Buprenorphine Dose Limits - What Is The Evidence?

Many clinicians, clinics, and payors limit buprenorphine doses to 16 or 24 milligrams per day. However, much patient-centered research shows higher retention rates, reduced craving, lower rates of opiate-positive urine test results, and reduced hepatitis C infection rates at higher dose levels up to at least 32 mg/day. Patients may be deemed to be poor matches for buprenorphine if they report inadequate symptom control at doses of 24 mg/day or lower. However, many patients do not reach therapeutic targets under conventional dose limits. A return to illicit opioid use may be ascribed to patient factors rather than to insufficient buprenorphine dosing. In this workshop, the evidence base and reasoning used to justify commonly used dose limits will be explored and contrasted with the substantial evidence of improved outcomes at higher doses. We will review literature on a range of issues surrounding dosing and dose limits, including pharmacokinetics, patient characteristics which correlate with higher doses (such as opioid tolerance, polysubstance use, and chronic pain), increases in dose requirements during pregnancy, and the potential implications of widespread fentanyl use on adequacy of common buprenorphine dosing. We will present case vignettes to illustrate the decision-making process about buprenorphine dose. We will discuss factors that limit the prescribing of higher doses (such as prior authorizations, administrative and cultural constraints, and concerns about diversion risk), and the application of public health principles and professional ethics in choosing adequate dose levels.Three of the presenters care for patients in Washington State, where Medicaid plans cover buprenorphine doses to 32 mg/day without prior authorization. This flexibility has allowed us experience with higher-dose buprenorphine. With optimal dosing, a significant barrier to patient success can be overcome. We will discuss the policy implications of statewide dose limitations, and strategies for changing those policies.