(159) Buprenorphine Microinduction: A New Tool for Consultation-Liaison Psychiatrists

Abstract:

Background: Buprenorphine is a partial mu-opioid receptor agonist that is effective at reducing all-cause and overdose mortality in patients with opioid use disorder (OUD). Buprenorphine microinduction is a novel and clinically useful strategy in which very low doses of buprenorphine are titrated concurrently with full opioid agonists, allowing for initiation of buprenorphine without a period of opioid withdrawal (Ahmed, 2021), (De Aquino 2021). In 2021, NYU Langone Health adopted an inpatient buprenorphine microinduction protocol that was developed by Addiction Psychiatry and Clinical Pharmacy. In order to highlight its clinical applications in the hospital setting, we describe a series of patients on our Addiction Consultation-Liaison (C-L) Service who were successfully transitioned to buprenorphine using microinduction.



Methods: Our microinduction protocol utilizes buprenorphine buccal films (Belbuca^®) with doses increased in a step-wise manner over several days prior to transitioning to buprenorphine-naloxone (Suboxone^®). A short and long titration schedule were created taking into consideration anticipated length of stay and milligram morphine equivalence (titration schedules to be included in poster).

Case 1: A 77-year-old woman with a history of opioid misuse, anxiety, panic attacks, chronic back pain and a T12 compression fracture was seen for suicidal ideation in the context of pain and opioid withdrawal. A short schedule microinduction was administered, together with oxycodone, resolving her pain and suicidal ideation.

Case 2: A 41-year-old man with a history of OUD, depression, and GAD was admitted with C7-T1 osteomyelitis requiring neurosurgical intervention. A long schedule microinduction was administered, along with postoperative hydromorphone, resulting in maintenance of buprenorphine without precipitating opioid withdrawal symptoms.

Case 3: A 69-year-old man with a history of OUD admitted for an infected foot ulcer was found using fentanyl in the hospital and demonstrating signs of opioid withdrawal. He was started on low dose methadone in tandem with a short schedule microinduction, which resolved withdrawal symptoms with a therapeutic buprenorphine regimen.



Discussion: These cases demonstrate the clinical utility of buprenorphine microinduction in the hospital setting. This method is particularly useful for patients with co-occurring pain, methadone exposure, or a history of precipitated withdrawal with buprenorphine. By using microinduction protocols, C-L psychiatrists can overcome common barriers associated with conventional buprenorphine initiation.



Conclusion: Buprenorphine microinduction is a novel and effective way to initiate treatment for OUD in the hospital setting. By utilizing microinduction, C-L psychiatrists can play a greater role in offering life-saving medication for OUD. Future research should evaluate the impact of microinduction on OUD treatment retention.



References:
1. Ahmed S, Bhivandkar S, Lonergan BB, Suzuki J. Microinduction of Buprenorphine/Naloxone: A Review of the Literature. Am J Addict. 2021;30(4):305-15.
2. De Aquino JP, Parida S, Sofuoglu M. The Pharmacology of Buprenorphine Microinduction for Opioid Use Disorder. Clin Drug Investig. 2021;41(5):425-36.