Low Dose Buprenorphine Initiation: An Essential Tool for C-L Psychiatrists

Abstract: Persons with opioid use disorder (OUD) frequently require hospitalizations and surgical procedures to manage complications of substance use although many do receive adequate treatment, even though medications to treat OUD have been shown to reduce infectious complications of drug use, improve quality of life and reduce all-cause mortality. Buprenorphine is often preferred over methadone because of its superior safety profile and availability through office-based prescribers. Yet in recent years the illicit opioid supply shifted increasingly to synthetic opioids including fentanyl. The rise of fentanyl has been paralleled by widespread reports that conventional buprenorphine initiation is ineffective in avoiding precipitated opioid withdrawal – an observation likely explained by fentanyl’s complex pharmacokinetics and extended terminal elimination half-life. Moreover, traditional means for initiating buprenorphine may be impractical or even contraindicated in certain patient populations, such as patients receiving high-dose methadone requiring abrupt transitions to buprenorphine, patients experiencing acute pain postoperatively in need of round-the-clock opioid administration, and pregnant women for whom any opioid withdrawal should be avoided if possible. To address each of these clinical scenarios, it is essential that CL psychiatrists be aware of an alternative approach known as low-dose buprenorphine initiation (LDBI) (also referred to as “microdosing” or “microinduction.” or “the Bernese method”), which is withdrawal-sparing and does not require patients to discontinue opioids. As the name implies, LDBI entails the administration of small initial doses of buprenorphine (0.25-0.5mg) and providing gradually increasing dosages concurrent with other full agonist opioids. While there are numerous titration schedules and buprenorphine products than can be utilized in LDBI, the end result is the same: full opioid agonist agents are slowly displaced at the opioid receptor level by high affinity, high potency, but low efficacy buprenorphine molecules at a rate that is so gradual that any change may be largely imperceptible to the patient.

In this workshop, we will review the pharmacology and rapidly growing evidence base supporting LDBI, discuss regulatory and cost considerations, review various indications and several commonly employed methodologies for implementing LDBI, and conclude by engaging our audience in a case-based discussion. All presenters actively work on Addiction Consultation Psychiatry Services with LDBI protocols and have a combined clinical experience of over one-hundred cases utilizing LDBI.

Moderator:
Joji Suzuki, MD is the Director of the Division of Addiction Psychiatry at Brigham and Women's Hospital and Program Director of the Brigham and Women's Hospital Addiction Medicine Fellowship Program. Dr. Suzuki helped to create and implement the LDBI at Brigham and Women's Hospital and has published a recent and comprehensive recent review of LDBI. Dr. Suzuki will help moderate the workshop and lead an interactive case-based discussion highlighting the clinical applications of LDBI.