Buprenorphine, not naloxone, as first-line rescue medication for patients with cancer-associated pain on chronic opioid therapy complicated by respiratory depression: A realist review

Abstract

Background

Untreated pain is a source of significant physical and psychosocial distress in patients with cancer. While guidelines for prescribing opioids have improved the treatment of cancer-related pain, all patients who take opioids are at risk for developing opioid-induced respiratory depression (OIRD). The current treatment for OIRD is naloxone although guidelines are highly variable on initial dose and indication. Patients with cancer on chronic opioids are at risk for increased suffering due to naloxone-induced opioid withdrawal and loss of pain control.

Aim

A review of the evidence for the safety and benefits of using buprenorphine instead of naloxone for reversal of OIRD in patients prescribed chronic opioids for cancer-related pain.

Methods

A realist review of the literature was completed following the RAMSES Framework. An iterative literature search of electronic databases was used to identify appropriate literature relating to buprenorphine and naloxone safety and use as reversal agents in OIRD.

Results

While naloxone does reverse OIRD it does have the risk of pulmonary edema and research has consistently shown that naloxone is usually given for the wrong indications and/or at an inappropriate dose for patients on chronic opioids for cancer-related pain. Buprenorphine has been shown to safely reverse OIRD with less incidence and severity of withdrawal and uncontrolled pain when compared to naloxone.

Conclusions

Because of the potential for decreased opioid withdrawal-associated symptoms, this review argues that buprenorphine warrants additional study and consideration to replace naloxone as the first-line rescue medication for patients with cancer on chronic opioids who experience OIRD.

Keywords:

• Buprenorphine
• Naloxone
• Opioid-induced respiratory depression
• Overdose
• Withdrawal

Acknowledgements

Chris Jones, MD; Kristina Podelnyk; Kristina Newport MD.

Disclaimer statements

Contributors Aaron K. Livingston: Conceptualization, RAMSES Evaluation of paper, Writing-original document, and Visualization. Jason A. Webb: Conceptualization, Writing- review, editing and Supervision.

Conflicts of interest None.

Ethics approval None.