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
