Buprenorphine, an opioid partial agonist, is primarily known as a medication used to treat substance use disorder. Its moderate to low physical dependence and ability to be combined with naloxone makes it useful for treating symptoms of withdrawal. But what could it mean for palliative care? Dr. Olivia Nguyen, a palliative medicine physician at CIUSSS Nord-de-l'Île de Montréal and President of the , strongly believes in the potential of buprenorphine in palliative care. At this year’s upcoming Continuing Professional Development (CPD) Day, they will tell us everything we need to know about how to use and dose this game-changing molecule.
Lexa Frail (LF): So, can you tell us a bit about your CPD day talk?
Olivia Nguyen (ON): I'm going to talk about buprenorphine, which is a molecule that I really like. It was a game changer for many of my patients, especially in the outpatient clinic, for pain management and side effects control.
LF: How is buprenorphine currently used?
ON: Buprenorphine is mostly used for people who have substance use disorder, but it's actually a great molecule for us in palliative medicine because it can help us relieve people’s pain when some of the usual side effects are a concern, such as drowsiness, respiratory depression, and tolerance. Then, there are problematic side effects that emerge over a longer period: immunosuppression, hypogonadism, mood changes, etc. With buprenorphine, we can reduce patients' risk of developing these.
LF: What makes buprenorphine a useful tool for palliative care physicians?
ON: Buprenorphine is a partial agonist of the mu receptor, a weak antagonist of the kappa receptor, and a delta receptor agonist. It has a ceiling effect on respiratory depression. As mentioned earlier, buprenorphine's side effects profile is fascinating, and it’s safe in kidney failure. This makes it a perfect opioid for patients who are particularly sensitive to side effects, or for whom the side effects limit the use of opioids. I’ve had patients tell me that when they took buprenorphine, it felt like a veil in front of them had lifted. They felt awake and aware in a way they hadn’t been in a long time—essentially, they felt alive again. Not many of my patients need buprenorphine, but when they do, oftentimes, the result is very satisfying!
LF: What are the current challenges of administering buprenorphine?
ON: There are two main forms of buprenorphine: Suboxone, the pill or film form, and Butrans, the patch form. Suboxone contains much higher doses of buphrenorphine and is combined with naloxone. I think the main barrier for using Suboxone in palliative care is clinicians’ lack of knowledge on how to prescribe it and do the rotation using micro dosing. Butrans comes in much lower doses, but the biggest restriction with this drug is securing RAMQ (Régie de l’assurance maladie du Quebec) coverage. Unfortunately, RAMQ covers Suboxone but not Butrans. Because it’s not covered, you need to convince the insurers that it's the best, most appropriate medication for your patients. That can be a challenge.Â
LF: Is there anything you’d like to add?
ON: I think it’s important to really listen to our patients. Sometimes, as clinicians, we’re not good at feeling powerless, so it’s easy to gloss over side effects and convince ourselves that a medication is working. Patients want to please us, too, so sometimes, they will minimize the reality of their pain. While listening to our patients can be uncomfortable, understanding and acknowledging their experience creates a better relationship between us and our patients, and can give us the necessary clues for a better treatment plan.
Dr. Nguyen’s talk will go into further detail on the pharmacology of buprenorphine. To attend this talk and more, make sure you for CPD Day 2025.