Skip to main content
SpringerLink
Log in

Low-Dose Initiation of Buprenorphine: A Narrative Review

  • Acute Pain Medicine (R Urman, Section Editor)
  • Published:
Current Pain and Headache Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

Opioid use disorder (OUD) is a chronic disorder in which a person loses control over the use of opioids, develops a compulsive behavior, and defends the use despite knowing the negative consequences. There are numerous treatments for OUD, including buprenorphine. Since it is displacing a full agonist opioid, precipitated withdrawal can occur with standard inductions involving buprenorphine.

Recent Findings

Case reports have noted success with a low-dose initiation of buprenorphine, which is different from typical protocols, relatively limited by adverse effects when patients were recently administered full agonists. A cohort investigation studied the use of a transdermal patch as part of the protocol, which was fairly well tolerated.

Summary

While ongoing research is being conducted on this topic, recent case studies and smaller cohort studies have demonstrated the feasibility of a trial to treat OUD with low-dose initiation of buprenorphine.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

Data Availability

All data presented in this review is available on PubMed.

References

  1. Kumar R, Viswanath O, Saadabadi A. Buprenorphine. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 [cited 2023 Jan 22]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK459126/.

  2. Hoffman KA, Ponce Terashima J, McCarty D. Opioid use disorder and treatment: challenges and opportunities. BMC Health Serv Res. 2019;19(1):884.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Edinoff A, Murnane K, Rosa C, Giepert S, Cornett E, Kaye D, et al. Physiologic considerations in opioid addiction. In: Substance use and addiction research. 1st ed. Academic Press Inc.; 2023. p. 204–10.

  4. Brown KG, Capili B. The pathophysiology of and nursing interventions for opioid use disorder. Am J Nurs. 2020;120(6):38–46.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Milivojevic V, Sinha R. Central and peripheral biomarkers of stress response for addiction risk and relapse vulnerability. Trends Mol Med. 2018;24(2):173–86.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Walsh SL, Eissenberg T. The clinical pharmacology of buprenorphine: extrapolating from the laboratory to the clinic. Drug Alcohol Depend. 2003;70(2 Suppl):S13-27.

    Article  CAS  PubMed  Google Scholar 

  7. Bell J, Strang J. Medication treatment of opioid use disorder. Biol Psychiatry. 2020;87(1):82–8.

    Article  CAS  PubMed  Google Scholar 

  8. Buresh M, Stern R, Rastegar D. Treatment of opioid use disorder in primary care. BMJ. 2021;19(373):n784.

    Article  Google Scholar 

  9. Webster L, Gudin J, Raffa RB, Kuchera J, Rauck R, Fudin J, et al. Understanding buprenorphine for use in chronic pain: expert opinion. Pain Med. 2020;21(4):714–23.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Heidbreder C, Fudala PJ, Greenwald MK. History of the discovery, development, and FDA-approval of buprenorphine medications for the treatment of opioid use disorder. Drug Alcohol Depend Rep. 2023;1(6):100133.

    Article  Google Scholar 

  11. Urits I, Pham C, Swanson D, Berardino K, Bandi P, Amgalan A, et al. The utilization of buprenorphine in chronic pain. Best Pract Res Clin Anaesthesiol. 2020;34(3):355–68.

    Article  PubMed  Google Scholar 

  12. Shearer D, Young S, Fairbairn N, Brar R. Challenges with buprenorphine inductions in the context of the fentanyl overdose crisis: a case series. Drug Alcohol Rev. 2022;41(2):444–8.

    Article  PubMed  Google Scholar 

  13. Varshneya NB, Thakrar AP, Hobelmann JG, Dunn KE, Huhn AS. Evidence of buprenorphine-precipitated withdrawal in persons who use fentanyl. J Addict Med. 2022;16(4):e265–8.

    Article  CAS  PubMed  Google Scholar 

  14. Hämmig R, Kemter A, Strasser J, von Bardeleben U, Gugger B, Walter M, et al. Use of microdoses for induction of buprenorphine treatment with overlapping full opioid agonist use: the Bernese method. Subst Abuse Rehabil. 2016;20(7):99–105.

    Google Scholar 

  15. DeWeese JP, Krenz JR, Wakeman SE, Peckham AM. Rapid buprenorphine microdosing for opioid use disorder in a hospitalized patient receiving very high doses of full agonist opioids for acute pain management: titration, implementation barriers, and strategies to overcomes. Subst Abuse. 2021;42(4):506–11.

    Article  CAS  Google Scholar 

  16. Rozylo J, Mitchell K, Nikoo M, Durante SE, Barbic SP, Lin D, et al. Case report: successful induction of buprenorphine/naloxone using a microdosing schedule and assertive outreach. Addict Sci Clin Pract. 2020;15:2.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Baumgartner K, Salmo E, Liss D, Devgun J, Mullins M, Galati B, et al. Transdermal buprenorphine for in-hospital transition from full agonist opioids to sublingual buprenorphine: a retrospective observational cohort study. Clin Toxicol Phila Pa. 2022;60(6):688–93.

    Article  CAS  Google Scholar 

  18. Moe J, Badke K, Pratt M, Cho RY, Azar P, Flemming H, et al. Microdosing and standard-dosing take-home buprenorphine from the emergency department: a feasibility study. J Am Coll Emerg Physicians Open. 2020;1(6):1712–22.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Wong JSH, Nikoo M, Westenberg JN, Suen JG, Wong JYC, Krausz RM, et al. Comparing rapid micro-induction and standard induction of buprenorphine/naloxone for treatment of opioid use disorder: protocol for an open-label, parallel-group, superiority, randomized controlled trial. Addict Sci Clin Pract. 2021;16(1):11.

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Psychiatry, Harvard Medical School, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA

    Amber N. Edinoff MD

  2. Louisiana Addiction Research Center, Shreveport, LA, 71103, USA

    Amber N. Edinoff MD, Elyse M. Cornett Ph.D & Alan D. Kaye MD, Ph.D

  3. Department of Family Medicine, Louisiana State University Health Science Center at Shreveport/Monroe, Monroe, LA, 71202, USA

    Omar H. Fahmy MD

  4. School of Medicine, Louisiana State University Health Science Center at Shreveport, Shreveport, LA, 71103, USA

    Noah J. Spillers BS & Alexa R. Zaheri BS

  5. University of Arizona College of Medicine-Phoenix, Phoenix, AZ, 85004, USA

    Eric D. Jackson BS & Danielle M. Wenger BS

  6. Department of Anesthesiology, Louisiana State University Health Sciences Center at Shreveport, Shreveport, LA, 71103, USA

    Audrey J. De Witt BS, Elyse M. Cornett Ph.D, Kimberly L. Skidmore MD & Alan D. Kaye MD, Ph.D

  7. Thomas J. Long School of Pharmacy and Health Sciences, Department of Pharmacy Practice, University of the Pacific, Stockton, CA, 95211, USA

    Adam M. Kaye PharmD

Authors
  1. Amber N. Edinoff MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Omar H. Fahmy MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Noah J. Spillers BS
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Alexa R. Zaheri BS
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Eric D. Jackson BS
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Audrey J. De Witt BS
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Danielle M. Wenger BS
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Elyse M. Cornett Ph.D
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Kimberly L. Skidmore MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Adam M. Kaye PharmD
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Alan D. Kaye MD, Ph.D
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

A. N. E. was responsible for the conception of this manuscript. A. N. E., O. F., N. S., and A. Z. were responsible for the writing of the first draft of the manuscript with revisions. A. N. E., E. D. J., D. M. W., E. M. C., A. M. K., K. L. S., and A. D. K. were responsible for all subsequence revisions. All authors give consent for the publication of this manuscript in this journal.

Corresponding author

Correspondence to Amber N. Edinoff MD.

Ethics declarations

Ethics Statement

This narrative review did not require consent from subjects or review by an institutional review board.

Conflict of Interest

The authors declare no competing interests.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Edinoff, A.N., Fahmy, O.H., Spillers, N.J. et al. Low-Dose Initiation of Buprenorphine: A Narrative Review. Curr Pain Headache Rep 27, 175–181 (2023). https://doi.org/10.1007/s11916-023-01116-3

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11916-023-01116-3

Keywords

Search

Navigation