Successful rotation from long-acting full agonist opioids to sublingual buprenorphine/naloxone using a microdosing approach

René C. Vytialingam, MBBS, FRACGP, FAChAM; Stephan A. Schug, MD, FANZCA, FFPMANZCA, EDPM; Richard O’Regan, MBBS, FAChAM

doi:10.5055/jom.2021.0653

Authors

René C. Vytialingam, MBBS, FRACGP, FAChAM https://orcid.org/0000-0003-2266-4353
Stephan A. Schug, MD, FANZCA, FFPMANZCA, EDPM
Richard O’Regan, MBBS, FAChAM

DOI:

https://doi.org/10.5055/jom.2021.0653

Keywords:

microdosing, buprenorphine/naloxone, buprenorphine, opioid use disorder, opioid substitution therapy

Abstract

Buprenorphine/naloxone (BPN/NX) is a first-line treatment for opioid use disorder. Conventional treatment guidelines recommend a period of opioid abstinence and the presence of moderate withdrawal before initiation to avoid precipitated withdrawal. A newer approach of “microdosing” removes this requirement and has potential benefits. We present two cases of successful induction of BPN/NX using a microdosing regimen in an inpatient withdrawal unit. Both cases did not result in precipitated withdrawal and did not necessitate prior cessation of other opioids. This case report highlights how the use of microdosing to induct BPN/NX treatment can reduce potential barriers and complications with treatment initiation.

Author Biographies

René C. Vytialingam, MBBS, FRACGP, FAChAM

Consultant in Addiction Medicine, Next Step Drug and Alcohol Services, Mental Health Commission, Western Australia, Perth, Australia

Stephan A. Schug, MD, FANZCA, FFPMANZCA, EDPM

Emeritus Professor and Honorary Senior Research Fellow, Anaesthesiology and Pain Medicine, Medical School, University of Western Australia, Perth, Australia

Richard O’Regan, MBBS, FAChAM

Director of Clinical Services, Next Step Drug and Alcohol Services, Mental Health Commission, Western Australia, Perth, Australia

References

Chrzanowska A, Dobbins T, Degenhardt L, et al.: Trends in Drug-Induced Deaths in Australia, 1997-2017, Drug Trends Bulletin Series. Sydney: National Drug and Alcohol Research Centre, UNSW Sydney, 2019.

Mattick RP, Ward J, Hall W: Methadone Maintenance Treatment and Other Opioid Replacement Therapies. Amsterdam: Harwood Academic Publishers, 1998.

Mattick RP, Kimber J, Breen C, et al.: Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database Syst Rev. 2014; 2: CD002207.

American Society of Addiction Medicine: The ASAM national practice guideline for the treatment of opioid use disorder: 2020 focused update. J Addict Med. 2020; 14: 2S.

Bruneau J, Ahamad K, Goyer M-È, et al.: Management of opioid use disorders: A national clinical practice guideline. CMAJ. 2018; 190(9): E247-E257.

Gowing L, Ali R, Dunlop A, et al.: National Guidelines for Medication-Assisted Treatment of Opioid Dependence. Canberra: Commonwealth of Australia, 2014.

Lintzeris N, Dunlop A, Masters D: Clinical Guidelines for Use of Depot Buprenorphine (Buvidal® and Sublocade®) in the Treatment of Opioid Dependence. Sydney: NSW Ministry of Health, 2019.

Orman JS, Keating GM: Buprenorphine/naloxone a review of its use in the treatment of opioid dependence. Drugs. 2009; 69(5): 577-607.

Adams E, Sharifi N, Lappalainen LA: Guideline for the Clinical Management of Opioid Use Disorder. British Colombia: British Columbia Centre on Substance Use, 2017. Available at http://www.bccsu.ca/care-guidance-publications. Accessed June 18, 2020.

Mattick RP, Ali R, White JM, et al.: Buprenorphine versus methadone maintenance therapy: A randomized double-blind trial with 405 opioid-dependent patients. Addiction. 2003; 98(4): 441-452.

Bell J, Trinh L, Butler B, et al.: Comparing retention in treatment and mortality in people after initial entry to methadone and buprenorphine treatment. Addiction. 2009; 104: 1193-1200.

Hämmig R, Kemter A, Strasser J, et al.: Use of microdoses for induction of buprenorphine treatment with overlapping full opioid agonist use: The bernese method. SAR. 2016; 7: 99-105.

Terasaki D, Smith C, Calcaterra SL: Transitioning hospitalized patients with opioid use disorder from methadone to buprenorphine without a period of opioid abstinence using a microdosing protocol. Pharmacotherapy. 2019; 39(10): 1023-1029.

Rozylo J, Mitchell K, Nikoo M, et al.: Case report: Successful induction of buprenorphine/naloxone using a microdosing schedule and assertive outreach. Addict Sci Clin Pract. 2020; 15(1): 1-6.

Klaire S, Zivanovic R, Barbic SP, et al.: Rapid micro-induction of buprenorphine/naloxone for opioid use disorder in an inpatient setting: A case series. Am J Addict. 2019; 28(4): 262-265.

Martin L, Lennox R, Regenstreif L, et al.: Case report: “striving to skip the withdrawal” using buprenorphine–naloxone microdosing for hospitalized patients. Can J Addict. 2019; 110(4): 35-40.

Brar R, Fairbairn N, Sutherland C, et al.: Use of a novel prescribing approach for the treatment of opioid use disorder: Buprenorphine/naloxone micro-dosing—A case series. Drug Alcohol Rev. 2020; 39(5): 588-594.

Wesson DR, Ling W: The clinical opiate withdrawal scale (COWS). J Psychoactive Drugs. 2003; 35(2): 253-259.

Government of Western Australia, Department of Health: WA Cancer and Palliative Care Network. Opioid conversion guide. 2016. Available at https://ww2.health.wa.gov.au/~/media/Files/Corporate/general%20documents/Palliative/Opioid-conversionchart.ashx. Accessed December 10, 2020.

Lintzeris N, Monds LA, Rivas C, et al.: Transferring patients from methadone to buprenorphine: The feasibility and evaluation of practice guidelines. J Addict Med. 2018; 12(3): 234-240.

Bao YP, Liu ZM, Epstein DH, et al.: A meta-analysis of retention in methadone maintenance by dose and dosing strategy. Am J Drug Alcohol Abuse. 2009; 35(1): 28-33.

Chong J, Frei M, Lubman D: Managing long-term high-dose prescription opioids in patients with non-cancer pain: The potential role of sublingual buprenorphine. Aust J Gen Pract. 2020; 49(6): 339-343.

Khanna IK, Pillarisetti S: Buprenorphine—An attractive opioid with underutilized potential in treatment of chronic pain. J Pain Res. 2015; 8: 859.

Daitch D, Daitch J, Novinson D, et al.: Conversion from high-dose full-opioid agonists to sublingual buprenorphine reduces pain scores and improves quality of life for chronic pain patients. Pain Med. 2014; 15(12): 2087-2094.

Liebschutz JM, Crooks D, Herman D, et al.: Buprenorphine treatment for hospitalized, opioid-dependent patients: A randomized clinical trial. JAMA Intern Med. 2014; 174(8): 1369-1376.

Donroe JH, Holt SR, Tetrault JM: Caring for patients with opioid use disorder in the hospital. CMAJ. 2016; 188(17-18): 1232-1239.