an exercise program that pain had been preventing for more than 10 years. T.A. remains stable on the buprenorphine patch with well-controlled chronic pain.

Conclusion

Managing cancer-related pain is complex, given the multitude of side effects patients may experience related to prescribed treatments. Full agonist opioids are often prescribed to manage acute and chronic pain; however, the side effect profile may limit use. In addition, these opioid medications must be avoided or extremely limited for patients with a history of OUD or medication misuse. Buprenorphine is well tolerated and effective for cancer-related pain without the use of a full agonist opioid. In addition, buprenorphine facilitates opioid tapering for patients with stable cancer-related pain or no evidence of disease without a compromise in their functional status. Buprenorphine is a safe pain management strategy that clinicians can consider for facilitating opioid tapering and treating acute and chronic cancer pain.

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Consider how you can apply findings from this article to your own practice using the following questions:

• ■ How might the use of buprenorphine for managing cancer-related pain benefit patients in your practice, particularly those with a history of opioid use disorder or medication misuse?

• ■ What challenges have you encountered in managing cancer-related pain in patients with a history of opioid use disorder, and how could the strategies discussed in this article help address those challenges?