Buprenorphine

From IDWiki

Background

  • Recommended as first-line treatment for opioid use disorder in Canadian guidelines
  • Typically coformulated with naloxone (trade name Suboxone) at a dose of 2 mg buprenorphine to 0.5 mg naloxone
  • Buprenorphine is partial μ-opioid receptor agonist
  • Strong receptor affinity, displaces other opioids and can precipitate withdrawal
  • Theoretical ceiling effect on side effects

Dosing

Standard Induction Protocol

  • It's use can precipitate withdrawal, so wait 12-24h after short-acting opioids, 18-36h after long-acting, or after tapering methadone, before starting buprenorphine
Day Buprenorphine Opioid
stop to ensure withdrawal (COWS ≥12)
1 2 to 4 mg + 2 mg q1h prn (max 12 mg) none
2 dose from yesterday + 2 mg q1h prn (max 16 mg) none

Microdosing Protocols

  • Suboxone combined with a short-acting opioid such as hydromorphone
  • In general, all opioids can be stopped once at a dose of buprenorphine 12 mg daily

Short-Acting Opioids (Daily Dosing)

Day Burprenorphine Short-acting opioid
1 0.5 mg maintain
2 1 mg maintain
3 1.5 mg maintain
4 2 mg maintain
5 2.5 mg maintain
6 3 mg maintain
7 4 mg + 2 mg q1h prn (max 12 mg) stop

Short-Acting Opioids (Twice-Daily Dosing)

Day Burprenorphine Short-acting opioid
1 0.5 mg daily maintain
2 0.5 mg bid maintain
3 1 mg bid maintain
4 2 mg bid + 2 mg q1h prn (maximum of 12 mg) stop

Long-Acting Opioids (Daily Dosing)

  • Including fentanyl, fentanyl patches, and methadone
Day Burprenorphine Short-acting opioid
1 0.5 mg maintain
2 1 mg maintain
3 1.5 mg maintain
4 2 mg maintain
5 2.5 mg maintain
6 3 mg maintain
7 4 mg maintain long-acting; stop any short-acting opioids
8 5 mg maintain
9 6 mg maintain
10 7 mg maintain
11 8 mg maintain
12 10 mg maintain
13 12 mg maintain
14 12 mg stop all remaining opioids

Long-Acting Opioids (Twice-Daily Dosing)

Day Burprenorphine Short-acting opioid
1 0.5 mg daily maintain
2 0.5 mg bid maintain
3 1 mg bid maintain
4 2 mg bid maintain long-acting, stop any short-acting opioids
5 3 mg bid maintain
6 4 mg bid maintain
7 12 mg + 2 mg q1h prn (maximum 16 mg) stop all remaining opioids

Extended-Release Monthly Injection (BUP-XR)

  • Consider once stabilized on 8 to 24 mg buprenorphine for at least 7 days
  • 300 mg SC monthly for the first 2 months, followed by 100 mg SC monthly maintenance

Perioperative Management

  • Ideally, continue buprenorphine treatment without interruption and use higher doses of opioid analgesia
  • If going to hold buprenorphine for surgery:
    • Consider tapering to 12 mg daily 2 to 3 days prior to surgery, or as low as 8 mg if a large or painful surgery
    • For the surgery itself, use NSAIDs, fentanyl, regional blocks, adjuncts, and non-pharmacologic options
    • Post-op, resume original dose as soon as possible, possibly split bid to tid to optimize for pain control, and continue non-buprenorphine pain management, including full agonist opioids if needed

Further Reading