Case Series: Limited Opioid Withdrawal With Use of Transdermal Buprenorphine to Bridge to Sublingual Buprenorphine in Hospitalized Patients

Tang, Victor M.; Lam-Shang-Leen, Jessica; Hansen, K.; Caudarella, Alexander; Lamba, Wiplove; Guimond, Tim

doi:10.1111/ajad.12964

Cited by 23 publications

(60 citation statements)

References 18 publications

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“…27,[35][36][37][38][39][40][48][49][50]52,54,55 Transdermal buprenorphine was used exclusively in 2 protocols. 46,51 Two protocols provided multiple buprenorphine formulations. 47,53 Buprenorphine sublingual or buccal dosing varied widely, from a first-day total dose of 600 μg 27 to a maximum possible dose of 32 mg. 49,50 Nine protocols divided administration into 2 to 4 doses per day.…”

Section: Rotation Protocolsmentioning

confidence: 99%

“…Rotation to buprenorphine was associated with decreased pain severity in 12 of 17 studies (70.6%). 35,36,42,43,[46][47][48][49][50][51][52]54 For example, Roux et al 36 found that higher doses of buprenorphine were associated with better pain control among participants. Under the highest dose condition (16 mg vs 2 mg), the McGill Pain Questionnaire scores significantly decreased (odds ratio, 0.42; 95% CI, 0.20-0.90).…”

Section: Pain Severity and Interferencementioning

confidence: 99%

“…The 17 studies that examined this outcome included 4 small RCTs, 27,35-37 5 controlled observational studies, 39,40,42-44 and 8 uncontrolled observational studies. [46][47][48][49][50][51][52]54 Substantial heterogeneity in timing of pain assessment was found, with some studies assessing pain immediately after buprenorphine was administered 27,36 and other studies assessing pain only at the end of the study period 37,49,50 or after buprenorphine was discontinued. 39 Only 7 studies used detailed, validated instruments, such as the Brief Pain Inventory 37,[42][43][44]54 and McGill Pain Questionnaire.…”

Section: Pain Severity and Interferencementioning

confidence: 99%

“…36,46 Other studies used unidimensional pain assessments, such as the visual analog scale or numeric rating scale, 27,39,40,[48][49][50]52 or unvalidated measures. 35,47,51 Pain interference may decrease after rotation to buprenorphine, but only 4 studies examined this outcome and all had high risk of bias. 35,37,47,54 Neumann et al 37 found a 21.4% improvement in self-reported function overall but was underpowered to detect a difference that was specific to the buprenorphine group.…”

Section: Pain Severity and Interferencementioning

confidence: 99%

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Evaluation of Buprenorphine Rotation in Patients Receiving Long-term Opioids for Chronic Pain

et al. 2021

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IMPORTANCE Individuals with chronic pain who use long-term opioid therapy (LTOT) are at risk of opioid use disorder and other harmful outcomes. Rotation to buprenorphine may be considered, but the outcomes of such rotation in this population have not been systematically reviewed.OBJECTIVE To synthesize the evidence on rotation to buprenorphine from full μ-opioid receptor agonists among individuals with chronic pain who were receiving LTOT, including the outcomes of precipitated opioid withdrawal, pain intensity, pain interference, treatment success, adverse events or adverse effects, mental health condition, and health care use. EVIDENCE REVIEW PubMed, CINAHL, Embase, and PsycInfo were searched from inception through November 3, 2020, for peer-reviewed original English-language research that reported the prespecified outcomes of rotation from prescribed long-term opioids to buprenorphine among individuals with chronic pain. Two independent reviewers extracted data as well as assessed risk of bias and study quality according to the Preferred Reporting Items for Systematic Reviews and Metaanalyses (PRISMA) reporting guidelines. Quality of evidence was assessed with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. FINDINGS A total of 22 studies were analyzed, of which 5 (22.7%) were randomized clinical trials, 7 (31.8%) were case-control or cohort studies, and 10 (45.5%) were uncontrolled pre-post studies, which involved 1616 unique participants (675 female [41.8%] and 941 male [58.2%] individuals). Six of the 22 studies (27.3%) were primary or secondary analyses of a large randomized clinical trial.Participants had diverse pain and opioid use histories. Rationale for buprenorphine rotation included inadequate analgesia, intolerable adverse effects, risky opioid regimens (eg, high dose and/or sedative coprescriptions), and aberrant opioid use. Most protocols were adapted from protocols for initiating treatment in patients with opioid use disorder and used buccal or sublingual buprenorphine. Very low-quality evidence suggested that buprenorphine rotation was associated with maintained or improved analgesia, with a low risk of precipitating opioid withdrawal. Steadydose buprenorphine was better tolerated than tapered-dose buprenorphine. Adverse effects were manageable, and severe adverse events were rare. Only 2 studies evaluated mental health outcomes, but none evaluated health care use. Limitations included a high risk of bias in most studies. CONCLUSIONS AND RELEVANCEIn this systematic review, buprenorphine was associated with reduced chronic pain intensity without precipitating opioid withdrawal in individuals with chronic pain who were receiving LTOT. Future studies are necessary to ascertain the ideal starting dose, formulation, and administration frequency of buprenorphine as well as the best approach to buprenorphine rotation.

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Section: Rotation Protocolsmentioning

confidence: 99%

Section: Pain Severity and Interferencementioning

confidence: 99%

Section: Pain Severity and Interferencementioning

confidence: 99%

Section: Pain Severity and Interferencementioning

confidence: 99%

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Evaluation of Buprenorphine Rotation in Patients Receiving Long-term Opioids for Chronic Pain

et al. 2021

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“…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.…”

Section: Introductionmentioning

confidence: 99%

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

Crane

Snead

Stanley

et al. 2021

Journal of the Academy of Consultation-Liaison Psychiatry

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Introduction Buprenorphine in the treatment of opioid use disorder (OUD) has several benefits including better long-term treatment adherence (1) and is a safer option for many patients due to buprenorphine’s limited potential to cause respiratory depression (4). In comparison to standard buprenorphine induction, induction via micro-dosing does not require a period of withdrawal and dramatically shortens the time required to complete induction. Prior micro-dosing protocols using sublingual (SL) (7-10) and transdermal forms (11) have been reported. We present a case of buprenorphine induction using a novel inpatient intravenous micro-dosing 4-day protocol in a patient on methadone. Case Presentation A 62-year-old man with chronic obstructive pulmonary disease (COPD) on chronic methadone 80mg daily for OUD presented with respiratory failure and was diagnosed with opioid overdose. He was transitioned from a naloxone infusion to intravenous micro-doses of buprenorphine and low dose methadone without experiencing significant withdrawal, and he was discharged on buprenorphine/naloxone SL. Discussion This case demonstrates a successful and well tolerated buprenorphine induction without interruption of methadone treatment or precipitation of significant opioid withdrawal. To the best of our knowledge, this is the first report describing micro-induction with intravenous buprenorphine.

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Buprenorphine initiation strategies for opioid use disorder and pain management: A systematic review

et al. 2022

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Buprenorphine possesses many unique attributes that make it a practical agent for adults and adolescents with opioid use disorder (OUD) and/or acute or chronic pain. Sublingual buprenorphine has been the standard of care for treating OUD, but its use in pain management is not as clearly defined. Current practice guidelines recommend a period of mild‐to‐moderate withdrawal from opioids before transitioning to buprenorphine due to its ability to displace full agonists from the μ‐opioid receptor. However, this strategy can lead to negative physical and psychological outcomes for patients. Novel initiation strategies suggest that concomitant administration of small doses of buprenorphine with opioids can avoid the unwanted withdrawal associated with buprenorphine initiation. We aim to systematically review the buprenorphine initiation strategies that have emerged in the last decade. Embase, PubMed, and Cochrane Databases were searched for relevant literature. Studies were included if they were published in the English language and described the transition to buprenorphine from opioids. Data were collected from each study and synthesized using descriptive statistics. This review included 7 observational studies, 1 feasibility study, and 39 case reports/series which included 924 patients. The strategies utilized between the literature included traditional initiation (47.9%), microdosing with various buprenorphine formulations (16%), and miscellaneous methods (36.1%). Traditional initiation and microdosing initiation were compared in the data synthesis and analysis; miscellaneous methods were omitted given the high variability between methods. Overall, 95.6% of patients in the traditional initiation group and 96% of patients in the microdosing group successfully rotated to sublingual buprenorphine. Initiation regimens can vary widely depending on patient‐specific factors and buprenorphine formulation. A variety of buprenorphine transition strategies are published in the literature, many of which were effective for patients with OUD, pain, or both.

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Case Series: Limited Opioid Withdrawal With Use of Transdermal Buprenorphine to Bridge to Sublingual Buprenorphine in Hospitalized Patients

Cited by 23 publications

References 18 publications

Evaluation of Buprenorphine Rotation in Patients Receiving Long-term Opioids for Chronic Pain

Evaluation of Buprenorphine Rotation in Patients Receiving Long-term Opioids for Chronic Pain

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

Buprenorphine initiation strategies for opioid use disorder and pain management: A systematic review

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