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

Abstract

Background: The requirement for moderate withdrawal prior to initiation can be a barrier to buprenorphine/naloxone induction. Case presentation: We aimed to use a microdosing regimen to initiate regular dosing of buprenorphine/naloxone in a high-risk patient with a history of failed initiations due, in part, to withdrawal symptoms. Using an assertive outreach model and a buprenorphine/naloxone microdosing schedule, we initiated treatment of an individual's opioid use disorder. There was a successful buprenorphine/naloxone microdosing induction as the team reached a therapeutic dose of buprenorphine/naloxone. Including the induction period, the medication was used consistently for 4 weeks. Conclusions: A microdosing schedule can be used to induce a patient onto buprenorphine/naloxone with no apparent withdrawal; gradually reducing illicit substance use. This case report builds on previous literature, highlighting ways to minimize barriers to induction of buprenorphine/naloxone, using a microdosing schedule and assertive outreach. Given the safety profile of buprenorphine and its potential to be a lifesaving intervention, a larger study of microdosing is indicated.

Comparing rapid micro-induction and standard induction of buprenorphine/naloxone for treatment of opioid use disorder: protocol for an open-label, parallel-group, superiority, randomized controlled trial

“…To overcome the difficulties of a standard induction method of buprenorphine, a novel induction method, known as micro-induction (also called micro-dosing), is being explored and increasingly employed by many clinicians in Canada, the United States, and other parts of the world [13][14][15][16][17][18][19][20][21]. This induction method was first described as the Bernese method in a Swiss case series in 2016 [14].…”

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.…”

Intravenous Buprenorphine Micro-dosing Induction in a Patient on Methadone Treatment: A Case Report

“…Unlike traditional induction, buprenorphine micro-dosing allows for initiation of buprenorphine without requiring a period of opioid withdrawal. Successful protocols utilizing sublingual (SL) 7 , 8 , 9 , 10 and transdermal 11 forms have been reported. Micro-dosing is intended to both improve tolerability and decrease duration of induction.…”