Buprenorphine is an effective and safe treatment for opioid use disorder, but the requirement for moderate opioid withdrawal symptoms to emerge prior to initiation is a significant treatment barrier.
We report on two cases of hospitalized patients with severe, active opioid use disorder, in which we initiated treatment with transdermal buprenorphine over 48 h, followed by the administration of a single dose of sublingual buprenorphine/naloxone and then extended-release subcutaneous buprenorphine. The patients did not experience precipitated withdrawal and only had mild withdrawal symptoms.
This provides preliminary evidence for a rapid induction strategy that may improve tolerability, caregiver burden, and treatment retention as compared to previous induction strategies.

UNASSIGNED: Buprenorphine may provide superior analgesia to full opioid agonist therapy and reverse the effects of opioid-induced hyperalgesia, while having a favorable safety profile and fewer adverse effects, in chronic non-cancer pain treatment. Low-dose initiation of buprenorphine is a useful strategy for patients on long-term opioid therapy because it avoids the need for moderate opioid withdrawal required for traditional buprenorphine initiations. However, there are few published reports of low-dose initiation regimens in the setting of chronic pain.
UNASSIGNED: The aim of the study was to describe a case series of individuals living with chronic pain who were transitioned from long-term full opioid agonist therapy onto sublingual buprenorphine/naloxone using low-dose initiation regimens.
UNASSIGNED: This study is a retrospective case series that included all patients who received care at an outpatient chronic pain clinic and were scheduled for low-dose initiation of buprenorphine/naloxone between March 2020 and December 2022. Data were collected through a retrospective review of electronic medical records and results were analyzed using descriptive statistics.
UNASSIGNED: Eighteen patients underwent transitions from their baseline opioids onto buprenorphine/naloxone using a low-dose initiation regimen. Of those patients, 17 successfully completed the initiation (94.44%), 12 experienced adverse effects during the initiation (66.67%), with only one patient requiring treatment discontinuation, and all adverse effects resolved once maintenance doses of buprenorphine/naloxone were established. The mean Clinical Global Impression-Improvement score after initiation was 2 (1-5).
UNASSIGNED: Low-dose initiation is an effective approach to transition patients with chronic non-cancer pain from long-term opioid therapy to buprenorphine/naloxone without major complications or worsening pain.
Contexte: La buprénorphine peut offrir une analgésie supérieure à celle d’un traitement par agonistes opioïdes complet et inverser les effets de l’hyperalgésie induite par les opioïdes, tout en présentant un profil d’innocuité favorable et moins d’effets indésirables dans le traitement de la douleur chronique non cancéreuse. L’initiation à faible dose de la buprénorphine est une stratégie utile pour les patients sous traitement opioïde à long terme, car elle évite le besoin de sevrage des opioïdes modéré nécessaire pour les traitements traditionnels à base de buprénorphine. Cependant, il existe peu de rapports publiés sur les régimes d’initiation à faible dose dans le cadre de la douleur chronique.Objectifs: L’objectif de cette étude était de décrire une série de cas d’individus vivant avec une douleur chronique qui sont passés d’un traitement opioïde complet à long terme à un traitement par buprénorphine sublinguale/naloxone en ayant recours à des régimes d’initiation à faible dose.Méthodes: Cette étude est une série de cas rétrospective incluant tous les patients pris en charge dans une clinique externe de traitement de la douleur chronique et pour lesquels un schéma d’initiation à faible dose de buprénorphine/naloxone a été programmé entre mars 2020 et décembre 2022. Les données ont été collectées par le biais d’un examen rétrospectif des dossiers médicaux électroniques et les résultats ont été analysés à l’aide de statistiques descriptives.Résultats: Dix-huit patients ont fait la transition des opioïdes de base à la buprénorphine/naloxone en utilisant un régime d’initiation à faible dose. Parmi ces patients, 17 ont terminé l’initiation avec succès (94,44 %), 12 ont présenté des effets indésirables pendant l’initiation (66,67 %) et un seul patient a dû interrompre son traitement. Tous les effets indésirables ont disparu une fois les doses d’entretien de buprénorphine/naloxone établies. Le score d’impression clinique globale-amélioration moyen après le début du traitement était de 2 (1-5).Conclusion: L’initiation à faible dose est une approche efficace pour faire passer les patients souffrant de douleur chronique non cancéreuse d’un traitement opioïde à long terme à la buprénorphine/naloxone sans complications majeures ni aggravation de la douleur.

UNASSIGNED: Access to prescribed interventions and retention in treatment services are associated with improved health outcomes and reduced premature mortality rates for people living with opioid use disorder (OUD). In Leeds, transactional sex-workers frequently cycled in and out of treatment for OUD such that they never reached a level of engagement that permitted opportunities to meet their healthcare or housing needs. Barriers to accessing care provision include an itinerant lifestyle, difficulties with travel at unpredictable hours, impacting upon adherence to medication regimens including daily supervised consumption.
UNASSIGNED: To use a co-produced, \"health at the margins\" approach, to reach the sex-working population in Leeds, and support informed choices about the potential to receive buprenorphine prolonged-release injection (BPRI) as a treatment option for OUD.
UNASSIGNED: BPRI was introduced using a theory of change model and improvements in sex-worker care delivery was reviewed. Strategies included buprenorphine micro-induction, shared decision-making, collaborative multi-agency working and supporting a strengths-based and trauma-informed approach.
UNASSIGNED: Benefits of BPRI included removal of the need for daily pharmacy visits, reducing the risk of diversion, improved medication adherence, stability and engagement with treatment and supportive services.
UNASSIGNED: BPRI may offer an additional option for pharmacological interventions for people with OUD where there may be increased barriers to accessing treatment for example due to sex-working. Strategies for effective BPRI include micro-induction, shared decision-making, collaborative multi-agency working and supporting a strengths-based approach.

UNASSIGNED: To describe the use of buprenorphine/naloxone micro-inductions in hospitalized patients and characterize the success rate of these inductions.
UNASSIGNED: We conducted a retrospective chart review of hospitalized patients receiving a buprenorphine/naloxone micro-induction for opioid use disorder in a tertiary care hospital from Jan 2020-Dec 2020. The primary outcome was a description of the micro-induction prescribing patterns used. The secondary outcomes were a description of the demographic characteristics of patients, the estimated frequency of withdrawal symptoms experienced by patients undergoing a micro-induction, and the overall success rate of the micro-inductions defined as retention on buprenorphine/naloxone therapy with no precipitated withdrawal experienced.
UNASSIGNED: Thirty-three patients were included in the analysis. Three main micro-induction regimens were identified, including rapid micro-inductions (8 patients), 0.5 mg SL BID initiations (6 patients), and 0.5 mg SL daily initiations (19 patients). Twenty-four patients (73%) met the criteria for a successful micro-induction, defined as being retained in buprenorphine/naloxone therapy with no precipitated withdrawal experienced. The most common reason for micro-induction failure was patient request to discontinue buprenorphine/naloxone therapy due to perceived adverse effects or personal preference.
UNASSIGNED: Buprenorphine/naloxone micro-induction in hospitalized patients resulted in a majority of patients being successfully initiated on buprenorphine/naloxone therapy without requiring opioid abstinence prior to induction. Dosing regimens were variable, and the ideal regimen remains unclear.

Buprenorphine/naloxone has been shown to be effective for treating opioid use disorder (OUD). However, the traditional method of induction requires a patient to be in moderate-to-severe withdrawal, which is challenging, time-consuming, and a common reason for leaving against medical advice. Induction strategies that minimize the severity and duration of patient discomfort while enabling patients to reach therapeutic doses during short hospital admissions can mitigate difficulties when inducing a patient on buprenorphine/naloxone. This case-series illustrates two patients with OUD using illicit fentanyl, who were successfully started on buprenorphine/naloxone using 24-hour and 6-hour micro-dosing induction protocol. During induction, the patients were up-titrated to a therapeutic dose through ultrarapid micro-dosing with ongoing use of short-acting opioids. Both patients reached therapeutic doses experiencing minimal levels of withdrawal. This case-series is a proof of concept for the use of a buprenorphine/naloxone ultrarapid micro-induction protocol for inpatients with OUD. By reducing the length of induction and precluding the need for withdrawal, this method offers several advantages over previously published inductions protocols and can improve the accessibility of buprenorphine/naloxone to patients with OUD.

Buprenorphine/naloxone (Suboxone) is a current first-line treatment for opioid use disorder (OUD). The standard induction method of buprenorphine/naloxone requires patients to be abstinent from opioids and therefore experience withdrawal symptoms prior to induction, which can be a barrier in starting treatment. Rapid micro-induction (micro-dosing) involves the administration of small, frequent does of buprenorphine/naloxone and removes the need for a period of withdrawal prior to the start of treatment. This study aims to compare the effectiveness and safety of rapid micro-induction versus standard induction of buprenorphine/naloxone in patients with OUD.
This is a randomized, open-label, two-arm, superiority, controlled trial comparing the safety and effectiveness of rapid micro-induction versus standard induction of buprenorphine/naloxone for the treatment of OUD. A total of 50 participants with OUD will be randomized at one Canadian hospital. The primary outcome is the completion of buprenorphine/naloxone induction with low levels of withdrawal. Secondary outcomes are treatment retention, illicit drug use, self-reported drug use behaviour, craving, pain, physical health, safety, and client satisfaction.
This is the first randomized controlled trial to compare the effectiveness and safety of rapid micro-induction versus standard induction of buprenorphine/naloxone. This study will thereby generate evidence for a novel induction method which eliminates substantial barriers to the use of buprenorphine/naloxone in the midst of the ongoing opioid crisis. Trial registration ClinicalTrials.gov, NCT04234191; date of registration: January 21, 2020; https://clinicaltrials.gov/ct2/show/NCT04234191.