Buprenorphine
From IDWiki
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
- 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
