Buprenorphine: Difference between revisions
From IDWiki
(→: added Canadian guidelines) |
(added small periop section) |
||
| Line 1: | Line 1: | ||
== |
==Background== |
||
| ⚫ | |||
| ⚫ | |||
| ⚫ | |||
| ⚫ | |||
| ⚫ | |||
| ⚫ | |||
| ⚫ | |||
| ⚫ | |||
| ⚫ | |||
| ⚫ | |||
| ⚫ | |||
| ⚫ | |||
| ⚫ | |||
| ⚫ | |||
| ⚫ | |||
| ⚫ | |||
{| class="wikitable" |
{| class="wikitable" |
||
! |
!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=== |
||
| ⚫ | |||
| ⚫ | |||
| ⚫ | |||
| ⚫ | |||
| ⚫ | |||
| ⚫ | |||
{| class="wikitable" |
{| class="wikitable" |
||
! |
!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==== |
||
{| class="wikitable" |
{| class="wikitable" |
||
! |
!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==== |
||
{| class="wikitable" |
{| class="wikitable" |
||
! |
!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==== |
||
{| class="wikitable" |
{| class="wikitable" |
||
! |
!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 |
||
|} |
|} |
||
== |
=== Perioperative management === |
||
| ⚫ | |||
* 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== |
|||
| ⚫ | |||
| ⚫ | |||
| ⚫ | |||
[[Category:Opioid substitution therapy]] |
[[Category:Opioid substitution therapy]] |
||
Revision as of 00:08, 10 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 |
Perioperative management
- 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
