Low-dose buccal buprenorphine: Relative abuse potential and postoperative analgesic acceptability

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ABSTRACT About 25% of the 69,710 U.S. opioid overdose deaths in 2020 involved prescription opioids directly, and many of the remaining overdose victims started opioid use with prescribed medication. Post-surgical opioid prescribing comprises an increasing share of opioid prescribing, with considerable risks for misuse, new persistent opioid use (NPOU), and opioid use disorder (OUD). There is a need to decrease these iatrogenic risks without compromising postoperative analgesia. Buccal buprenorphine represents a potential alternative to traditional post-surgical opioid prescribing with known lower respiratory depression risk. However, minimal data exists regarding whether its administration yields: (1) decreased abuse potential or (2) acceptable analgesia for acute pain. The Research Training Plan addresses these key gaps in understanding regarding the risk/benefit ratio of postoperative buccal buprenorphine. Aim 1 involves pharmacodynamic and psychophysical assessment of abuse potential and analgesia following buccal buprenorphine administration in a controlled experimental setting. Aim 2 entails a preliminary study assessing the feasibility and acceptability of a randomized clinical trial of prescribing buccal buprenorphine for postoperative pain management. In each aim, buccal buprenorphine will be compared with oxycodone, a commonly prescribed postoperative opioid. The candidate has prior experience with small observational studies and large clinical database studies related to post-surgical opioids and pain, with several first- and co-first-author publications in major journals. The Career Development Plan will allow him to gain new proficiencies in the assessment of abuse potential and pain as well as clinical trial design and execution, biostatistics, grantsmanship, and professional development. Mentor Dr. Stephen Bruehl specializes in the experimental assessment of the subjective and analgesic response to opioid administration. Co-mentor Dr. Sharon Walsh performed the seminal studies on buprenorphine pharmacodynamics and is an expert on OUD. Co-mentors Dr. Chad Brummett and Dr. David Edwards are authorities on postoperative opioid prescribing, and co-mentor Dr. Benjamin French is a specialist in clinical trial design and biostatistics. Vanderbilt’s setting is highly conducive to research training and implementation. This project will set the candidate on course for a career as an independent translational and clinical investigator. The proposed studies promise to offer insights into whether buccal buprenorphine can serve as an alternative postoperative analgesic with lower abuse potential. The subsequent planned definitive trial could reshape post-surgical opioid prescribing patterns.