Microinduction of Buprenorphine/Naloxone: A Review of the Literature

Ahmed, Saeed; Bhivandkar, Siddhi; Lonergan, Brady B; Suzuki, Joji

doi:10.1111/ajad.13135

Cited by 88 publications

(123 citation statements)

References 31 publications

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“…The same microdosing formulations were described in this review, and the authors reported a 100% completion rate. According to the authors, a total of 58.3% of patients experienced some type of withdrawal symptoms during the initiation 71 …”

Section: Discussionmentioning

confidence: 99%

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

et al. 2022

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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.

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Section: Discussionmentioning

confidence: 99%

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

et al. 2022

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“…There is currently no consensus regarding a singular microdosing approach. 25 Further research is needed to de ne optimal microdosing protocols, assess for long-term outcomes using transdermal buprenorphine for microinductions, and increase provider comfort with this approach, especially for patients on methadone and who wish to switch.…”

Section: Discussionmentioning

confidence: 99%

Microdosing Transdermal Buprenorphine to Transition a Patient off a Higher-Dose Methadone Regimen

Braun

Blackwood

Bratberg

et al. 2022

Preprint

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Background Buprenorphine is a partial µ-opioid agonist with high receptor binding affinity and long half-life—qualities that reduce overdose risk with concomitant opioid use, though may precipitate withdrawal by displacing full agonists. Traditional buprenorphine induction typically requires patients endure moderate withdrawal prior to initiation, with challenges intensifying for patients transitioning from higher-dose methadone. Novel microinduction reports aim to remove this prerequisite, though with significant limitations. Methods Case report (n=1). Results Our patient taking high-dose methadone transitioned to buprenorphine using a transdermal microdosing protocol with an as needed full opioid agonist that did not require methadone dose tapering prior to initiation and avoided symptoms of opioid withdrawal. Conclusions Further research is needed to define optimal microdosing protocols, especially for patients on methadone and/or using illicit fentanyl.

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“…Microdosing (or microinduction) is an alternative approach that involves the overlapping use of low-dose sublingual or transdermal buprenorphine as a bridge to higher doses while full MOR agonists are cross-tapered. 53 , 74 , 75 , 76 , 77 , 78 Given that this is a relatively new method, more research is needed to assess its superiority over other approaches.…”

Section: Discussionmentioning

confidence: 99%

Evaluation of Buprenorphine Rotation in Patients Receiving Long-term Opioids for Chronic Pain

et al. 2021

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IMPORTANCE Individuals with chronic pain who use long-term opioid therapy (LTOT) are at risk of opioid use disorder and other harmful outcomes. Rotation to buprenorphine may be considered, but the outcomes of such rotation in this population have not been systematically reviewed.OBJECTIVE To synthesize the evidence on rotation to buprenorphine from full μ-opioid receptor agonists among individuals with chronic pain who were receiving LTOT, including the outcomes of precipitated opioid withdrawal, pain intensity, pain interference, treatment success, adverse events or adverse effects, mental health condition, and health care use. EVIDENCE REVIEW PubMed, CINAHL, Embase, and PsycInfo were searched from inception through November 3, 2020, for peer-reviewed original English-language research that reported the prespecified outcomes of rotation from prescribed long-term opioids to buprenorphine among individuals with chronic pain. Two independent reviewers extracted data as well as assessed risk of bias and study quality according to the Preferred Reporting Items for Systematic Reviews and Metaanalyses (PRISMA) reporting guidelines. Quality of evidence was assessed with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. FINDINGS A total of 22 studies were analyzed, of which 5 (22.7%) were randomized clinical trials, 7 (31.8%) were case-control or cohort studies, and 10 (45.5%) were uncontrolled pre-post studies, which involved 1616 unique participants (675 female [41.8%] and 941 male [58.2%] individuals). Six of the 22 studies (27.3%) were primary or secondary analyses of a large randomized clinical trial.Participants had diverse pain and opioid use histories. Rationale for buprenorphine rotation included inadequate analgesia, intolerable adverse effects, risky opioid regimens (eg, high dose and/or sedative coprescriptions), and aberrant opioid use. Most protocols were adapted from protocols for initiating treatment in patients with opioid use disorder and used buccal or sublingual buprenorphine. Very low-quality evidence suggested that buprenorphine rotation was associated with maintained or improved analgesia, with a low risk of precipitating opioid withdrawal. Steadydose buprenorphine was better tolerated than tapered-dose buprenorphine. Adverse effects were manageable, and severe adverse events were rare. Only 2 studies evaluated mental health outcomes, but none evaluated health care use. Limitations included a high risk of bias in most studies. CONCLUSIONS AND RELEVANCEIn this systematic review, buprenorphine was associated with reduced chronic pain intensity without precipitating opioid withdrawal in individuals with chronic pain who were receiving LTOT. Future studies are necessary to ascertain the ideal starting dose, formulation, and administration frequency of buprenorphine as well as the best approach to buprenorphine rotation.

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Microinduction of Buprenorphine/Naloxone: A Review of the Literature

Cited by 88 publications

References 31 publications

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

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

Microdosing Transdermal Buprenorphine to Transition a Patient off a Higher-Dose Methadone Regimen

Evaluation of Buprenorphine Rotation in Patients Receiving Long-term Opioids for Chronic Pain

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