Buprenorphine: Difference between revisions

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== Background ==
  
== Background ==
−
* Recommended as first-line treatment for [[opioid use disorder]]
 +
* 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
 +
* Typically coformulated with [[naloxone]] (trade name Suboxone) at a dose of 2 mg buprenorphine to 0.5 mg [[naloxone]]
−
* Buprenorphine is partial mu-opioid receptor agonist
 +
* Buprenorphine is partial μ-opioid receptor agonist
  ⚫
* Strong receptor affinity, displaces other opioids and can precipitate withdrawal
−
* Theoretical ceiling effect
 +
* Theoretical ceiling effect on side effects
⚫
* Strong receptor affinity, displaces other opioids
  
   
 
== Dosing ==
  
== Dosing ==
−
=== Full Start ===
 +
=== 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
  
* 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 1: Ensure they are in mild withdrawal ([[COWS]] ≥12), then give 4mg, wait a few hours, give another 4mg
  
  +
{| class="wikitable"
−
* Day 2: 12mg
  
  +
! Day !! Buprenorphine !! Opioid
−
* Day 3: 16mg; discharge and refer to Addictions clinic
  
  +
|-
  +
| — || — || 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 ====
  +
{| 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"
  +
! 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"
  +
! 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"
  +
! 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 ==
  
== Further Reading ==

Revision as of 09:38, 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

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