Buprenorphine: Difference between revisions

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== Background ==
 +
==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
  
   
  +
*Recommended as first-line treatment for [[opioid use disorder]] in Canadian guidelines
−
== Dosing ==
  
  +
*Typically coformulated with [[naloxone]] (trade name Suboxone) at a dose of 2 mg buprenorphine to 0.5 mg [[naloxone]]
−
=== Standard Induction Protocol ===
  
  +
*Buprenorphine is partial μ-opioid receptor agonist
−
* 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
  
  +
*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
   
 
{| class="wikitable"
  
{| class="wikitable"
−
! Day !! Buprenorphine !! Opioid
 +
!Day!!Buprenorphine!!Opioid
 
|-
  
|-
−
| — || — || stop to ensure withdrawal ([[COWS]] ≥12)
 +
|—||—||stop to ensure withdrawal ([[COWS]] ≥12)
 
|-
  
|-
−
| 1 || 2 to 4 mg + 2 mg q1h prn (max 12 mg) || none
 +
|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
 +
|2||dose from yesterday + 2 mg q1h prn (max 16 mg)||none
 
|}
  
|}
   
−
=== Microdosing Protocol ===
 +
===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
  
   
  +
*Suboxone combined with a short-acting opioid such as [[hydromorphone]]
−
==== Standard ====
  
  +
*In general, all opioids can be stopped once at a dose of buprenorphine 12 mg daily
  +
  +
====Short-Acting Opioids (Daily Dosing)====
 
{| class="wikitable"
  
{| class="wikitable"
−
! Day !! Burprenorphine !! Short-acting opioid
 +
!Day!!Burprenorphine!!Short-acting opioid
 
|-
  
|-
−
| 1 || 0.5 mg || maintain
 +
|1||0.5 mg||maintain
 
|-
  
|-
−
| 2 || 1 mg || maintain
 +
|2||1 mg||maintain
 
|-
  
|-
−
| 3 || 1.5 mg || maintain
 +
|3||1.5 mg||maintain
 
|-
  
|-
−
| 4 || 2 mg || maintain
 +
|4||2 mg||maintain
 
|-
  
|-
−
| 5 || 2.5 mg || maintain
 +
|5||2.5 mg||maintain
 
|-
  
|-
−
| 6 || 3 mg || maintain
 +
|6||3 mg||maintain
 
|-
  
|-
−
| 7 || 4 mg + 2 mg q1h prn (max 12 mg) || stop
 +
|7||4 mg + 2 mg q1h prn (max 12 mg)||stop
 
|}
  
|}
   
  +
==== Short-Acting Opioids (Twice-Daily Dosing) ====
−
==== Moderate ====
  
 
{| class="wikitable"
  
{| class="wikitable"
−
! Day !! Burprenorphine !! Short-acting opioid
 +
!Day!!Burprenorphine!!Short-acting opioid
 
|-
  
|-
−
| 1 || 0.5 mg daily || maintain
 +
|1||0.5 mg daily||maintain
 
|-
  
|-
−
| 2 || 0.5 mg bid || maintain
 +
|2||0.5 mg bid||maintain
 
|-
  
|-
−
| 3 || 1 mg bid || maintain
 +
|3||1 mg bid||maintain
 
|-
  
|-
−
| 4 || 2 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
  +
  +
{| class="wikitable"
  +
!Day!!Burprenorphine!!Short-acting opioid
 
|-
  
|-
−
| 5 || 3 mg bid || maintain
 +
|1||0.5 mg||maintain
 
|-
  
|-
−
| 6 || 4 mg bid || maintain
 +
|2||1 mg||maintain
 
|-
  
|-
−
| 7 || 5 mg bid || maintain
 +
|3||1.5 mg||maintain
 
|-
  
|-
−
| 8 || 12 mg daily || stop
 +
|4||2 mg||maintain
−
|}
  
−  
−
==== Rapid ====
  
−
{| class="wikitable"
  
−
! Day !! Burprenorphine !! Short-acting opioid
  
 
|-
  
|-
−
| 1 || 0.5 mg q4h x4 || maintain
 +
|5||2.5 mg||maintain
 
|-
  
|-
−
| 2 || 1 mg q4h x4 || maintain
 +
|6||3 mg||maintain
 
|-
  
|-
  +
|7||4 mg||maintain long-acting; stop any short-acting opioids
−
| 3 || 2 mg q4h x4 || maintain
  
 
|-
  
|-
  +
|8
−
| 4 || 4 mg q4h x4 || stop
  
  +
|5 mg
  +
|maintain
 
|-
  
|-
  +
|9
−
| 5 || 16 mg daily + 2 mg prn || stop
  
  +
|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
 
|}
  
|}
   
−
==== Ultra-rapid ====
 +
====Long-Acting Opioids (Twice-Daily Dosing)====
 
{| class="wikitable"
  
{| class="wikitable"
−
! Day !! Burprenorphine !! [[Hydromorphone]]
 +
!Day!!Burprenorphine!!Short-acting opioid
 
|-
  
|-
  +
|1||0.5 mg daily||maintain
−
| 1 || 0.5 mg q3h (max 2.5 mg) || 3 mg po q4h + 2-4 mg po q4h prn
  
 
|-
  
|-
  +
|2||0.5 mg bid||maintain
−
| 2 || 1 mg q3h (max 8 mg) || 3 mg po q4h + 2-4 mg po q4h prn
  
 
|-
  
|-
−
| 3 || 12 mg daily || stop
 +
|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) ===
−
== Further Reading ==
  
  +
−
* 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]
  
  +
* Consider once stabilized on 8 to 24 mg buprenorphine for at least 7 days
−
* [https://www.porticonetwork.ca/documents/204049/0/Opioids+enabler+PDF/f67d20ec-3666-489a-a2dc-ebb5d63225f6 Opioid Enabler] cheat sheet from Portico Network
  
  +
* 300 mg SC monthly for the first 2 months, followed by 100 mg SC monthly maintenance
−
* 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]
  
  +
  +
=== 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: [https://doi.org/10.1503/cmaj.170958 10.1503/cmaj.170958]
  +
*[https://www.porticonetwork.ca/documents/204049/0/Opioids+enabler+PDF/f67d20ec-3666-489a-a2dc-ebb5d63225f6 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: [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
   
 
[[Category:Opioid substitution therapy]]
  
[[Category:Opioid substitution therapy]]

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

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