Buprenorphine: Difference between revisions
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+ | ==Background== |
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− | == Further Reading == |
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+ | *Recommended as first-line treatment for [[opioid use disorder]] in Canadian guidelines |
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− | * [https://www.porticonetwork.ca/documents/204049/0/Opioids+enabler+PDF/f67d20ec-3666-489a-a2dc-ebb5d63225f6 Opioid Enabler] |
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+ | *Typically coformulated with [[naloxone]] (trade name Suboxone) at a dose of 2 mg buprenorphine to 0.5 mg [[naloxone]] |
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− | * Hämmig R ''et al.'' [https://dx.doi.org/10.2147%2FSAR.S109919 Use of microdoses for induction of buprenorphine treatment with overlapping full opioid agonist use: the Bernese method]. ''Subst Abuse Rehabil''. 2016; 7: 99–105. |
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+ | *Buprenorphine is partial μ-opioid receptor agonist |
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+ | *Strong receptor affinity, displaces other opioids and can precipitate withdrawal |
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+ | *Theoretical ceiling effect on side effects |
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+ | |||
+ | ==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 |
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+ | |||
+ | {| class="wikitable" |
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+ | !Day!!Buprenorphine!!Opioid |
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+ | |- |
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+ | |—||—||stop to ensure withdrawal ([[COWS]] ≥12) |
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+ | |- |
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+ | |1||2 to 4 mg + 2 mg q1h prn (max 12 mg)||none |
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+ | |- |
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+ | |2||dose from yesterday + 2 mg q1h prn (max 16 mg)||none |
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+ | |} |
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+ | |||
+ | ===Microdosing Protocols=== |
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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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+ | |||
+ | ====Short-Acting Opioids (Daily Dosing)==== |
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+ | {| class="wikitable" |
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+ | !Day!!Burprenorphine!!Short-acting opioid |
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+ | |- |
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+ | |1||0.5 mg||maintain |
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+ | |- |
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+ | |2||1 mg||maintain |
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+ | |- |
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+ | |3||1.5 mg||maintain |
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+ | |- |
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+ | |4||2 mg||maintain |
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+ | |- |
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+ | |5||2.5 mg||maintain |
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+ | |- |
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+ | |6||3 mg||maintain |
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+ | |- |
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+ | |7||4 mg + 2 mg q1h prn (max 12 mg)||stop |
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+ | |} |
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+ | |||
+ | ==== Short-Acting Opioids (Twice-Daily Dosing) ==== |
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+ | {| class="wikitable" |
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+ | !Day!!Burprenorphine!!Short-acting opioid |
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+ | |- |
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+ | |1||0.5 mg daily||maintain |
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+ | |- |
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+ | |2||0.5 mg bid||maintain |
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+ | |- |
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+ | |3||1 mg bid||maintain |
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+ | |- |
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+ | |4||2 mg bid + 2 mg q1h prn (maximum of 12 mg)||stop |
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+ | |} |
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+ | |||
+ | ==== Long-Acting Opioids (Daily Dosing) ==== |
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+ | |||
+ | * Including fentanyl, fentanyl patches, and methadone |
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+ | |||
+ | {| class="wikitable" |
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+ | !Day!!Burprenorphine!!Short-acting opioid |
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+ | |- |
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+ | |1||0.5 mg||maintain |
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+ | |- |
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+ | |2||1 mg||maintain |
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+ | |- |
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+ | |3||1.5 mg||maintain |
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+ | |- |
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+ | |4||2 mg||maintain |
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+ | |- |
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+ | |5||2.5 mg||maintain |
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+ | |- |
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+ | |6||3 mg||maintain |
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+ | |- |
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+ | |7||4 mg||maintain long-acting; stop any short-acting opioids |
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+ | |- |
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+ | |8 |
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+ | |5 mg |
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+ | |maintain |
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+ | |- |
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+ | |9 |
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+ | |6 mg |
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+ | |maintain |
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+ | |- |
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+ | |10 |
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+ | |7 mg |
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+ | |maintain |
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+ | |- |
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+ | |11 |
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+ | |8 mg |
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+ | |maintain |
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+ | |- |
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+ | |12 |
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+ | |10 mg |
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+ | |maintain |
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+ | |- |
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+ | |13 |
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+ | |12 mg |
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+ | |maintain |
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+ | |- |
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+ | |14 |
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+ | |12 mg |
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+ | |stop all remaining opioids |
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+ | |} |
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+ | |||
+ | ====Long-Acting Opioids (Twice-Daily Dosing)==== |
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+ | {| class="wikitable" |
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+ | !Day!!Burprenorphine!!Short-acting opioid |
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+ | |- |
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+ | |1||0.5 mg daily||maintain |
||
+ | |- |
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+ | |2||0.5 mg bid||maintain |
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+ | |- |
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+ | |3||1 mg bid||maintain |
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+ | |- |
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+ | |4||2 mg bid||maintain long-acting, stop any short-acting opioids |
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+ | |- |
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+ | |5 |
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+ | |3 mg bid |
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+ | |maintain |
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+ | |- |
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+ | |6 |
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+ | |4 mg bid |
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+ | |maintain |
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+ | |- |
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+ | |7 |
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+ | |12 mg + 2 mg q1h prn (maximum 16 mg) |
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+ | |stop all remaining opioids |
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+ | |} |
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+ | |||
+ | === Extended-Release Monthly Injection (BUP-XR) === |
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+ | |||
+ | * Consider once stabilized on 8 to 24 mg buprenorphine for at least 7 days |
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+ | * 300 mg SC monthly for the first 2 months, followed by 100 mg SC monthly maintenance |
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+ | |||
+ | === Perioperative Management === |
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+ | *Ideally, continue buprenorphine treatment without interruption and use higher doses of opioid analgesia |
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+ | *If going to hold buprenorphine for surgery: |
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+ | **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 |
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+ | **For the surgery itself, use NSAIDs, [[fentanyl]], regional blocks, adjuncts, and non-pharmacologic options |
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+ | **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 |
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+ | |||
+ | ==Further Reading== |
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+ | |||
+ | *Management of opioid use disorders: a national clinical practice guideline. ''CMAJ''. 2018;190(9):E247-E257. doi: [https://doi.org/10.1503/cmaj.170958 10.1503/cmaj.170958] |
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+ | *[https://www.porticonetwork.ca/documents/204049/0/Opioids+enabler+PDF/f67d20ec-3666-489a-a2dc-ebb5d63225f6 Opioid Enabler] cheat sheet from Portico Network |
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+ | *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: [https://doi.org/10.2147/SAR.S109919 10.2147/SAR.S109919] |
||
+ | *Buprenorphine/Naloxone Microdosing: The Bernese Method. A Brief Summary for Primary Care Clinicians. 2019. Available at https://www.metaphi.ca/wp-content/uploads/Guide_Microdosing.pdf |
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[[Category:Opioid substitution therapy]] |
[[Category:Opioid substitution therapy]] |
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+ | [[Category:Addiction medicine]] |
Latest revision as of 17:22, 12 March 2023
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 Protocols
- 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
Short-Acting Opioids (Daily Dosing)
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 |
Short-Acting Opioids (Twice-Daily Dosing)
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 + 2 mg q1h prn (maximum of 12 mg) | stop |
Long-Acting Opioids (Daily Dosing)
- Including fentanyl, fentanyl patches, and methadone
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 | maintain long-acting; stop any short-acting opioids |
8 | 5 mg | maintain |
9 | 6 mg | maintain |
10 | 7 mg | maintain |
11 | 8 mg | maintain |
12 | 10 mg | maintain |
13 | 12 mg | maintain |
14 | 12 mg | stop all remaining opioids |
Long-Acting Opioids (Twice-Daily Dosing)
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 long-acting, stop any short-acting opioids |
5 | 3 mg bid | maintain |
6 | 4 mg bid | maintain |
7 | 12 mg + 2 mg q1h prn (maximum 16 mg) | stop all remaining opioids |
Extended-Release Monthly Injection (BUP-XR)
- Consider once stabilized on 8 to 24 mg buprenorphine for at least 7 days
- 300 mg SC monthly for the first 2 months, followed by 100 mg SC monthly maintenance
Perioperative Management
- Ideally, continue buprenorphine treatment without interruption and use higher doses of opioid analgesia
- If going to hold buprenorphine for surgery:
- 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
- Buprenorphine/Naloxone Microdosing: The Bernese Method. A Brief Summary for Primary Care Clinicians. 2019. Available at https://www.metaphi.ca/wp-content/uploads/Guide_Microdosing.pdf