“Macrodosing” Sublingual Buprenorphine and Extended-release Buprenorphine in a Hospital Setting: 2 Case Reports

Abstract

Objectives: To describe 2 case reports in which high-dose administration of sublingual buprenorphine/naloxone quickly stabilized fentanyl users who presented to the hospital. To discuss how early administration of extended-release buprenorphine, before the patient is discharged, may improve retention rates for outpatient buprenorphine treatment. Methods: Two case reports of fentanyl users presented to the emergency department at the general hospital in Timmins, Canada are described. They were rapidly stabilized on high-dose sublingual buprenorphine/ naloxone and then transitioned within 24 to 36 hours to buprenorphine extended-release subcutaneous injection. Results: In both cases, their withdrawal symptoms quickly resolved, without sedation or precipitated withdrawal. Both patients followed up with the outpatient clinic for another injection of extended-release buprenorphine. Conclusions: High-dose sublingual buprenorphine/naloxone followed by early administration of extended-release buprenorphine quickly and safely relieved withdrawal symptoms in 2 fentanyl users who presented to the hospital emergency department. This novel approach shows promise in improving treatment retention rates for patients using fentanyl. Further research is required to evaluate the safety and effectiveness of this approach.

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

“…In a recent case series, 2 patients with unregulated fentanyl use presenting to the emergency department in Ontario, Canada, received high doses of BUP/NX after scoring high on COWS and transitioned to BUP-XR within 24 to 36 hours. 15 This study replicated the findings of a case series of 5 patients with heroin and unregulated fentanyl use in New York, United States, who also received BUP-XR within 24 to 36 hours after receiving BUP/ NX on day one. 16 Although these case series did initiate BUP-XR very rapidly, they required patients to experience high levels of withdrawal and the use of a COWS threshold before receiving BUP/NX, which can be difficult for patients to tolerate.…”

“…Rapid initiation protocols of BUP-XR have been previously described. In a recent case series, 2 patients with unregulated fentanyl use presenting to the emergency department in Ontario, Canada, received high doses of BUP/NX after scoring high on COWS and transitioned to BUP-XR within 24 to 36 hours 15 . This study replicated the findings of a case series of 5 patients with heroin and unregulated fentanyl use in New York, United States, who also received BUP-XR within 24 to 36 hours after receiving BUP/NX on day one 16 .…”

High-Dose Buprenorphine Initiation: A Scoping Review

“…Three of the included studies were RCTs with a total of 171 patients (of whom 140 patients were randomized to high-dose initiations), [17][18][19] 5 were prospective cohort studies, retrospective cohort studies, or trials without control groups, 11,[20][21][22][23] and 7 were case reports 12,[24][25][26][27][28][29] (Table 1). Nine studies took place in the United States, 11,12,18,20,22,24,25,28,29 2 in Canada, 26,27 2 in Iran, 17,19 1 in Israel, 23 and 1 in Sweden. 21 Four studies were published in the 2000s, 18,21,23,24 3 in the 2010s, 19,22,29 and 8 between 2020 and February 13, 2023.…”

“…21 Four studies were published in the 2000s, 18,21,23,24 3 in the 2010s, 19,22,29 and 8 between 2020 and February 13, 2023. 11,12,17,20,[25][26][27][28] Eight studies were set in an inpatient setting (hospital, medically supervised withdrawal unit, or residential treatment facility), [17][18][19]21,22,24,26,29 3 studies in an emergency department, 11,12,27 and 3 studies in the outpatient clinic setting. 20,23,28 One study setting took place when medications were provided by emergency first responders after overdose-related calls.…”

“…Fentanyl (or high-potency synthetic opioid) use was explicitly identified in 4 studies with 12 identified individuals. 20,[26][27][28] Studies varied in their inclusion and exclusion criteria and the evaluation of patients before receiving high-dose buprenorphine (Table 1). Several studies excluded individuals with medical comorbidities (Table 1).…”