Buprenorphine versus full agonist opioids for acute postoperative pain management: a systematic review and meta-analysis of randomized controlled trials

Background/Importance Opioids continue to play a key role in managing acute postoperative pain, but their use contributes to adverse outcomes. Buprenorphine may offer effective analgesia with a superior safety profile. Objective To compare the efficacy and safety of buprenorphine with other opioids for acute postoperative pain management in adults. Evidence review MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and Web of Science were searched from inception to February 2024. Randomized controlled trials comparing buprenorphine with other opioids for acute postoperative pain management in adults were included. Of 2421 records identified, 58 studies met inclusion criteria. Two reviewers independently extracted data and assessed risk of bias. Random-effects meta-analysis was performed using Stata/BE V.18. The primary outcome was pain intensity. Secondary outcomes included rescue analgesia use, duration of analgesia, and adverse effects. Findings Analysis of 41 comparisons (2587 participants) showed buprenorphine significantly reduced pain intensity compared with all other opioids (Hedges's g=-0.36, 95% CI=-0.59 to -0.14, p<0.001, 95% prediction interval (PI)=-1.70 to 0.97). This effect persisted when compared with full agonist opioid (FAO) alone (standardized mean difference -0.34, 95% CI=-0.59 to -0.10, p<0.001, 95% PI=-1.76 to 1.07). Patients receiving buprenorphine were less likely to require rescue analgesia (OR=0.40, 95% CI=0.26 to 0.63, p<0.001, 95% PI=0.12 to 1.36). Mean duration of analgesia was 8.5 hours (SD 1.84). There were no significant differences in other adverse effects including nausea and respiratory depression. Inconsistency was significant for pain intensity (I-2=86.28%, 95% CI=81.55% to 88.99%) and moderate for rescue analgesia (I-2=38.93%, 95% CI=1.44% to 64.37%). Risk of bias was low in 19 studies, with some concerns in 37 studies, and high in two studies. Conclusions Buprenorphine demonstrated superior efficacy in managing acute postoperative pain compared with FAOs, with a favorable safety profile and longer duration of action. These findings support the use of buprenorphine as a first-line opioid analgesic for acute postoperative pain management requiring opioid analgesia, potentially reducing opioid-related harm in the postoperative period.