Buprenorphine: Difference between revisions
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== Background == |
== Background == |
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* Recommended as first-line treatment for [[opioid use disorder]] |
* Recommended as first-line treatment for [[opioid use disorder]] in Canadian guidelines |
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* Typically coformulated with naloxone (trade name Suboxone) at a dose of 2 mg buprenorphine to 0.5 mg naloxone |
* Typically coformulated with [[naloxone]] (trade name Suboxone) at a dose of 2 mg buprenorphine to 0.5 mg [[naloxone]] |
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* Buprenorphine is partial |
* Buprenorphine is partial μ-opioid receptor agonist |
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* Theoretical ceiling effect |
* Theoretical ceiling effect on side effects |
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== Dosing == |
== Dosing == |
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=== |
=== Standard Induction Protocol === |
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* 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 |
* 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 |
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* Day 1: Ensure they are in mild withdrawal ([[COWS]] ≥12), then give 4mg, wait a few hours, give another 4mg |
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* Day 2: 12mg |
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! Day !! Buprenorphine !! Opioid |
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* Day 3: 16mg; discharge and refer to Addictions clinic |
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| — || — || stop to ensure withdrawal ([[COWS]] ≥12) |
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| 1 || 2 to 4 mg + 2 mg q1h prn (max 12 mg) || none |
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| 2 || dose from yesterday + 2 mg q1h prn (max 16 mg) || none |
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=== Microdosing Protocol === |
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* Suboxone combined with a short-acting opioid such as [[hydromorphone]] |
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* In general, all opioids can be stopped once at a dose of buprenorphine 12 mg daily |
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==== Standard ==== |
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! Day !! Burprenorphine !! Short-acting opioid |
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| 1 || 0.5 mg || maintain |
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| 2 || 1 mg || maintain |
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| 3 || 1.5 mg || maintain |
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| 4 || 2 mg || maintain |
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| 5 || 2.5 mg || maintain |
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| 6 || 3 mg || maintain |
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| 7 || 4 mg + 2 mg q1h prn (max 12 mg) || stop |
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==== Moderate ==== |
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{| class="wikitable" |
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! Day !! Burprenorphine !! Short-acting opioid |
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| 1 || 0.5 mg daily || maintain |
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| 2 || 0.5 mg bid || maintain |
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| 3 || 1 mg bid || maintain |
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| 4 || 2 mg bid || maintain |
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| 5 || 3 mg bid || maintain |
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| 6 || 4 mg bid || maintain |
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| 7 || 5 mg bid || maintain |
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| 8 || 12 mg daily || stop |
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==== Rapid ==== |
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{| class="wikitable" |
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! Day !! Burprenorphine !! Short-acting opioid |
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| 1 || 0.5 mg q4h x4 || maintain |
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| 2 || 1 mg q4h x4 || maintain |
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| 3 || 2 mg q4h x4 || maintain |
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| 4 || 4 mg q4h x4 || stop |
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| 5 || 16 mg daily + 2 mg prn || stop |
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==== Ultra-rapid ==== |
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{| class="wikitable" |
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! Day !! Burprenorphine !! [[Hydromorphone]] |
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| 1 || 0.5 mg q3h (max 2.5 mg) || 3 mg po q4h + 2-4 mg po q4h prn |
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| 2 || 1 mg q3h (max 8 mg) || 3 mg po q4h + 2-4 mg po q4h prn |
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| 3 || 12 mg daily || stop |
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== Further Reading == |
== Further Reading == |
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Revision as of 13:38, 5 July 2020
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 Protocol
- 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
Standard
| 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 |
Moderate
| 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 |
| 5 | 3 mg bid | maintain |
| 6 | 4 mg bid | maintain |
| 7 | 5 mg bid | maintain |
| 8 | 12 mg daily | stop |
Rapid
| Day | Burprenorphine | Short-acting opioid |
|---|---|---|
| 1 | 0.5 mg q4h x4 | maintain |
| 2 | 1 mg q4h x4 | maintain |
| 3 | 2 mg q4h x4 | maintain |
| 4 | 4 mg q4h x4 | stop |
| 5 | 16 mg daily + 2 mg prn | stop |
Ultra-rapid
| Day | Burprenorphine | Hydromorphone |
|---|---|---|
| 1 | 0.5 mg q3h (max 2.5 mg) | 3 mg po q4h + 2-4 mg po q4h prn |
| 2 | 1 mg q3h (max 8 mg) | 3 mg po q4h + 2-4 mg po q4h prn |
| 3 | 12 mg daily | stop |
Further Reading
- Opioid Enabler
- Hämmig R et al. Use of microdoses for induction of buprenorphine treatment with overlapping full opioid agonist use: the Bernese method. Subst Abuse Rehabil. 2016; 7: 99–105.
