Short communication: Systematic review on effectiveness of micro-induction approaches to buprenorphine initiation

Moe, Jessica; O’Sullivan, Fiona; Hohl, Corinne M.; Doyle‐Waters, Mary M.; Ronsley, Claire; Cho, Raymond J.; Liu, Qixin; Azar, Pouya

doi:10.1016/j.addbeh.2020.106740

Cited by 39 publications

(68 citation statements)

References 23 publications

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“…Our retrospective cohort study builds on existing single case reports or small case series, sharing our experiences from 72 in-hospital low-dose buprenorphine initiations. This more than doubles existing published cases from 63 patients across 20 publications 12,13 to 131 patients and 135 low-dose initiation experiences. We found that low-dose initiation can address significant barriers associated with the traditional buprenorphine initiation and can expand feasibility and acceptability of buprenorphine for hospitalized patients.…”

Section: Discussionmentioning

confidence: 65%

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Low-dose Buprenorphine Initiation in Hospitalized Adults With Opioid Use Disorder: A Retrospective Cohort Analysis

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Hartley

Robbins

et al. 2021

Journal of Addiction Medicine

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Objectives:Patients with opioid use disorder (OUD) can initiate buprenorphine without requiring a withdrawal period through a low-dose (sometimes referred to as “micro-induction”) approach. Although there is growing interest in low-dose buprenorphine initiation, current evidence is limited to case reports and small case series.Methods:We performed a retrospective cohort study of patients with OUD seen by a hospital-based addiction medicine consult service who underwent low-dose buprenorphine initiation starting during hospital admission. We then integrated our practice-based experiences with results from the existing literature to create practice considerations.Results:Sixty-eight individuals underwent 72 low-dose buprenorphine initiations between July 2019 and July 2020. Reasons for low-dose versus standard buprenorphine initiation included co-occurring pain (91.7%), patient anxiety around the possibility of withdrawal (69.4%), history of precipitated withdrawal (9.7%), opioid withdrawal intolerance (6.9%), and other reason/not specified (18.1%). Of the 72 low-dose buprenorphine initiations, 50 (69.4%) were completed in the hospital, 9 (12.5%) transitioned to complete as an outpatient, and 13 (18.1%) were terminated early. We apply our experiences and findings from literature to recommendations for varied clinical scenarios, including acute illness, co-occurring pain, opioid withdrawal intolerance, transition from high dose methadone to buprenorphine, history of precipitated withdrawal, and rapid hospital discharge. We share a standard low-dose initiation protocol with potential modifications based on above scenarios.Conclusions:Low-dose buprenorphine initiation offers a well-tolerated and versatile approach for hospitalized patients with OUD. We share lessons from our experiences and the literature, and provide practical considerations for providers.

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Section: Discussionmentioning

confidence: 65%

“…8 The standard approach to starting buprenorphine in the hospital can be challenging due to patients' severe illness, chronic pain, and anxiety around withdrawal. [9][10][11][12]13 There is, therefore, an urgent need for strategies to reduce barriers to in-hospital buprenorphine initiation to increase accessibility to this lifesaving medication.…”

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confidence: 99%

Low-dose Buprenorphine Initiation in Hospitalized Adults With Opioid Use Disorder: A Retrospective Cohort Analysis

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Hartley

Robbins

et al. 2021

Journal of Addiction Medicine

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“…Recent years have seen the development of novel buprenorphine micro-induction regimens that do not require initiation in a state of significant opioid withdrawal and may reduce the risk of precipitated withdrawal [22][23][24]. The median starting doses of these published regimens is 0.5 mg, uptitrated over a median of 6 days; further research is necessary to determine effectiveness and optimal dosing [25].…”

Section: Discussionmentioning

confidence: 99%

Challenges with buprenorphine inductions in the context of the fentanyl overdose crisis: A case series

Shearer

Young

Fairbairn

et al. 2021

Drug and Alcohol Review

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Introduction and Aims. North America is currently experiencing an epidemic of opioid overdose deaths, driven by the proliferation of fentanyl in the street drug market. Although buprenorphine/naloxone (BUP/NX) is an evidence-based, first-line opioid agonist for the management of opioid use disorder, a key challenge in its prescribing lies in the fact that it can precipitate opioid withdrawal during its initial induction process. At this time, there is minimal literature on the BUP/NX induction process in individuals who use illicit fentanyl regularly. Design, Methods and Results. A case series from a Vancouver, Canada addiction medicine clinic of three fentanyl-exposed patients who experienced unexpected, precipitated withdrawal when initiating BUP/NX. Discussion and Conclusion. These cases describe incidents of precipitated opioid withdrawal occurring after unusually long periods of fentanyl abstention. Although fentanyl is experienced as a short-acting opioid, the drug persists much longer in the body's peripheral tissues. Here, we highlight the new challenges fentanyl may pose to current BUP/NX induction strategies, and explore the possibility of a long-acting pharmacokinetic effect of fentanyl in the setting of repeated illicit use. [Shearer D, Young S, Fairbairn N, Brar R. Challenges with buprenorphine inductions in the context of the fentanyl overdose crisis: A case series.

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“…For transition to sublingual burprenorphine, a reduction to 30-40 mg methadone and initiation of burprenorphine treatment after the first withdrawal symptoms appear is usually recommended (5). Recently, the use of buprenorphine microdosing to facilitate transition to sublingual buprenorphine has been suggested as a possible approach (40,41).…”

Section: Discussionmentioning

confidence: 99%

Transition from methadone to subcutaneous buprenorphine depot in patients with opioid use disorder in custodial setting – a case series

Soyka

Gross

2021

The American Journal of Drug and Alcohol Abuse

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Background: Methadone, a full opioid agonist, and buprenorphine, a partial agonist at the opioid receptor, are established first-line medications for opioid maintenance therapy. Transition from methadone to sublingual buprenorphine may precipitate withdrawal and is usually performed only in patients on low dose of methadone (<30-40 mg). Transition from methadone to a novel subcutaneous buprenorphine depot (Buvidal) has not been previously described. Objectives: To test the hypothesis that a rapid transition from methadone to buprenorphine depot after a single dose of buprenorphine 4 mg sublingual is safe and well tolerated. Methods: Retrospective chart analysis of a case series of seven opioid users under custodial setting (prison) who were switched from methadone to buprenorphine depot (initial dose 16 mg weekly subcutaneously) after an initial test dose of buprenorphine 4 mg sublingual within 48 hours. Results: Clinical data indicate that a rapid transition from methadone to depot buprenorphine is feasible (six patients within 48 hours, one within 4 days). All patients were successfully switched to buprenorphine depot and the transfer period was completed without dropouts or major medical problems. Further dose adjustments were performed in 4 of 7 patients. Conclusions: Transition of opioid users from methadone to buprenorphine depot is feasible and safe via 4 mg buprenorphine sublingual. This procedure may facilitate induction of buprenorphine depot formulations in patients treated with methadone.

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Short communication: Systematic review on effectiveness of micro-induction approaches to buprenorphine initiation

Cited by 39 publications

References 23 publications

Low-dose Buprenorphine Initiation in Hospitalized Adults With Opioid Use Disorder: A Retrospective Cohort Analysis

Low-dose Buprenorphine Initiation in Hospitalized Adults With Opioid Use Disorder: A Retrospective Cohort Analysis

Challenges with buprenorphine inductions in the context of the fentanyl overdose crisis: A case series

Transition from methadone to subcutaneous buprenorphine depot in patients with opioid use disorder in custodial setting – a case series

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