Emerging Alternatives: Buprenorphine for Acute Pain Management in the ED

Low-dose buprenorphine in the emergency department provides effective, opioid-sparing analgesia with durable pain control and lower risks of respiratory depression and misuse than full opioid agonists. That combination makes it a practical option for acute pain in busy EDs: it reduces full‑agonist opioid exposure without sacrificing analgesic effect.

As a partial opioid agonist, buprenorphine's pharmacology differs from full agonists, yielding preserved analgesia with a ceiling effect on respiratory depression and reduced euphoria. Those mechanistic differences alter the ED risk–benefit calculus and support selective use for acute pain when opioid-sparing is a goal.

ED dosing typically uses low-dose IV microdoses titrated to effect rather than maintenance regimens for opioid-use disorder. Practice favors small IV increments, reassessment after brief intervals, and adjunctive nonopioid analgesics while monitoring respiratory rate, level of consciousness, and hemodynamics.

Appropriate candidates include patients who would otherwise require IV opioids, those at elevated overdose risk, and people with opioid-use disorder. Contraindications include recent use of very high-potency full agonists without adequate washout, severe respiratory compromise, and true buprenorphine allergy. In bedside terms: start low, titrate to comfort, observe for expected sedative effects, and document response and counseling to enable safe integration into ED workflows.

Positioned within broader multimodal strategies, buprenorphine augments rather than replaces nonopioid agents and regional techniques. It pairs well with NSAIDs, acetaminophen, neuropathic adjuncts, and short regional blocks to extend analgesia and limit repeat opioid dosing, maximizing coverage while minimizing reliance on full agonists. Patients most likely to benefit are those at high risk for opioid-related harm and those who need reliable, durable ED analgesia.

Successful implementation requires a multidisciplinary workflow: pharmacy to secure formulary availability and dosing protocols; nursing for monitoring, observation criteria, and patient education; and pathways to link patients to pain or addiction services when indicated. Practical checkpoints include staff training on pharmacology and titration, EMR order sets with monitoring parameters, patient handouts on expected effects and follow-up, and defined referral processes. These measures reduce unwarranted variation and support institutional opioid stewardship.

Key Takeaways:

• Low-dose buprenorphine is an effective, opioid‑sparing option in the ED
• It complements multimodal analgesia and other agents to limit full‑agonist exposure
• ED‑initiated buprenorphine with arranged follow‑up can facilitate linkage to ongoing opioid-use disorder care.