Buprenorphine

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