Using Microdosing to Induct Patients Into a Long-Acting Injectable Buprenorphine Depot Medication in Low Threshold Community Settings: A Case Study

Abstract

Healthcare innovation has never been more important as it is now when the world is facing up to the unprecedented challenges brought by the COVID-19 pandemic. Within addictions services in Scotland, the priority has been to tackle our rising drug related death rate by maintaining and improving access to treatment while protecting frontline workers and managing operational challenges as a result of the pandemic. We present here a case study of five patients with opioid use disorder whose treatment represents a confluence of three important Medication Assisted Treatment (MAT) service innovations. The first was a low threshold drop in and outreach MAT service to rapidly and safely initiate opiate replacement therapy (ORT). The second was the provision of a microdosing regimen to enable same day induction to oral buprenorphine while minimizing the risk of precipitated opioid withdrawals and/or treatment disengagement. The third was rapid transitioning to an injectable long-acting buprenorphine depot which reduced unnecessary face to face patient contact and treatment non-adherence. This case study of five patients highlights the valuable role that buprenorphine microdosing can play in making induction to long-acting buprenorphine depot feasible to a broader range of patients, including those on a high dose methadone treatment regime.

Buprenorphine microdosing regimen using transdermal buprenorphine patches to transition from methadone to buprenorphine

“…There is growing evidence of the utility and efficacy of buprenorphine microdose regimens in transitioning patients from methadone or other full agonist opioids onto buprenorphine [6,[8][9][10][11]. However, most of the evidence is limited to small-scale case studies, case series or cohort studies with varied protocols and inclusion criteria and there are no high powered or high quality large-scale studies that can provide more generalisable results about the overall efficacy of buprenorphine microdose induction [7].…”

“…Since the advent of the Bernese method there have been a number of papers and case series on different buprenorphine microdose regimens [8][9][10][11]. This paper explores an outpatient, fixed dose buprenorphine microdose regimen using transdermal buprenorphine patches in a staged manner.…”

Inpatient Low-dose Transitions From Full Agonist Opioids Including Methadone Onto Long-acting Depot Buprenorphine: Case Series From a Multicenter Clinical Trial

“…The pivotal trials evaluating the efficacy of LAB excluded participants with severe medical or psychiatric comorbidity and were conducted in outpatient settings with 7 days of stable buprenorphine dosing before injection 5 . A Scottish case series, 25 to our knowledge the only other published cohort with transitions from long acting opioids to LAB, also was limited to participants who were managed exclusively in the outpatient setting with no reported major comorbidities. This dearth of inpatient LAB data despite the Sublocade formulation being FDA approved since 2017 is likely due to its limited commercial availability on inpatient formularies; Sublocade in this case series was available before discharge as part of the clinical trial protocol.…”

“…In 1 case, Sublocade was administered on day 6 of the low-dose transition, the shortest in this case series, and was tolerated well without precipitated withdrawal or adverse effects. The Scottish case series 25 had an average time duration between induction initiation and LAB dosing of 13 to 14 days on average. In this series, the average time was 8 days in a patient population that was hospitalized with high degree of comorbidity (and critically ill at times during their hospitalization).…”

Transition From Full Mu Opioid Agonists to Buprenorphine in Opioid Dependent Patients—A Critical Review

“…A recent case series of Soyka and Groß (2021) of patients with opioid use disorder in a custodial setting suggests that a rapid transfer from methadone, in part at high dosages, to depot buprenorphine via an initial 4 mg sublingual buprenorphine dose is possible. Microdosing techniques to introduce a patient to depot buprenorphine medication has been recently advocated also by Tay Wee Teck et al (2021) .…”