Buprenorphine/naloxone induction for treatment of acute on chronic pain using a micro-dosing regimen: A case report

Abstract

Background: Due to its unique pharmacologic properties, efficacy as an analgesic, and role as a first-line medication for the treatment of opioid use disorder, sublingual buprenorphine has emerged as a treatment for patients with concurrent chronic pain and opioid use disorders. One challenge to utilizing buprenorphine is that precipitated opioid withdrawal can result if this medication is initiated in the presence of other opiates with lesser binding affinities. Microdosing induction regimens utilize a slower titration to avoid the need for a period of abstinence from other opiates and decrease the risk of precipitated withdrawal. Aims: The aim of this article is to present a case where a standardized micro-dosing induction regimen was used to transition a patient from other opiate analgesia to a sublingual formulation of buprenorphine/naloxone. Methods: This case took place on an inpatient neurosurgical unit of a Canadian tertiary-care city hospital. Written informed consent was collected prior to a detailed chart review. Results: Here we present a case of a postoperative neurosurgical inpatient who was referred to our team for pain management in the context of chronic pain and a past history of opioid use disorder. She was successfully transitioned to buprenorphine/naloxone, replacing all other opioid analgesia, without a period of opioid withdrawal using a micro-dosing induction regimen. Conclusions: Sublingual buprenorphine/naloxone can be safe and effective for treatment of chronic pain, particularly for those with past or current opioid use disorder. Micro-dosing provides a preferable induction strategy for patients who are not able to tolerate the requirement for moderate opioid withdrawal prior to initiation with existing regimens. RÉSUMÉ

Ambulatory microdose induction of buprenorphine‐naloxone in two adolescent patients with sickle cell disease

“…3 Case reports describe alternative approaches utilizing small, frequent doses of buprenorphine-naloxone to avoid withdrawal symptoms, and rapidly transition patients off full agonist opioids. [4][5][6][7][8][9][10][11][12][13] None of these case studies include adolescents or individuals with SCD.…”

“…Historically, induction of buprenorphine in opioid‐dependent individuals required mild to moderate opioid withdrawal and cessation of full opioid agonists for 24‐48 h in a clinical setting 3 . Case reports describe alternative approaches utilizing small, frequent doses of buprenorphine‐naloxone to avoid withdrawal symptoms, and rapidly transition patients off full agonist opioids 4–13 . None of these case studies include adolescents or individuals with SCD.…”

Buprenorphine-naloxone microdosing

“…5 Higher doses of buprenorphine might be required for longer-acting opioids ( Table 1). [4][5][6][7][8] The role of naloxone in buprenorphine-naloxone is to discourage injection or snorting of the drug, as the naloxone would become an active compound and precipitate withdrawal. 9 When taken orally or sublingually, naloxone has minimal absorption and does not antagonize buprenorphine or other opioids in the central nervous system.…”

Case report: Successful induction of buprenorphine/naloxone using a microdosing schedule and assertive outreach

“…The Bernese Method is a potential compliment to patients who want treatment with buprenorphine/naloxone, but are adverse to the traditional induction method because of the need for withdrawal and/or have difficulty attending scheduled appointments. This method has also shown promise for other indications such as pain management [19].…”