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13 AUTHORS, INCLUDING:
Joseph Pergolizzi
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Sebastiano Mercadante
Paola Sacerdote
University of Milan
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papr_378
428..450
REVIEW ARTICLE
Current Knowledge of
Buprenorphine and Its Unique
Pharmacological Profile
Joseph Pergolizzi, MD*; Anna Maria Aloisi, MD, PhD;
Albert Dahan, MD, PhD; Joerg Filitz, MD; Richard Langford, MD, PhD;
Rudolf Likar, MD, FRCA**; Sebastiano Mercadante, MD;
Bart Morlion, MD; Robert B. Raffa, PhD; Rainer Sabatowski, MD;
Paola Sacerdote, PhD***; Luis M. Torres, MD, PhD;
Avi A. Weinbroum, MD
*Johns Hopkins University, Baltimore, Maryland, U.S.A.; University of Siena, Siena, Italy;
Abstract: Despite the increasing clinical use of transdermal buprenorphine, questions have persisted about the
possibility of a ceiling effect for analgesia, its combination
Address correspondence and reprint requests to: Joseph Pergolizzi,
MD, 4840 Sycamore Drive, Naples, FL 34119, U.S.A. E-mail: jpjmd@
msn.com.
Disclosure: Dr. Pergolizzi is a consultant for Grnenthal GmbH. There
was industry funding involved in the Expert meeting sponsored by Grnenthal GmbH, Aachen, Germany and editorial support.
Submitted: December 1, 2009; Revision accepted: February 7, 2010
DOI. 10.1111/j.1533-2500.2010.00378.x
INTRODUCTION
The launch of the transdermal formulation in 2001 saw
a resurgence of interest in the use of buprenorphine to
treat chronic moderate to severe cancer pain and nonmalignant pain which does not respond to non-opioid
analgesics. However, questions persisted about its use in
clinical practice as a result of misinterpreted animal
data,1 particularly regarding the possibility of an analgesic ceiling effect, its combination with other m-opioid
agonists, and the reversibility of side effects. Open questions also remained about buprenorphines dose
response curve for other pharmacodynamic parameters,
its efficacy in neuropathic pain, equipotency ratios,
interaction with the immune and hormonal systems, and
suitability for patients with impaired renal function.
Scientific and clinical research has not only aimed to
increase knowledge about buprenorphine, but also to
confute lingering myths about the drug by providing
scientific data and statistical evidence. Open questions
have been systematically investigated by preclinical
experiments, volunteer studies, and clinical trials which
addressed the efficacy, safety and tolerability of the
compound. A strong body of evidence has now been
accumulated which supports its use. For example, the
original registration data included a meta-analysis of
three randomized, placebo-controlled, double-blind
studies in 435 patients, 55% with cancer pain.26 Over a
15- to 16-day period, a clear doseresponse effect was
observed, based on the reduction in pain intensity and
consumption of rescue medication. There were also
dose-dependent differences with respect to placebo,
both for the single studies and the pooled database.
Long-term data are essential to determine the performance of an analgesic in the management of chronic
pain. Therefore an open-label, uncontrolled, follow-up
study in patients from the the previous clinical trials was
Pain intensity
Pain intensity (NRS)
10
3
2
1
1
14
Use of co-medication
1.8
1.3
1.0
0.7
0.4
14
undertaken, to obtain data on the efficacy and tolerability of long-term transdermal buprenorphine treatment
in patients with chronic persistent pain.7 The maximum
study participation was 3.4 years in cancer patients
(n = 134) and 5.75 years in noncancer patients
(n = 105). Pain relief was at least satisfactory in 90% of
the subjects, clearly demonstrating that transdermal
buprenorphine is effective against cancer and noncancer
pain.7 The buprenorphine patch was generally well tolerated; the most common systemic adverse drug reactions were nausea (9.2%) and dizziness (4.6%), whereas
the most common local reactions were erythema
(12.1%) and pruritis (10.5%).7
Strong opioids are recommended for treating severe
pain in the advanced stages of cancer. The efficacy
and safety of high-dose transdermal buprenorphine
(70 mg/h) has been compared with placebo in a randomized, double-blind, placebo-controlled, parallel group
study in patients with severe cancer pain.8 Opioidtolerant patients requiring strong opioids (90150 mg/
day oral morphine equivalents) were switched to
transdermal buprenorphine during a 2-week run-in
phase. Those who could be stabilized on this regime
were randomized to receive either a transdermal
buprenorphine or placebo patch for a 2-week maintenance phase. Rescue medication was allowed as necessary. Response was defined as a pain intensity of 24 on
an 11-point numerical rating scale (NRS) and a mean
daily buprenorphine sublingual tablet intake of 22
tablets. The proportion of responders was significantly
higher in the active treatment group (P = 0.0003) and
this was supported by a consistently lower pain intensity
and requirement for rescue medication in this group (see
Figure 1).8 The buprenorphine patch was well tolerated,
with a comparable incidence of adverse events in the
two groups, showing that it is safe as well as effective in
patients with severe cancer pain.8
A substantial body of evidence has also been collected on the efficacy and safety of transdermal
buprenorphine under routine clinical conditions.9 A
postmarketing surveillance survey gathered data on
13,179 patients who had been prescribed transdermal
buprenorphine in accordance with its Summary of
Product Characteristics, from hospitals, outpatient
clinics, and general practitioners in Germany. A total of
3,690 (28%) suffered from cancer pain and 9,489
(72%) from noncancer pain, most frequently musculoskeletal disorders and neuropathy. Buprenorphine
patches provided effective, sustained, and dosedependent analgesia in patients with both cancer and
noncancer pain, irrespective of their age or pain syndromes.9 Only 6% of patients rated their pain relief as
good or very good at the initial assessment; this
increased to 71% at the first follow-up visit and 80% at
the final assessment. Fewer than 5% of subjects discontinued treatment owing to unsatisfactory pain relief.
The tolerability profile was typical of an opioid and did
not vary with either the patients age or cause of pain
(cancer or noncancer).
No evidence emerged of any previously unknown
side effects and there was no clinically relevant development of tolerance.9
By October 2008 a wide range of projects had been
completed, and a multidisciplinary group of experts in
pharmacology, toxicology, pain management, and anaesthesia met in Berlin to review and critically evaluate
the outcomes, with the object of achieving consensus on
the conclusions to be drawn from this work.
PHARMACOLOGY
New Insights into the Pharmacology of Buprenorphine
The terminology used to characterize agonist action in
preclinical studies must be carefully applied according
to the fundamental concepts of receptor theory.10 The
terms intrinsic activity, efficacy, and full- or
partial- agonists are especially important; failure to
apply or interpret these terms correctly can lead to erroneous prediction or perception of a compounds clinical
utility. For example, buprenorphine has sometimes been
labeled a partial agonist based on the results of early
preclinical studies, but more recent work demonstrates
that it is inappropriate to regard buprenorphine as a
partial agonist on the basis of preclinical data, or to
predict a ceiling effect in the clinical setting.10
Affinity characterizes the interaction between drug
and receptor. Intrinsic activity involves the binding of
Figure 2. (A) Analgesic and (B) antihyperalgesic effects after sublingual and
intravenous buprenorphine (Koppert
et al.).28
tate stimuli and touch, caused by the activation of primarily mechano-insensitive (silent) C-nociceptors.26
In this randomized, double-blind, placebocontrolled, cross-over study, pain intensity and the area
of secondary hyperalgesia were repeatedly assessed
before and up to 150 minutes after administration of
one of the following: 0.15 mg of i.v. buprenorphine and
s.l. placebo pill, 0.2 mg of s.l. buprenorphine and i.v.
saline 0.9%, or i.v. saline 0.9% and s.l. placebo pill as a
control.25 Three separate treatment trials, at least 2
weeks apart, were performed. For both routes of administration, antihyperalgesic effects were more pronounced than analgesic effects. The decreases in pain
ratings were 26 1 5% for i.v. and 10 1 6% for s.l.
administration. The corresponding reductions in hyperalgesic areas were 66 1 9% and 43 1 10%, respectively
(see Figure 2), and these lasted significantly longer.25
This is in direct contrast to the intravenous administration of pure m-opioid agonists in the same model, in
which analgesic effects were stronger than antihyperalgesic ones.22,27 In the placebo group, the intensity of pain
decreased to about 42% of the initial level after 3 hours.
This had been observed in previous studies and was
found to be reversed by naloxone, indicating that the
electrical stimulation induces a release of endogenous
opioids.28
The mechanism for the pronounced antihyperalgesic
effect of buprenorphine is not yet understood. Its receptor subtype selectivity, binding characteristics and coupling to G-proteins are quite different from typical
m-opioid agonists.2931 Systemic opioids increase the
spinal expression of dynorphin, an endogenous
k-receptor agonist which has been shown to promote
SAFETY PHARMACOLOGY
Buprenorphine-Induced Respiratory Depression
and Reversibility
Opioids are generally well-tolerated. However, the
development of respiratory depression is a particularly
important adverse event, because of the possibility of a
fatal outcome. Although all potent opioid analgesics act
via the m-opioid receptor system, they differ in how they
affect respiratory control.34 The analgesia and respiratory depression induced by fentanyl and buprenorphine
have been compared by a team based at Leiden University, in order to quantify the balance between efficacy
and safety. As part of this project, the ability of naloxone to reverse buprenorphine-induced respiratory
depression was measured.
Fentanyl is widely used for the treatment of chronic
pain. It is a full agonist at the m-opioid receptor, with
fast receptor association/dissociation kinetics and no
active metabolites. Buprenorphine has previously been
classified as a partial agonist at the m-opioid receptor
with slow receptor association/dissociation kinetics.
Approximately 10% is converted to the active metabolite norbuprenorphine, but this plays only a minor role
in buprenorphines respiratory effect, owing to its lower
potency and lower receptor affinity.35,36 Respiratory
depression and analgesia were recorded after the administration of these opioids in rats and human volunteers,
as there is evidence that the m-opioid receptor functions
almost identically in both species.37
depression and analgesia were compared.20 Experimental pain was induced using transcutaneous electrical
stimulation and a gradually increasing current. Pain tolerance was measured at regular intervals before and up
to 8 hours after drug infusion. Ventilation showed a
rapid, dose-independent decline after drug infusion,
reaching a peak effect after 150180 minutes. The
0.2 mg dose produced a short-lived analgesic effect with
a maximum pain tolerance of 6.7 mA (29% above baseline current) after 75 minutes. By contrast, the longlasting analgesia produced by the 0.4 mg dose was
significantly higher, peaking at 23.8 mA (160% above
baseline current) after 130 minutes. The implication is
that buprenorphine displays a ceiling effect for respiratory depressionie, it acts as a partial agonist for this
endpointbut not for analgesia over the dose range
tested.20 The comparison between buprenorphine and
fentanyl, taking into account their analgesic and respiratory effects, can be expressed in terms of their therapeutic utility, as shown in Figure 5. This clearly shows
the greater safety margin offered by buprenorphine.39
It was originally believed that the strong affinity of
buprenorphine for the m-opioid receptor, and the slow
association/dissociation kinetics, would preclude its
effects being reversed by naloxone, but this has recently
been shown to be incorrect. In 21 opioid-nave volunteers, 0.2 mg/kg of buprenorphine was administered as
a continuous intravenous infusion for 1 hour.34 After 30
minutes from the start of infusion, naloxone (0.55 mg)
was infused for 30 minutes, and the effect on breathing
assessed for a further 30 minutes afterwards. Low-dose
naloxone (0.5 mg) had little discernible effect, but
2.0 mg produced a full reversal of respiratory depression, with ventilation returning to its baseline level.34
Thus full reversal can be achieved by a continuous infusion of sufficiently high dosages of naloxone.
Another study found that higher doses of naloxone
(5 mg7 mg) caused a decline in reversal activity, as the
naloxone/buprenorphine doseresponse relation is bellshaped.40 Taking this into account, an infusion scheme
consisting of a naloxone bolus of 2 to 3 mg, followed by
a continuous infusion of 4 mg/h, was developed. This
achieved full reversal of the respiratory depression
caused by 0.2 mg to 0.4 mg of buprenorphine within
4060 minutes.40 The high affinity of buprenorphine for
the m-opioid receptor explains why relatively high doses
of naloxone are needed before reversal occurs. A continuous infusion is then required to maintain the supply
of naloxone to opioid receptor sites in the brain; otherwise, the naloxone bolus is rapidly washed out and
eliminated from the body.40 Furthermore, to remove
higher doses of buprenorphine requires not higher doses
of naloxone but a longer period of infusion.40
The respiratory depression produced by buprenorphine, and its reversibility using naloxone, has also been
measured in a double blind, double dummy, randomized, placebo-controlled, parallel group study (data on
file, Langford). Patients (n = 84) under general anesthesia, breathing spontaneously, were randomized to
receive normal saline (5 mL), i.v. morphine (0.1 mg/kg),
i.v. buprenorphine (3 mg/kg) or i.m. buprenorphine
(0.85 mg/kg). Patients were connected to a wet wedge
spirometer.41 The threshold for respiratory depression
was a >33% decrease in respiration rate or an end tidal
CO2 increase of >1.5 kPa within the first 20 minutes.
Those patients who experienced respiratory depression
were further randomized to receive either naloxone
(2 mg followed by 1 mg in 50 mL of normal saline over
30 minutes) or placebo (data on file, Langford).
Figure 6 shows clearly that no respiratory depression
was seen in patients receiving either placebo or
0.85 mg/kg of i.m. buprenorphine. Plasma concentrations of i.m. buprenorphine, measured at 5, 10 and 15
minutes after administration, were broadly equivalent
to those produced by the 35 mg/h buprenorphine patch,
indicating that normal doses of transdermal buprenorphine do not produce clinically relevant respiratory
depression. Naloxone fully reversed the respiratory
depression induced in all the i.v. morphine patients (not
shown). In the i.v. buprenorphine patients, naloxone
produced a statistically significant improvement in
minute ventilation after 5 minutes (data on file, Lang-
1
Buprenorphine (ng/ml)
0.5
Median
0.1
0.05
Before
hemodialysis
After
hemodialysis
CLINICAL DATA
Registration Studies
The key features of the three randomized, placebocontrolled, double-blind registration studies previously
mentioned are as follows. Study 1 evaluated the efficacy
and tolerability of three doses of transdermal buprenorphine in 151 patients (83 with cancer) suffering from
severe to very severe chronic pain.2 Patients who
obtained satisfactory pain relief during a 5-day run-in
phase with sublingual buprenorphine (0.81.2 mg/day)
were randomized to receive two consecutive patches of
transdermal buprenorphine (35, 52.5 or 70 mg/h) or
placebo. In study 2, a total of 157 patients (121 with
cancer) who reported inadequate pain relief from
weak opioids or morphine (30 mg) were randomized
to receive transdermal buprenorphine (35, 52.5 or
70 mg/h) or placebo.3 There was no run-in phase and
patients received five consecutive patches over 15 days.
In Study 3, 137 patients (45 with cancer) received sublingual buprenorphine (0.81.6 mg/day) as needed
during a 6-day run-in phase.6 Those who achieved satisfactory pain relief were randomized to receive three
consecutive patches (transdermal buprenorphine
35 mg/h or placebo). Sublingual buprenorphine tablets
(0.2 mg) were permitted as rescue medication for all
patients in all three studies.
The endpoints for assessment of efficacy included
pain intensity, pain relief, duration of sleep undisturbed
by pain and the consumption of rescue medication.
Patients were considered to be responders if they
reported at least satisfactory pain relief and needed no
more than one sublingual tablet per day. A metaanalysis of the three trials clearly shows that the percentage of responders increased with the dosage of
transdermal buprenorphine. Among cancer patients,
40% with the 70 mg/h patch, 42% with the 52.5 mg/h
patch and 36% with the 35 mg/h patch were responders.4 Patients receiving active treatment also had longer
sleep periods uninterrupted by pain than those treated
with placebo. A decline in the need for rescue medication was seen at all dose levels of transdermal buprenorphine.4 Tolerability was very good, with a favorable
side-effect profile that was generally benign. Adverse
events were typical of those associated with opioid
drugs and, notably, constipation was reported by only
5.3% of the patients who received the active drug in the
three trials.4
More than half the patients in the three trials participated in the open-label follow-up study, which used
only the 35 mg/h patch. On a 5-point verbal rating scale
(VRS), 42.3% of the patients reported good to complete
pain relief, and a further 47.7% rated their pain relief as
satisfactory.4 More than 50% required only one sublingual buprenorphine tablet (0.2 mg) per day or less to
keep their pain well controlled.4 The most frequently
reported adverse events were typical of those associated
with strong opioids.7 Constipation occurred in 3.8% of
patients, comparable with the incidence reported in
long-term studies of transdermal fentanyl and morphine, in which the prophylactic use of a laxative is
almost always necessary.7,79
Transdermal Buprenorphine in Elderly Patients
The proportion of the population aged over 65 years is
rising throughout the Western world and these people
present particular problems as patients. Multiple morbidity and polypharmacy are frequent, the latter often
complicated by altered pharmacodynamics and pharmacokinetics. Renal impairment is a common problem but
may remain undetected owing to the effect of decreasing
muscle mass on creatinine clearance. Adverse drug reactions are also common.
Buprenorphine has a favorable safety profile, producing limited respiratory depression38 and no immunosuppressive effects.64 Also, no dose adjustment is necessary
in patients with renal impairment who are receiving
doses up to 70 mg/h.35,36 However, questions remained
about the efficacy and safety of buprenorphine in geriatric patients and its metabolism in this age group, so a
recent study evaluated these properties in patients 365
years of age and <65 years who were treated with the
20
18
16
16
14
14
% of patients
18
12
10
8
12
Baseline
10
W2
W4
W8
Nausea
Baseline
W1
W2
W3
W4
Vomiting
Dizziness
Constipation
W8
T. Lattinen
12.7
10
8.3
7.4
6.9
6.2
S.D
2.13
3.1
3.1
3.1
3.04
their potential for worsening pain and biliary obstruction. However, investigations using endoscopic manometry have demonstrated that buprenorphine does not
induce SO spasm, but significantly decreases the amplitude of SO contraction waves without altering
other parameters.92,93 This suggests that buprenorphine
offers potential benefits for patients suffering from
pancreatitis.
5.0
4.5
4.0
3.5
3.0
2.5
2.0
Baseline
Week 2
Week 4
Week 8
Another study of 297 patients with nociceptive, neuropathic or mixed pain of any aetiology evaluated the
efficacy and safety of transdermal buprenorphine and its
compatibility with tramadol as rescue medication.90
Pain had been present for an average of 49.7 months
and previous pain management had been unsatisfactory
in 96% of subjects. The mean NRS score decreased
from 7.7 to 3.6 over the 8-week observation period,
with a mean dose of 27.5 mg/h. The buprenorphine
patch was well tolerated and no problems were encountered in combining it with tramadol.90 Similar results
were obtained in 93 patients with chronic pain of any
type who were switched from morphine to the transdermal buprenorphine patch for basal analgesia and morphine as rescue medication.90
Collectively, these studies demonstrate that transdermal buprenorphine provided effective pain relief in
chronic nociceptive, neuropathic and cancer-related
pain in a total of 1,152 patients. Safety and tolerability
were good, with a reduction in opioid-induced adverse
events over the course of treatment, but dose titration is
very important in order to minimize side effects. No case
of respiratory depression was recorded in any of the
studies. Buprenorphine could be safely combined with
pure m-opioid receptor agonists like tramadol and morphine, whereas the convenience and compliance of the
patch delivery system was rated highly by both doctors
and patients.
Also, it should be noted that spasm of the sphincter
of Oddi (SO) is a well-recognized effect of narcotic
drugs (eg, morphine and pentazocine), which can occasionally cause debilitating pain.91 Consequently, many
clinicians are reluctant to prescribe strong opioids in
patients with acute or chronic pancreatitis, because of
Buprenorphine TDS
Starting Dose (mg/h)
3060
6190
91120
121150
151210
211240
241270
>270
17.5
35
52.5
70
9
8
7
6
5
4
3
2
1
0
Visit 1
Visit 2
buprenorphine
Visit 3
Visit 4
gabapentine
5
4
3
2
1
0
Visit 1
Visit 2
buprenorphine
Visit 3
Visit 4
gabapentine
Thus transdermal buprenorphine appears to be effective in different neuropathic pain indications, with
potent antihyperalgesic and antiallodynic effects. It alleviates typical neuropathic pain symptoms and retains its
analgesic properties with long-term administration.
Buprenorphine in Combination with Morphine
Pain after major abdominal surgery is intense in the first
few hours and requires large amounts of analgesics.
Intravenous opioids are most frequently used for early
postoperative pain control. Morphine is the reference
opioid, but is associated with adverse events, including
sedation, respiratory depression, pruritus, nausea, and
vomiting.108 The slow receptor kinetics and bell-shaped
doseresponse curve of buprenorphine had originally
raised fears of possible interaction with other m-opioid
agonists or antagonists, but recent preclinical data109
and human models110 suggest these fears are groundless.
In addition, the concomitant administration of mor-
CONCLUSION
Opioids are the mainstay of treatment for chronic,
cancer and noncancer pain. Available research on the
pharmacology of buprenorphine suggests that it may
offer a number of advantages over other opioids, and
this is supported by the clinical experience gained to
date, although further studies are required to confirm
certain aspects of its therapeutic action. The introduction of a transdermal formulation has facilitated the
maintenance of constant plasma levels of the drug, and
significantly increased its clinical use.
Modern receptor theory makes it clear that the action
of a drug can vary according to the individual tissue,
species, or endpoint involved. Thus it is perfectly possible for the drug to be a partial agonist for one effect,
but a full agonist for another. Despite earlier misconceptions, buprenorphine has been shown to act as a full
m-agonist for analgesia with no ceiling effect in animal
and human pain models, and in cancer patients. Unlike
other opioids, it exhibits a ceiling effect for respiratory
depressionie, it acts as a partial agonist for this endpoint. The margin of safety for patients, in whom respiratory depression may be fatal, is thereby improved.
This property may be caused by a novel supraspinal
signaling pathway that is not mediated via opioid or
NOP receptors and which is not activated by, for
example, morphine, or fentanyl. Moreover, if buprenorphine does induce respiratory depression, it has been
demonstrated that the effect can be fully reversed by
naloxone.
Different mechanisms have been suggested for
opioid-induced analgesia and antihyperalgesia, with
some studies suggesting that pure m-opioid receptor agonists may contribute to the induction of hyperalgesia.
Thus, in a patient being treated with such an agent,
increasing pain intensity could be caused by either the
development of tolerance or opioid-induced hyperalgesia, posing a diagnostic dilemma. By contrast, buprenorphine has a pronounced antihyperalgesic effect, which
may be because of its k-receptor antagonism. Other
benefits include its lack of immunosuppressive properties, found in some opioids, which can compromise
treatment and hasten tumor metastasis. This is particu-
larly important in patients who may already be immunocompromised. Unlike other opioids it does not affect
the HPG axis, making buprenorphine suitable for longterm administration without the risk of hypogonadism,
and it has no significant effect on driving ability, an
important aspect of patients self-determination.
Elderly patients present particular problems, owing
to the prevalence of co-morbidity, polypharmacy, renal
impairment and their susceptibility to adverse drug reactions. The efficacy and safety of buprenorphine remain
unaltered in this age group, whereas the ease of use of
the transdermal patch and the long duration of application are especially suitable for these patients. In particular, buprenorphine metabolism is largely unaffected by
renal insufficiency, so that no dose adjustment is
required in patients with renal impairment, even in endstate renal failure requiring hemodialysis.
Further randomized, placebo-controlled clinical trials
are required to provide additional evidence, but transdermal buprenorphine has so far been shown to be
effective in chronic nociceptive, neuropathic and mixed
pain caused by a wide variety of conditions, including
cancer, osteoarthritis, low back pain, diabetic neuropathy, and post-herpetic neuralgia. In many cases the analgesia previously provided by other opioids had proved
inadequate. Where appropriate, transdermal buprenorphine can be combined with pure m-opioid agonists as
rescue medication, whereas switching from buprenorphine to other opioids and vice versa does not present any
problems. Given its favorable safety profile, buprenorphine can now be considered an effective and realistic
option for treating chronic cancer and noncancer pain.
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