Buprenorphine Low-Dose Induction using a Cross-Tapering Strategy

Background

Buprenorphine is a mu-opioid receptor partial agonist that is indicated for pain management and the treatment of opioid use disorder (OUD). Traditional induction for patients with OUD requires a patient to experience opioid withdrawal (measured via the COWS score) prior to buprenorphine initiation. This is necessary in order to prevent the experience of precipitated withdrawal due to the partial agonist effects in the setting of a full opioid agonist when using high doses of buprenorphine (mg doses). Micro-dosing of buprenorphine uses microgram (mcg) doses, allowing for the induction of buprenorphine without the need to first experience withdrawal or the risk of precipitated withdrawal given the very small doses. In the inpatient setting, this can be accomplished through several formulations of buprenorphine that can be given in micrograms — buccal films (Belbuca®), patches (Butrans®), and intravenous buprenorphine. In the outpatient setting, this can be accomplished through cutting of sublingual films into smaller pieces. Doses are increased over 3-7 days to achieve full maintenance dosing.

Intent

For use as an alternative to standard or higher-dose buprenorphine induction strategies

Intended Patient Population

1. Patients requesting buprenorphine treatment for OUD who have a history of illicit opioid use (fentanyl, in most cases) – UDS confirmation not necessary

AND

Who wish to avoid the need for moderate-severe withdrawal symptoms prior to induction with higher doses of buprenorphine.

• For example:
  • Patients wishing to transition from methadone to buprenorphine
  • Patients with chronic, heavy use of IV or intranasal fentanyl
  • Patients who have experienced prior precipitated withdrawal

2. In hospitalized patients, those who are being maintained on a full opioid agonist for the treatment of pain or withdrawal. In outpatients, those who are continuing to use full agonist opioids through the induction process.

• For example:
  • Patients admitted with acute pain and concomitant OUD, requiring full agonist therapy for analgesia but wishing to initiate buprenorphine
  • Patients on chronic opioids for analgesia and diagnosed with OUD who would like to be transitioned to buprenorphine for MOUD