Buprenorphine: Difference between revisions

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===Microdosing Protocol===
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===Microdosing Protocols===
   
 
*Suboxone combined with a short-acting opioid such as [[hydromorphone]]
  
*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
  
*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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====Standard====
  
 
{| class="wikitable"
  
{| class="wikitable"
 
!Day!!Burprenorphine!!Short-acting opioid
  
!Day!!Burprenorphine!!Short-acting opioid
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|}
  
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==== Short-Acting Opioids (Twice-Daily Dosing) ====
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====Moderate====
  
 
{| class="wikitable"
  
{| class="wikitable"
 
!Day!!Burprenorphine!!Short-acting opioid
  
!Day!!Burprenorphine!!Short-acting opioid
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|3||1 mg bid||maintain
  
|3||1 mg bid||maintain
 
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|4||2 mg bid||maintain
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|4||2 mg bid + 2 mg q1h prn (maximum of 12 mg)||stop
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|5||3 mg bid||maintain
  
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|6||4 mg bid||maintain
  
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|7||5 mg bid||maintain
  
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|8||12 mg daily||stop
  
 
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|}
   
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==== Long-Acting Opioids (Daily Dosing) ====
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====Rapid====
  
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  +
* Including fentanyl, fentanyl patches, and methadone
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{| class="wikitable"
  
{| class="wikitable"
 
!Day!!Burprenorphine!!Short-acting opioid
  
!Day!!Burprenorphine!!Short-acting opioid
 
|-
  
|-
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|1||0.5 mg q4h x4||maintain
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|1||0.5 mg||maintain
 
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|2||1 mg q4h x4||maintain
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|2||1 mg||maintain
 
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|3||2 mg q4h x4||maintain
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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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|5||2.5 mg||maintain
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|6||3 mg||maintain
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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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|13
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|4||4 mg q4h x4||stop
  
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|12 mg
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|maintain
 
|-
  
|-
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|14
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|5||16 mg daily + 2 mg prn||stop
  
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|12 mg
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|stop all remaining opioids
 
|}
  
|}
   
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====Long-Acting Opioids (Twice-Daily Dosing)====
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====Ultra-rapid====
  
 
{| class="wikitable"
  
{| class="wikitable"
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!Day!!Burprenorphine!!Short-acting opioid
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!Day!!Buprenorphine!![[Hydromorphone]]
  
 
|-
  
|-
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|1||0.5 mg q3h (max 2.5 mg)||3 mg po q4h + 2-4 mg po q4h prn
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|1||0.5 mg daily||maintain
 
|-
  
|-
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|2||0.5 mg bid||maintain
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|2||1 mg q3h (max 8 mg)||3 mg po q4h + 2-4 mg po q4h prn
  
 
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|3||12 mg daily||stop
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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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===Perioperative management===
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=== Perioperative Management ===
−  
 
*Ideally, continue buprenorphine treatment without interruption and use higher doses of opioid analgesia
  
*Ideally, continue buprenorphine treatment without interruption and use higher doses of opioid analgesia
 
*If going to hold buprenorphine for surgery:
  
*If going to hold buprenorphine for surgery:
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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
  
*[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]
  
*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]]

Revision as of 21:46, 26 July 2022

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

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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