Low-Dose Initiation of Buprenorphine: A Narrative Review

Edinoff, Amber N.; Fahmy, Omar H; Spillers, Noah J; Zaheri, Alexa R; Jackson, Eric D.; Witt, Audrey J De; Wenger, Danielle M.; Cornett, Elyse M.; Skidmore, Kimberly L.; Kaye, Adam M.; Kaye, Alan D.

doi:10.1007/s11916-023-01116-3

Cited by 5 publications

(3 citation statements)

References 17 publications

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“…The current literature supports continuing buprenorphine during episodes of acute pain as it offers distinct advantages (Kohan et al, 2021). By capitalizing on buprenorphine's unique pharmacological properties, clinicians can achieve effective pain control while minimizing the risk of opioid withdrawal, and potentially use buprenorphine as a bridge between analgesia and addiction management (Ahmed et al, 2021;Edinoff et al, 2023). This approach aligns with the overarching shift towards individualized pain management paradigms and reinforces the importance of personalized care plans.…”

Section: Discussion/conclusionmentioning

confidence: 87%

“…While the reviewed evidence and case studies underscore the potential benefits, it is crucial to acknowledge the complexities associated with continuing buprenorphine in the setting of acute pain. Challenges such as individual variability in response, potential drug interactions, and the need for clear communication among clinicians is paramount (Spreen et al, 2022;Edinoff et al, 2023). Further research is warranted to delve into the nuances of dosing strategies, patient selection criteria, and the long-term impact of this approach on pain trajectories and addiction management.…”

Section: Discussion/conclusionmentioning

confidence: 99%

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

Shelton,

Nama,

Hall

et al. 2024

Front. Pharmacol.

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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.

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Section: Discussion/conclusionmentioning

confidence: 87%

Section: Discussion/conclusionmentioning

confidence: 99%

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

Shelton,

Nama,

Hall

et al. 2024

Front. Pharmacol.

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“…More advanced harm reduction skills are distinct from those in our Basic Harm Reduction Skills theme as they include a practical understanding of harm reduction principles which offer insight into how people obtain, prepare, and use drugs and recognize the affect structural and contextual factors have on individuals’ daily lives. The provision of clean supplies/works [ 83 , 92 ], fentanyl & xylazine test strips [ 93 , 94 ], and advanced buprenorphine initiation in the era of fentanyl [ 71 , 95 , 96 ] are all evidence-based strategies that can be used in one-on-one clinical encounters with patients and merit inclusion in future curricula. Finally, trainees can use their expertise as medical professionals and community leaders to advocate for harm reduction-based drug policy [ 72 , 97 ], safe supply [ 98 – 100 ], and drug checking programs [ 101 – 103 ] .…”

Section: Discussionmentioning

confidence: 99%

Harm reduction in undergraduate and graduate medical education: a systematic scoping review

Smith,

Shah,

Adamczyk

et al. 2023

BMC Med Educ

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Background Substance use increasingly contributes to early morbidity and mortality, which necessitates greater preparation of the healthcare workforce to mitigate its harm. The purpose of this systematic scoping review is to: 1) review published curricula on harm reduction for substance use implemented by undergraduate (UME) and graduate medical education (GME) in the United States and Canada, 2) develop a framework to describe a comprehensive approach to harm reduction medical education, and 3) propose additional content topics for future consideration. Methods PubMed, Scopus, ERIC: Education Resources Information Center (Ovid), and MedEdPORTAL were searched. Studies included any English language curricula about harm reduction within UME or GME in the United States or Canada from 1993 until Nov 22, 2021. Two authors independently reviewed and screened records for data extraction. Data were analyzed on trainee population, curricula objectives, format, content, and evaluation. Results Twenty-three articles describing 19 distinct educational programs across the United States were included in the final sample, most of which created their own curricula (n = 17). Data on educational content were categorized by content and approach. Most programs (85%) focused on introductory substance use knowledge and skills without an understanding of harm reduction principles. Based on our synthesis of the educational content in these curricula, we iteratively developed a Harm Reduction Educational Spectrum (HRES) framework to describe curricula and identified 17 discrete content topics grouped into 6 themes based on their reliance on harm reduction principles. Conclusions Harm reduction is under-represented in published medical curricula. Because the drug supply market changes rapidly, the content of medical curricula may be quickly outmoded thus curricula that include foundational knowledge of harm reduction principles may be more enduring. Students should be grounded in harm reduction principles to develop the advanced skills necessary to reduce the physical harm associated with drugs while still simultaneously recognizing the possibility of patients’ ongoing substance use. We present the Harm Reduction Educational Spectrum as a new framework to guide future healthcare workforce development and to ultimately provide the highest-quality care for patients who use drugs.

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Is buprenorphine maternal dose associated with neonatal opioid withdrawal syndrome severity?

Marc,

Marion,

François

et al. 2024

American J Addict

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BackgroundNeonatal opioid withdrawal syndrome (NOWS) is a drug withdrawal syndrome occurring mainly after in utero opioid exposure. Buprenorphine is commonly used for opioid withdrawal. Studies are conflicted about a potential dose effectObjectiveThe aim of our study was to investigate the impact of buprenorphine maternal maintenance therapy on the NOWS based on NOWS duration, birth weight and therapy.Study DesignWe conducted a retrospective study analysing data from infants admitted for NOWS in two Neonatal Intensive Care Unit between January 2010 and December 2020. Inclusion criteria: Nonpreterm infants born to mothers who were treated with buprenorphine or therapy during pregnancy and who had a Lipsitz score of 4 or higher.ResultsA total of 75 term newborns were hospitalized for the treatment of NOWS from mother substituted with buprenorphine during the study inclusion period. The duration of NOWS differed significantly between all dose cohorts, with higher doses of maternal buprenorphine maintenance correlating with longer length of NOWS duration. Infants exposed to high doses required 17 days [10; 23], while infants exposed to intermediate doses required 7 days [2; 16] and infants exposed to low doses required 3 days [2; 5], with p‐values < .003. Infants exposed to high doses required a longer time to regain their birth weight and higher morphine doses as therapy compared to others. Infants exposed to low doses, intermediate doses, and high doses of buprenorphine demonstrated dose‐dependent increases in the durations of hospitalization, respectively.Conclusion and Scientific SignificanceIncreased doses of maternal buprenorphine during pregnancy are correlated with NOWS severity. Our study shows that increased doses of maternal buprenorphine during pregnancy are correlated with NOWS severity. Exploring low doses and having different ranges are a new argument to define the impact of maternal buprenorphine consumption.

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Low-Dose Initiation of Buprenorphine: A Narrative Review

Cited by 5 publications

References 17 publications

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

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

Harm reduction in undergraduate and graduate medical education: a systematic scoping review

Is buprenorphine maternal dose associated with neonatal opioid withdrawal syndrome severity?

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