Inpatient Low-dose Transitions From Full Agonist Opioids Including Methadone Onto Long-acting Depot Buprenorphine: Case Series From a Multicenter Clinical Trial

Abstract

Objectives: Persons with opioid use disorder (OUD) suffer disproportionately from morbidity and mortality related to serious addictionrelated infections requiring hospitalization. Long-acting buprenorphine (LAB) is an underused medication for OUD that may facilitate linkage to care and treatment retention when administered before hospital discharge. Transition onto buprenorphine in the inpatient setting is often complicated by pain, active infection management, potential surgical interventions, and risk of opioid withdrawal in transition from full agonists to a partial agonist. Methods: The COMMIT Trial is a randomized controlled trial evaluating LAB administered by infectious disease physicians and hospitalists compared with treatment as usual for persons with OUD hospitalized with infections. We report a case series of participants on full agonist opioids including methadone who were transitioned to sublingual buprenorphine using low-dose (microdosing) strategies followed by LAB injection. Results: Seven participants with current opioid use disorder and life-threatening infections, all with significant concurrent pain and many requiring surgical intervention, underwent low-dose transitions starting at buccal buprenorphine doses ranging from 225 μg to 300 μg 3 times a day on the first day. All were well tolerated with average time to LAB injection of 7.5 days (range, 5-10 days).Conclusions: Inpatient low-dose buprenorphine transition from full agonist opioids including methadone onto LAB is feasible even in those with complex hospitalizations for concurrent infections and/or surgery. This strategy facilitates dosing of LAB before hospital discharge when risk of opioid relapse and overdose are significant.

Evaluation of Low-dose Buprenorphine Initiation With Buprenorphine Buccal Films in Hospitalized Patients: A Retrospective Cohort Study

“…23 To circumvent some of these challenges, centers have more recently adopted use of buprenorphine buccal films to facilitate LDBI, as they are supplied in low doses that prevent the need for product manipulation, are easily titratable, and seem to be cost-effective. 17,24,25 This study provides further evidence of the feasibility of buccal buprenorphine-based initiation strategies. We describe 4-and 7-day novel titration protocols that were both effective and safe in the hospitalized setting.…”

“…Buprenorphine IV solution has a short half-life requiring frequent administration and may be costly 23 . To circumvent some of these challenges, centers have more recently adopted use of buprenorphine buccal films to facilitate LDBI, as they are supplied in low doses that prevent the need for product manipulation, are easily titratable, and seem to be cost-effective 17,24,25 . This study provides further evidence of the feasibility of buccal buprenorphine-based initiation strategies.…”

ASAM Clinical Considerations: Buprenorphine Treatment of Opioid Use Disorder for Individuals Using High-potency Synthetic Opioids

“…3,4,16,35 Receipt of XR buprenorphine has also been described after both LDB-OC and HDB initiations. 16,39,42 Evidence is limited for XR buprenorphine for pregnant individuals. 43 One case series raises concern about the efficacy of XR buprenorphine (Sublocade) alone and describes that supplementation with SL buprenorphine may be needed in the first 1-3 months of treatment.…”

“…Initial guidance recommended a 7-day period of SL buprenorphine lead-in, but the ASAM NPG states “only 1 dose of SL buprenorphine is needed before XR buprenorphine initiation,” and this has been described in case reports 3,4,16,35 . Receipt of XR buprenorphine has also been described after both LDB-OC and HDB initiations 16,39,42 …”

Low Dose Buprenorphine Initiation: A Guide for the Inpatient Clinician

“…While vast, evidence surrounding LDBI is limited to case series, [8][9][10][11][12] feasibility studies, 13 single-arm retrospective cohort studies, [14][15][16] and comparative studies using historical controls. 17 There are no prospective, randomized studies directly comparing clinical outcomes of varying buprenorphine dosing strategies.…”