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
- Management of opioid use disorders: a national clinical practice guideline. CMAJ. 2018;190(9):E247-E257. doi: 10.1503/cmaj.170958
- Opioid Enabler cheat sheet from Portico Network
- Use of microdoses for induction of buprenorphine treatment with overlapping full opioid agonist use: the Bernese method. Subst Abuse Rehabil. 2016; 7: 99–105. doi: 10.2147/SAR.S109919
- Buprenorphine/Naloxone Microdosing: The Bernese Method. A Brief Summary for Primary Care Clinicians. 2019. Available at https://www.metaphi.ca/wp-content/uploads/Guide_Microdosing.pdf
