Community based buprenorphine micro-induction in the context of methadone maintenance treatment and fentanyl – Case report

Kaliamurthy, Sivabalaji; Jegede, Oluwole; Hermes, Gretchen

doi:10.1080/10550887.2022.2051985

Cited by 4 publications

(1 citation statement)

References 19 publications

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“…Our results showed a higher percentage of initiation attempts with precipitated withdrawal than in these studies, however these studies did not explicitly describe how they defined precipitated withdrawal, making comparison difficult. Additionally, our patients were not on prescribed full-agonist opioid therapy as were some patients in the literature [ 33 , 34 ]. For instance, an outpatient case series from Vancouver found no precipitated withdrawal in any of 7 patients using fentanyl, though more than half of these patients were continued on methadone or slow-release oral morphine therapy during initiation [ 33 ].…”

Section: Discussionmentioning

confidence: 99%

Withdrawal during outpatient low dose buprenorphine initiation in people who use fentanyl: a retrospective cohort study

Jones,

Geier,

Neuhaus

et al. 2024

Harm Reduct J

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Background Buprenorphine is an effective treatment for opioid use disorder (OUD); however, buprenorphine initiation can be complicated by withdrawal symptoms including precipitated withdrawal. There has been increasing interest in using low dose initiation (LDI) strategies to reduce this withdrawal risk. As there are limited data on withdrawal symptoms during LDI, we characterize withdrawal symptoms in people with daily fentanyl use who underwent initiation using these strategies as outpatients. Methods We conducted a retrospective chart review of patients with OUD using daily fentanyl who were prescribed 7-day or 4-day LDI at 2 substance use disorder treatment clinics in San Francisco. Two addiction medicine experts assessed extracted chart documentation for withdrawal severity and precipitated withdrawal, defined as acute worsening of withdrawal symptoms immediately after taking buprenorphine. A third expert adjudicated disagreements. Data were analyzed using descriptive statistics. Results There were 175 initiations in 126 patients. The mean age was 37 (SD 10 years). 71% were men, 26% women, and 2% non-binary. 21% identified as Black, 16% Latine, and 52% white. 60% were unstably housed and 75% had Medicaid insurance. Substance co-use included 74% who used amphetamines, 29% cocaine, 22% benzodiazepines, and 19% alcohol. Follow up was available for 118 (67%) initiations. There was deviation from protocol instructions in 22% of these initiations with follow up. 31% had any withdrawal, including 21% with mild symptoms, 8% moderate and 2% severe. Precipitated withdrawal occurred in 10 cases, or 8% of initiations with follow up. Of these, 7 had deviation from protocol instructions; thus, there were 3 cases with follow up (3%) in which precipitated withdrawal occurred without protocol deviation. Conclusions Withdrawal was relatively common in our cohort but was mostly mild, and precipitated withdrawal was rare. Deviation from instructions, structural barriers, and varying fentanyl use characteristics may contribute to withdrawal. Clinicians should counsel patients who use fentanyl that mild withdrawal symptoms are likely during LDI, and there is still a low risk for precipitated withdrawal. Future studies should compare withdrawal across initiation types, seek ways to support patients in initiating buprenorphine, and qualitatively elicit patients’ withdrawal experiences.

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Section: Discussionmentioning

confidence: 99%

Withdrawal during outpatient low dose buprenorphine initiation in people who use fentanyl: a retrospective cohort study

Jones,

Geier,

Neuhaus

et al. 2024

Harm Reduct J

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The Impact of High-Potency Synthetic Opioids on Pharmacotherapies for Opioid Use Disorder: A Scoping Review

Jegede,

De Aquino,

Hsaio

et al. 2024

J Addict Med

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Background The clinical implications of high potency synthetic opioids (HPSO) on medications for opioid use disorder (MOUDs) are not well understood. Although pharmacological interactions are plausible, the clinical significance of such interaction has not been systematically elucidated. This scoping review investigates the relationship between HPSO exposure and various MOUD treatment outcomes. Methods We followed PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-Analyses Extension for Scoping Reviews) for scoping reviews with extensive a priori search strategy of databases: MEDLINE, EMBASE, PsycINFO, Web of Science, CINAHL, and Cochrane. Results From 9149 studies, 34 fulfilled the inclusion criteria. Synthesized data reveal several critical insights: First, there is a variable but high occurrence (38%–80%) of HPSO usage among individuals with MOUDs. Second, MOUDs are linked to a decreased risk of overdoses and deaths associated with HPSO. Third, HPSO consumption is correlated with the risk of precipitated withdrawal when starting buprenorphine. Fourth, low-dose buprenorphine is being recognized as one method to avoid moderate withdrawal symptoms prior to treatment. Lastly, significant gaps exist in human experimental data concerning the effects of HPSO on key factors critical for treating OUD-craving, withdrawal symptoms, and pain. Conclusions Current evidence supports MOUD safety and effectiveness in reducing nonmedical opioid use. Further research is needed to explore HPSO’s influence on the acute factors preceding nonmedical opioid use, such as cravings, withdrawal symptoms, and pain. This research could inform the optimization of MOUD dosing strategies. Achieving consensus and harmonizing data across clinical and research protocols could diminish variability, enhancing our understanding of HPSOs effect on MOUD treatment outcomes.

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Rotation from methadone to buprenorphine using a micro‐dosing regime in patients with opioid use disorder and serious mental illness: A case series

Praeger,

Frei,

Pham

et al. 2024

Drug and Alcohol Review

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IntroductionInducting buprenorphine from methadone has traditionally involved initial opioid withdrawal, with risk of mental state deterioration in patients with serious mental illness (SMI). Micro‐dosing of buprenorphine, with small incremental doses, is a novel off‐label approach to transitioning from methadone and does not require a period of methadone abstinence. Given the limited literature about buprenorphine microdosing, we aimed to evaluate the feasibility and safety of inducting buprenorphine in a series of patients on methadone with SMI.MethodsFor this retrospective case series, we reviewed the records of 16 patients with SMI at a Melbourne addiction treatment centre, from January 2021 to July 2022, who transitioned via micro‐dosing, from high‐dose methadone (>30 mg) to buprenorphine and depot‐buprenorphine. Psychiatric diagnoses, mental state, other substance withdrawal, transfer success, transition time, opioid withdrawal symptoms and overall patient experience were collected via objective and subjective reporting.ResultsMethadone to buprenorphine transfer was completed by 88% of patients. Mental health measures remained stable with the exception of mildly increased anxiety. Median transfer time was 6.5 days for inpatients, 9 days for mixed setting and 10 days for outpatients. Most patients (93%) rated their experience ‘manageable’ reporting mild withdrawal symptoms. One patient met study criteria for precipitated withdrawal.Discussion and ConclusionsThis retrospective case series provides evidence that the use of a micro‐dosing buprenorphine induction for methadone to buprenorphine transitions, including to depot‐buprenorphine, has negligible risk, is tolerated by patients with SMI and is unlikely to precipitate an exacerbation of their mental illness.

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Community based buprenorphine micro-induction in the context of methadone maintenance treatment and fentanyl – Case report

Cited by 4 publications

References 19 publications

Withdrawal during outpatient low dose buprenorphine initiation in people who use fentanyl: a retrospective cohort study

Withdrawal during outpatient low dose buprenorphine initiation in people who use fentanyl: a retrospective cohort study

The Impact of High-Potency Synthetic Opioids on Pharmacotherapies for Opioid Use Disorder: A Scoping Review

Rotation from methadone to buprenorphine using a micro‐dosing regime in patients with opioid use disorder and serious mental illness: A case series

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