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. 2022 May;42(5):411-427.
doi: 10.1002/phar.2676. Epub 2022 Mar 25.

Buprenorphine initiation strategies for opioid use disorder and pain management: A systematic review

Lauren A Spreen  1   2 , Emma N Dittmar  2 , Kyle C Quirk  3 , Michael A Smith  1   2
Affiliations

Buprenorphine initiation strategies for opioid use disorder and pain management: A systematic review

Lauren A Spreen et al. Pharmacotherapy. 2022 May.

Abstract

Buprenorphine possesses many unique attributes that make it a practical agent for adults and adolescents with opioid use disorder (OUD) and/or acute or chronic pain. Sublingual buprenorphine has been the standard of care for treating OUD, but its use in pain management is not as clearly defined. Current practice guidelines recommend a period of mild-to-moderate withdrawal from opioids before transitioning to buprenorphine due to its ability to displace full agonists from the μ-opioid receptor. However, this strategy can lead to negative physical and psychological outcomes for patients. Novel initiation strategies suggest that concomitant administration of small doses of buprenorphine with opioids can avoid the unwanted withdrawal associated with buprenorphine initiation. We aim to systematically review the buprenorphine initiation strategies that have emerged in the last decade. Embase, PubMed, and Cochrane Databases were searched for relevant literature. Studies were included if they were published in the English language and described the transition to buprenorphine from opioids. Data were collected from each study and synthesized using descriptive statistics. This review included 7 observational studies, 1 feasibility study, and 39 case reports/series which included 924 patients. The strategies utilized between the literature included traditional initiation (47.9%), microdosing with various buprenorphine formulations (16%), and miscellaneous methods (36.1%). Traditional initiation and microdosing initiation were compared in the data synthesis and analysis; miscellaneous methods were omitted given the high variability between methods. Overall, 95.6% of patients in the traditional initiation group and 96% of patients in the microdosing group successfully rotated to sublingual buprenorphine. Initiation regimens can vary widely depending on patient-specific factors and buprenorphine formulation. A variety of buprenorphine transition strategies are published in the literature, many of which were effective for patients with OUD, pain, or both.

Keywords: buprenorphine; chronic pain; initiation; opioid use disorder.

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Conflict of interest statement

The authors declare no conflicts of interests.

Figures

FIGURE 1
FIGURE 1
Search strategy and study inclusion
See this image and copyright information in PMC

References

    1. Pathan H, Williams J. Basic opioid pharmacology: an update. Br J Pain. 2012;6(1):11‐16. doi: 10.1177/2049463712438493 - DOI - PMC - PubMed
    1. Cunningham C, Edlund MJ, Fishman M. The ASAM national practice guideline for the treatment of opioid use disorder: 2020 focused update. Am Soc Addict Med. 2020;14(2S):1‐91. doi: 10.1097/ADM.0000000000000633 - DOI - PubMed
    1. U.S Food and Drug Administration . Drug approval package. 2004. https://www.accessdata.fda.gov/drugsatfda_docs/nda/2002/20732_20733_subu.... Accessed March 11, 2022.
    1. Subutex [package insert]. North Chesterfield, VA; Indivior Inc. 2002. https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/020732s018lbl.pdf. Accessed March 11, 2022.
    1. Webster L, Gudin J, Raffa RB, et al. Understanding buprenorphine for use in chronic pain: expert opinion. Pain Med. 2020;21(4):714‐723. - PMC - PubMed

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