Rapid buprenorphine microdosing for opioid use disorder in a hospitalized patient receiving very high doses of full agonist opioids for acute pain management: Titration, implementation barriers, and strategies to overcomes

Case report: Successful induction of buprenorphine in medically complex patients concurrently on opioids: a case series at a tertiary care center

Effective pain management is essential for optimal surgical outcomes; however, it can be challenging in patients with a history of opioid use disorder (OUD). Buprenorphine, a partial opioid agonist, is a valuable treatment option for patients with OUD. Initiating buprenorphine treatment in patients concurrently taking opioids can be complex due to potential adverse outcomes like precipitated withdrawal. Evolving guidelines suggest there are benefits to continuing buprenorphine for surgical patients throughout the perioperative period, however situations do arise when buprenorphine has been discontinued. Typically, in this scenario patients would be restarted on buprenorphine after they have fully recovered from post-surgical pain and no longer require opioids for pain control. Unfortunately, holding MOUD may expose the patient to risks such as opioid induced respiratory depression or addiction relapse. In this case series, we discuss a novel method to restart buprenorphine in small incremental doses, known as micro-dosing, while the patient is still taking opioids for pain. We will present two complex clinical cases when this method was used successfully at a tertiary care hospital system.

48-hour Induction of Transdermal Buprenorphine to Extended-release Buprenorphine

ABSTRACT

Buprenorphine extended-release (BUP-XR) provides sustained delivery of buprenorphine to control withdrawal and craving symptoms in the form of a monthly injectable and has been shown to improve health outcomes in patients with opioid use disorder. It is recommended that patients are stabilized with a transmucosal buprenorphine product, for at least 7 days per the product monograph; however, clinically, this timeline may be expedited. We report a case of a hospitalized patient with unregulated fentanyl use who underwent a successful transdermal buprenorphine induction for 48 hours to initiate BUP-XR with minimal levels of withdrawal and without precipitating opioid withdrawal. The approach described could provide a practical, patient-centered, accelerated induction strategy that, once independently validated, could considerably facilitate the use of BUP-XR.

Low Dose Buprenorphine Initiation: A Guide for the Inpatient Clinician

Low dose buprenorphine initiation (LDBI) is a dosing strategy used to transition patients from full opioid agonists to buprenorphine. The purpose of LDBI is to circumvent obstacles associated with disruption in analgesia, precipitated withdrawal, and prerequisite opioid withdrawal prior to initiating buprenorphine, as not all patients are able to tolerate physical withdrawal symptoms recommended by national guidelines. No literature exists directly comparing traditional buprenorphine initiation to LDBI. Until information on long-term outcomes is available, these dosing strategies should be reserved for patients unable to tolerate traditional buprenorphine initiation. Available published research suggests LDBI strategies will allow some patients to successfully transition to buprenorphine with minimal or no symptoms of withdrawal. Ensuring access to pharmacotherapy during hospital admission is a crucial time for potential intervention and should be considered when appropriate. This narrative review discusses the background of LDBI strategies as well as practical clinical and operational considerations for the inpatient clinician.

Low-Dose Initiation of Buprenorphine: A Narrative Review

PURPOSE OF REVIEW

Opioid use disorder (OUD) is a chronic disorder in which a person loses control over the use of opioids, develops a compulsive behavior, and defends the use despite knowing the negative consequences. There are numerous treatments for OUD, including buprenorphine. Since it is displacing a full agonist opioid, precipitated withdrawal can occur with standard inductions involving buprenorphine.

RECENT FINDINGS

Case reports have noted success with a low-dose initiation of buprenorphine, which is different from typical protocols, relatively limited by adverse effects when patients were recently administered full agonists. A cohort investigation studied the use of a transdermal patch as part of the protocol, which was fairly well tolerated. While ongoing research is being conducted on this topic, recent case studies and smaller cohort studies have demonstrated the feasibility of a trial to treat OUD with low-dose initiation of buprenorphine.

48-hour Induction of Transdermal Buprenorphine to Sublingual Buprenorphine/Naloxone: The IPPAS Method

Buprenorphine is an effective medication for the treatment of opioid use disorder. However, the traditional method of buprenorphine induction requires a period of abstinence and the development of at least moderate withdrawal, which can be barriers in starting treatment. We present the case of a hospitalized patient with opioid use disorder using unregulated fentanyl, who underwent a transdermal buprenorphine induction over 48 hours to initiate sublingual buprenorphine/naloxone on the third day. The patient experienced minimal levels of withdrawal and did not experience precipitated withdrawal. The ease of use of this novel induction method over previously published induction protocols can greatly improve the accessibility of buprenorphine for patients and healthcare staff.

Recent Update on Pretreatment and Analysis Methods of Buprenorphine in Different Matrix

Buprenorphine is one of the most commonly used pain-killing drugs due to its lengthy duration of action and high potency. However, excessive usage of buprenorphine can be harmful to one's health and prolonged use might result in addiction. Additionally, an increasing number of cases have been documented involving the illegal use of buprenorphine. Therefore, a variety of effective and reliable methods for pretreatment and determination of buprenorphine and its main metabolite norbuprenorphine have been established. This review aims to update the current state of pretreatment and detection techniques for buprenorphine and norbuprenorphine from January 2010 to March 2022. Pretreatment methods include several traditional extraction methods, solid-phase extraction, QuECHERS, various micro-extraction techniques, etc. while analytical methods include LC-MS, LC coupled with other detectors, GC-MS, capillary electrophoresis, electrochemical sensors, etc. The pros and cons of various techniques were compared and summarized, and the prospects were provided. HIGHLIGHTSProgress in pretreatment and detection methods for buprenorphine is demonstrated.Pros and cons of different pretreatment and analysis methods are compared.New materials (such as nanomaterials and magnetic materials) used in buprenorphine pretreatment are summarized.Newly emerged environmental-friendly methods are discussed.

Buprenorphine initiation strategies for opioid use disorder and pain management: A systematic review

Buprenorphine possesses many unique attributes that make it a practical agent for adults and adolescents with opioid use disorder (OUD) and/or acute or chronic pain. Sublingual buprenorphine has been the standard of care for treating OUD, but its use in pain management is not as clearly defined. Current practice guidelines recommend a period of mild‐to‐moderate withdrawal from opioids before transitioning to buprenorphine due to its ability to displace full agonists from the μ‐opioid receptor. However, this strategy can lead to negative physical and psychological outcomes for patients. Novel initiation strategies suggest that concomitant administration of small doses of buprenorphine with opioids can avoid the unwanted withdrawal associated with buprenorphine initiation. We aim to systematically review the buprenorphine initiation strategies that have emerged in the last decade. Embase, PubMed, and Cochrane Databases were searched for relevant literature. Studies were included if they were published in the English language and described the transition to buprenorphine from opioids. Data were collected from each study and synthesized using descriptive statistics. This review included 7 observational studies, 1 feasibility study, and 39 case reports/series which included 924 patients. The strategies utilized between the literature included traditional initiation (47.9%), microdosing with various buprenorphine formulations (16%), and miscellaneous methods (36.1%). Traditional initiation and microdosing initiation were compared in the data synthesis and analysis; miscellaneous methods were omitted given the high variability between methods. Overall, 95.6% of patients in the traditional initiation group and 96% of patients in the microdosing group successfully rotated to sublingual buprenorphine. Initiation regimens can vary widely depending on patient‐specific factors and buprenorphine formulation. A variety of buprenorphine transition strategies are published in the literature, many of which were effective for patients with OUD, pain, or both.