Buprenorphine Induction
Goal
The goal of buprenorphine induction is to moderate patients' withdrawal as they transition from full agonist opioids (e.g. heroin, oxycodone, hydrocodone, and methadone) to buprenorphine maintenance. Buprenorphine is a partial agonist at the mu-opioid receptor but has a stronger affinity for the receptor than most full agonists. Buprenorphine will therefore displace most agonists from the mu-opioid receptor and can precipiate withdrawal if taken to early.
TIMING
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Induction should begin when the patient is experiencing mild to moderate withdrawal
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At least 6-12 hours after the last use of heroin or other short-acting opioids
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24-72 hours after last use of long-acting opioids (e.g. methadone)
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Patients should have a minimum COWS score of 11-12
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The patient should preferably be exhibiting early signs of opioid withdrawal (e.g., sweating, yawning, rhinorrhea, lacrimation)
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minimum of 12–24 hours should have elapsed since the last use of short-acting opioids
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at least 24 hours after the last dose of methadone
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patients should wait until they are experiencing mild opioid withdrawal
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at least 12 hours since last use of heroin or other short-acting opioids
Induction Dose
The risk of precipitated withdrawal can be reduced by using a lower initial dose of buprenorphine. It is recommended that induction start with a dose of 2–4 mg, and that the patient is observed for signs of precipitated withdrawal.
If 60–90 minutes have passed without the onset of withdrawal symptoms, then additional dosing can be done in increments of 2–4 mg. Repeat of the COWS during induction can be useful in assessing the effect of buprenorphine doses.
Once it has been established that the initial dose is well tolerated, the buprenorphine dose can be increased fairly rapidly to a dose that provides stable effects for 24 hours and is clinically effective.
...a first dose of 4/1–8/2 mg of the buprenorphine/naloxone combination (buprenorphine monotherapy for pregnant women).
If the initial dose of the buprenorphine/naloxone combination is 4/1 mg and opioid withdrawal symptoms subside but then return (or are still present) after 2 hours, a second dose of 4/1 mg can be administered.
The total amount of buprenorphine administered in the first day should not exceed 8 mg.
Patients with moderate levels of neuroadaptation will generally tolerate initial doses of 4–8 mg a day.
Once it has been established that the initial dose is well tolerated, the buprenorphine dose can be increased fairly rapidly to a dose that provides stable effects for 24 hours and is clinically effective.
Pregnant Women
Initiation or induction of buprenorphine may lead to withdrawal symptoms in patients with physical dependence on opioids. To minimize this risk, induction should be initiated when a woman begins to show objective, observable signs of moderate withdrawal, but before severe withdrawal symptoms are evidenced. This usually occurs 6 hours or more after the last dose of a short-acting opioid, and typically 24– 48 hours after the use of long-acting opioids. Hospitalization during initiation of treatment with buprenorphine may be advisable due to the potential for adverse events, especially in the third trimester.
*SAMHSA and WHO guidelines are comparatively outdated given recent advancement of research on the treatment of pregnant women with OUD