A case series of patients with head and neck cancer undergoing curative-intent chemoradiation receiving low dose transdermal buprenorphine for pain.

Abstract

Background: Buprenorphine is a semisynthetic partial µ-opioid receptor agonist used for opioid use disorder and increasingly for cancer-related pain. Transdermal buprenorphine (TDB) is effective for both nociceptive and neuropathic pain and may be particularly advantageous in patients with head and neck cancer (HNC) due to its pharmacologic profile and non-oral route of administration. Existing literature evaluates the efficacy of high dose TDB (>30 µg/h) in symptom management and demonstrates equivocal effectiveness to morphine. In the United States, TDB patches are only available in 5, 7.5, 10, 15, and 20 µg/h patches with a max dose of 20 µg/h approved by the Food and Drug Administration. Data on low-dose TDB for HNC-related pain and treatment-associated toxicities, including mucositis, are limited.

Case description: We performed a single center, retrospective review of nine patients with HNC who started or completed treatment between 2024 to 2025 All patients were treated in the HNC multidisciplinary clinic, which includes medical oncology, radiation oncology, otolaryngology, nutrition, navigation, and a palliative care physician at an academic hospital. Pain was treated primarily with TDB at varying doses, with adjuvant analgesics as needed, and patients were followed longitudinally during the course of their treatment. Analgesic regimens were adjusted as anticipated complications such as mucositis and odynophagia developed. While some patients required short-term full agonist opioids, most required fewer than 30 oral morphine equivalents daily in addition to their TDB. All patients were successfully weaned off full agonist opioids during post-treatment follow-up. Most patients completed their treatments with minimal interruptions. Instances of incomplete treatment included extenuating social circumstances, chemotherapy-related acute kidney injury, and dose-limiting cytopenias.

Conclusions: In our clinical experience, low dose TDB demonstrated efficacy in managing pain and limiting the need for full agonist opioids, and patients were able to achieve complete weaning of all full agonist opioids post-treatment. This study shows that low dose TDB can be a viable analgesic option for pain related to HNC and treatment sequelae while reducing total exposure to full agonist opioids, which makes it an ideal choice for patients who may have a history of substance use disorder.