How to Implement Low-Dose Buprenorphine Initiation in Your Practice: A Case-Based Workshop

Buprenorphine is a partial opioid agonist with formulations indicated for chronic pain or opioid use disorder (OUD). Unlike full opioid agonists like methadone or morphine, the partial opioid agonism of buprenorphine necessitates careful consideration of its initiation in people taking full opioid agonists (heroin, fentanyl, methadone, etc). Traditional buprenorphine initiation techniques advise against starting buprenorphine until full opioid agonists have been completely stopped for 8-36 hours to prevent precipitated opioid withdrawal. This technique is generally well tolerated and successful, however, barriers such as chronic pain, acute pain (e.g., post-operative setting), pharmaceutical and non-pharmaceutical fentanyl or other high potency synthetic opioid use, or transition from methadone to buprenorphine present clinical challenges that impact the success of the traditional buprenorphine initiation techniques. Low-dose ( < 2 mg of buprenorphine) buprenorphine strategies have been described to facilitate initiation in these situations, prevent worsening of acute and/or chronic pain, and prevent precipitated opioid withdrawal resulting from buprenorphine initiation. The gradual cross-titration with low-dose, and in some cases very low dose ( < 1 mg) buprenorphine allows the partial opioid agonist to slowly displace the full opioid agonist from the opioid receptor, thus minimizing symptoms of precipitated opioid withdrawal. In this 60 minute workshop, we will review the current evidence base for low dose initiation strategies, describe the various low dose initiation strategies that are in use across the United States, and provide a shared decision tool that prescribers can use with their patients. The workshop will use a combination of didactic presentation in the first section followed by 20 minutes of case presentation and discussion of a newly developed shared decision tool for this topic. At the end of the sessions, prescribers should have a better understanding of the current evidence for low dose buprenorphine initiation and know how to approach it with patients.