Microdosing and standard‐dosing take‐home buprenorphine from the emergency department: A feasibility study

Abstract

Objective: Emergency department (ED)-initiated buprenorphine may prevent overdose. Microdosing is a novel approach that does not require withdrawal, which can be a barrier to standard inductions. We aimed to evaluate the feasibility of an EDinitiated buprenorphine/naloxone program providing standard-dosing and microdosing take-home packages and of randomizing patients to either intervention. Methods: We broadly screened patients ≥18 years old for opioid use disorder at a large, urban ED. In a first phase, we provided consecutive patients with 3-day standarddosing packages, and then we provided a subsequent group with 6-day microdosing packages. In a second phase, we randomized patients to standard dosing or microdosing. We attempted 7-day telephone follow-ups and 30-day in-person community follow-ups. The primary feasibility outcome was number of patients enrolled and

Reddit discussions about buprenorphine associated precipitated withdrawal in the era of fentanyl

“…16 Our finding of multiple dosing regimens of buprenorphine microdosing (Table 3) is comparable to the multiple different dosing regimens described in case reports with a few exceptions. 2,3,8,9 For example, the lowest dose described in our data started at 0.125 mg of buprenorphine. Hammig et al (2016) describe one of the lowest starting doses of buprenorphine at 0.2 mg of buprenorphine, although their microdosing method was developed to avoid withdrawal during an abstinence period rather than avoiding POW among people with history of fentanyl use.…”

“…2 For the regimens we found that specified the time duration of microdosing initiation, the range was from 5-8 days, comparable to existing medical literature. 2,3,8 While Klaire et al (2019) describe a strategy for an in-hospital rapid uptitration of buprenorphine in 3 days, the largest study of outpatient treatment by Moe et al (2020), employed a 7 day incremental uptitration initiated in the emergency department. 8,9 While there is insufficient evidence to recommend a specific dosing regimen, these experiences should encourage clinicians who treat OUD to take a patient symptom guided approach.…”

“…2,3,8 While Klaire et al (2019) describe a strategy for an in-hospital rapid uptitration of buprenorphine in 3 days, the largest study of outpatient treatment by Moe et al (2020), employed a 7 day incremental uptitration initiated in the emergency department. 8,9 While there is insufficient evidence to recommend a specific dosing regimen, these experiences should encourage clinicians who treat OUD to take a patient symptom guided approach. Currently a randomized control trial has been proposed to compare a rapid microinduction of buprenorphine versus a standard buprenorphine induction in Vancouver, Canada.…”

“…However, several different regimens have been described in the medical literature. 2,6,8,9 While there is growing literature on this subject, many people with OUD have discovered these methods through their own lived experiences. 10 Paradoxically, POW is not a consistent phenomenon, as fentanyl use is highly prevalent in some regions of the United States now and buprenorphine initiation is not routinely complicated by POW in most areas.…”

Using Microdosing to Induct Patients Into a Long-Acting Injectable Buprenorphine Depot Medication in Low Threshold Community Settings: A Case Study

“…There are a limited number of good practice guidelines produced mainly by Canadian healthcare organizations ( McLean, 2018 ; Saskatchewan College of Pharmacy Professionals, 2020 ; The College of Physicians and Surgeons of Manitoba, 2020 ) which have used microdosing extensively where conventional induction methods are not possible and/or practical. Several variations in the original Bernese method are available ( Hämmig et al, 2016 ; Lu and Cho, 2018 ; McLean, 2018 ; Klaire et al, 2019 ; Terasaki et al, 2019 ; St.Vincent’s Department of Addiction Medicine, 2019 ; Moe et al, 2020 ; Rozylo et al, 2020 ; Saskatchewan College of Pharmacy Professionals, 2020 ; The College of Physicians and Surgeons of Manitoba, 2020 ; James et al, 2021 ) depending on prescriber and/or clinical settings, with starting dosages ranging from 0.2 to 0.5 mg daily. Table 1 outlines some of these regimens ranging from a 7–11-days induction period.…”