Buprenorphine: Difference between revisions

From IDWiki
(→: added Canadian guidelines)
(added BUP-XR)
 
(4 intermediate revisions by the same user not shown)
Line 1: Line 1:
== Background ==
==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


*Recommended as first-line treatment for [[opioid use disorder]] in Canadian guidelines
== Dosing ==
*Typically coformulated with [[naloxone]] (trade name Suboxone) at a dose of 2 mg buprenorphine to 0.5 mg [[naloxone]]
=== Standard Induction Protocol ===
*Buprenorphine is partial μ-opioid receptor agonist
* 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
*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


{| class="wikitable"
{| class="wikitable"
! Day !! Buprenorphine !! Opioid
!Day!!Buprenorphine!!Opioid
|-
|-
| — || — || stop to ensure withdrawal ([[COWS]] ≥12)
|—||—||stop to ensure withdrawal ([[COWS]] ≥12)
|-
|-
| 1 || 2 to 4 mg + 2 mg q1h prn (max 12 mg) || none
|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
|2||dose from yesterday + 2 mg q1h prn (max 16 mg)||none
|}
|}


=== Microdosing Protocol ===
===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


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

====Short-Acting Opioids (Daily Dosing)====
{| class="wikitable"
{| class="wikitable"
! Day !! Burprenorphine !! Short-acting opioid
!Day!!Burprenorphine!!Short-acting opioid
|-
|-
| 1 || 0.5 mg || maintain
|1||0.5 mg||maintain
|-
|-
| 2 || 1 mg || maintain
|2||1 mg||maintain
|-
|-
| 3 || 1.5 mg || maintain
|3||1.5 mg||maintain
|-
|-
| 4 || 2 mg || maintain
|4||2 mg||maintain
|-
|-
| 5 || 2.5 mg || maintain
|5||2.5 mg||maintain
|-
|-
| 6 || 3 mg || maintain
|6||3 mg||maintain
|-
|-
| 7 || 4 mg + 2 mg q1h prn (max 12 mg) || stop
|7||4 mg + 2 mg q1h prn (max 12 mg)||stop
|}
|}


==== Short-Acting Opioids (Twice-Daily Dosing) ====
==== Moderate ====
{| class="wikitable"
{| class="wikitable"
! Day !! Burprenorphine !! Short-acting opioid
!Day!!Burprenorphine!!Short-acting opioid
|-
|-
| 1 || 0.5 mg daily || maintain
|1||0.5 mg daily||maintain
|-
|-
| 2 || 0.5 mg bid || maintain
|2||0.5 mg bid||maintain
|-
|-
| 3 || 1 mg bid || maintain
|3||1 mg bid||maintain
|-
|-
| 4 || 2 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

{| class="wikitable"
!Day!!Burprenorphine!!Short-acting opioid
|-
|-
| 5 || 3 mg bid || maintain
|1||0.5 mg||maintain
|-
|-
| 6 || 4 mg bid || maintain
|2||1 mg||maintain
|-
|-
| 7 || 5 mg bid || maintain
|3||1.5 mg||maintain
|-
|-
| 8 || 12 mg daily || stop
|4||2 mg||maintain
|}

==== Rapid ====
{| class="wikitable"
! Day !! Burprenorphine !! Short-acting opioid
|-
|-
| 1 || 0.5 mg q4h x4 || maintain
|5||2.5 mg||maintain
|-
|-
| 2 || 1 mg q4h x4 || maintain
|6||3 mg||maintain
|-
|-
|7||4 mg||maintain long-acting; stop any short-acting opioids
| 3 || 2 mg q4h x4 || maintain
|-
|-
|8
| 4 || 4 mg q4h x4 || stop
|5 mg
|maintain
|-
|-
|9
| 5 || 16 mg daily + 2 mg prn || stop
|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
|}
|}


==== Ultra-rapid ====
====Long-Acting Opioids (Twice-Daily Dosing)====
{| class="wikitable"
{| class="wikitable"
! Day !! Burprenorphine !! [[Hydromorphone]]
!Day!!Burprenorphine!!Short-acting opioid
|-
|-
|1||0.5 mg daily||maintain
| 1 || 0.5 mg q3h (max 2.5 mg) || 3 mg po q4h + 2-4 mg po q4h prn
|-
|-
|2||0.5 mg bid||maintain
| 2 || 1 mg q3h (max 8 mg) || 3 mg po q4h + 2-4 mg po q4h prn
|-
|-
| 3 || 12 mg daily || stop
|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) ===
== Further Reading ==

* Management of opioid use disorders: a national clinical practice guideline. ''CMAJ''. 2018;190(9):E247-E257. doi: [https://doi.org/10.1503/cmaj.170958 10.1503/cmaj.170958]
* Consider once stabilized on 8 to 24 mg buprenorphine for at least 7 days
* [https://www.porticonetwork.ca/documents/204049/0/Opioids+enabler+PDF/f67d20ec-3666-489a-a2dc-ebb5d63225f6 Opioid Enabler] cheat sheet from Portico Network
* 300 mg SC monthly for the first 2 months, followed by 100 mg SC monthly maintenance
* 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: [https://doi.org/10.2147/SAR.S109919 10.2147/SAR.S109919]

=== 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: [https://doi.org/10.1503/cmaj.170958 10.1503/cmaj.170958]
*[https://www.porticonetwork.ca/documents/204049/0/Opioids+enabler+PDF/f67d20ec-3666-489a-a2dc-ebb5d63225f6 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: [https://doi.org/10.2147/SAR.S109919 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


[[Category:Opioid substitution therapy]]
[[Category:Opioid substitution therapy]]

Latest revision as of 21:22, 12 March 2023

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

Retrieved from "https://idwiki.org/index.php?title=Buprenorphine&oldid=9868"
Powered by MediaWiki
Powered by Semantic MediaWiki