Buprenorphine emerges as a viable first-line option for opioid-based postoperative pain management! 

Here is the review of an important study published in Regional Anesthesia & Pain Medicine, comparing buprenorphine with full agonist opioids (FAOs) for acute postoperative pain management​.

Why This Topic Matters

Postoperative pain management is a balancing act. While opioids remain a key component, their well-documented adverse effects—including respiratory depression, nausea, and the risk of prolonged use—continue to be a challenge. Buprenorphine, a partial opioid agonist, is gaining attention for its analgesic efficacy and potential safety benefits. This systematic review and meta-analysis aimed to evaluate how buprenorphine compares to traditional FAOs in managing acute postoperative pain.

How the Authors Conducted the Study

The authors conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing buprenorphine with other opioids for acute postoperative pain. They screened over 2,400 studies from databases like MEDLINE, Embase, and Cochrane Central, ultimately including 58 RCTs with over 2,500 patients. The primary outcome was pain intensity, while secondary outcomes included rescue analgesia requirements, duration of analgesia, and adverse effects.

Key Findings

• Pain Control: Buprenorphine provided better pain relief than FAOs, with a statistically significant reduction in pain intensity (Hedges’s g = −0.36, 95% CI = −0.59 to −0.14, p < 0.001). When compared solely to FAOs (excluding partial agonists like nalbuphine), the effect remained significant (SMD = −0.34, p < 0.001).
• Less Need for Rescue Analgesia: Patients receiving buprenorphine were less likely to require additional pain medications (OR = 0.40, p < 0.001), suggesting prolonged pain relief.
• Longer Duration of Action: The mean duration of analgesia for buprenorphine was 8.5 hours, significantly longer than that of common FAOs like morphine (3-5 hours) and fentanyl (~1 hour).
• Similar Adverse Effects: Rates of nausea, vomiting, dizziness, sedation, and respiratory depression were comparable between buprenorphine and FAOs. There was a trend toward less pruritus with buprenorphine, but this did not reach statistical significance.

The Bigger Picture

These findings challenge the conventional belief that full agonist opioids are the gold standard for postoperative pain. With comparable or superior analgesic effects, fewer rescue doses needed, and a longer duration of action, buprenorphine emerges as a viable first-line option for opioid-based postoperative pain management.

Importantly, the study supports the growing trend of continuing buprenorphine perioperatively in patients on maintenance therapy for opioid use disorder (OUD). Previous concerns that buprenorphine’s high receptor affinity might block the effects of other opioids are being reconsidered. Evidence now suggests that buprenorphine is compatible with FAOs when used in standard pain management doses.

However, the study also highlights heterogeneity in trial designs and dosing regimens, indicating that more research is needed to standardize buprenorphine protocols across different surgical settings.

The Takeaway

Buprenorphine should be considered as a first-line opioid analgesic for acute postoperative pain, especially in cases where prolonged pain relief is desired without increasing overall opioid burden. Its use may reduce opioid-related harm, including prolonged opioid use and overdose risk.

Clinical Implementation Tips

• Consider buprenorphine as an alternative to FAOs for postoperative pain, especially in patients at risk for opioid-related adverse effects.
• Use lower doses (e.g., 0.3 mg IV or 0.4 mg sublingual) for acute pain management—these doses provide effective analgesia without interfering with additional opioid administration.
• Do not discontinue buprenorphine preoperatively in patients on maintenance therapy for OUD; instead, optimize perioperative pain management strategies.
• Monitor for delayed onset of peak effect, particularly with sublingual or transdermal formulations.
• Educate anesthesia teams about buprenorphine’s efficacy and safety profile to encourage its adoption in perioperative protocols.

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Cited Study: Hickey TR, et al. Reg Anesth Pain Med 2025;0:1–16. doi:10.1136/rapm-2024-106014​.