Buprenorphine Cross-Tapering using a Micro-dosing 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 COWS scores) 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 the buprenorphine buccal films (Belbuca®), which are dosed in micrograms, allowing for the induction of buprenorphine without the need to first experience withdrawal or the risk of precipitated withdrawal given the very small doses. Doses are increased over 3-4 days to achieve full maintenance dosing. Case reports and case series support this approach in hospital settings, and we have successfully completed buprenorphine induction using this approach in two patients at HUP.

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 had a history of illicit opioid use (fentanyl)- UDS confirmation not necessary

AND

Who wish to avoid the need for moderate 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. On full opioid agonist for treatment of pain but also with OUD, as means to initiate buprenorphine for treatment of OUD while cross tapering full agonist therapy for pain control.

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