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

Abstract

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.

The Pharmacology of Buprenorphine Microinduction for Opioid Use Disorder

“…A total of 20 reports provided data relevant to our research question (Table 1 ) [ 44 – 52 , 65 – 78 ]. One was an open-label study, ten were case series, and nine were individual case reports.…”

Transition From Full Mu Opioid Agonists to Buprenorphine in Opioid Dependent Patients—A Critical Review

“…There are also some novel techniques including microinduction of buprenorphine ( Payler, 2016 ; Crane et al, 2020 ), use of transdermal buprenorphine patch ( Raheemullah and Lembke, 2019 ), or other “bridge” techniques (Fentanyl, hydromorphone, slow release morphine, or others), or the concomitant administration of lofexidine, analgesics, or psychotropic drugs to reduce withdrawal symptoms. The possible advantage of microdosing technique is to minimize the risk for precipitated withdrawal and to improve patient comfort.…”

“…In Canada slow release morphine was used for transferring patients on methadone to buprenorphine ( Ghosh et al, 2019a ). Finally, Crane et al (2020) reported the case of a 62-year-old patient on chronic methadone 80 mg daily referred to an emergency department with opioid overdose. He received 0.4 mg IV naloxone twice, then a naloxone infusion at 0.06 mg/h was started and an IV buprenorphine microdosing induction was initiated without interruption of methadone treatment.…”

“…A very recent review on microinduction of buprenorphine/naloxone identied 18 papers with 63 patients who were successfully transitioned using microdosing techniques, mostly case reports and series ( Ahmed et al, 2021 ). A variety of dosing schemes were used, with initial doses of often 0.2–0.5 mg ( Hämmig et al, 2016 ; Payler, 2016 ; Caulfield et al, 2020 ; Crane et al, 2020 ; Rozylo et al, 2020 ). The time frame for transition ranged from 3 to 112 (!)…”

Treating Chronic Pain with Buprenorphine—The Practical Guide

“…The strategy of microdosing was originally published by a group from Bern, Switzerland, and hence is called the "Bernese" microdosing strategy [60•]. Within the last 3 years, multiple groups have reported success with this approach in converting patients to buprenorphine [61][62][63][64][65][66]. The potent opioid is continued until SL buprenorphine doses are 8-12 mg. Buprenorphine gradually blocks the potent opioid access to MOR and becomes the primary analgesic or maintenance opioid.…”