Efficacy of Low-Dose Versus Traditional Buprenorphine Induction in the Hospital: A Quantitative and Qualitative Study

Abstract

Background: Emerging evidence suggests low-dose buprenorphine (LDB) induction can expand opportunities for buprenorphine induction in patients who are taking taking methadone, short-acting opioid agonists, or who have anxiety about opioid withdrawal.

Study question: How is a rapid LDB protocol using transdermal buprenorphine tolerated in the hospital?

Study design: A prospective study of 20 patient encounters (n = 20 patients) with traditional buprenorphine induction before implementation of study protocol (control group) and 37 patient encounters (n = 34 patients) with LDB induction protocol (pilot group). Summary statistics were used to describe demographics, clinical opioid withdrawal scale and pain scores within 24 hours preprotocol and within 24 hours postprotocol initiation, hospital length of stay after protocol initiation, receipt of a buprenorphine prescription at discharge, and prescription activity at 30 days. T test and chi-square tests were used to analyze comparisons. A subset of pilot group patients completed a survey about their experience.

Results: There were no statistically significant differences in pain and clinical opioid withdrawal scale scores between the pilot and control groups. There were 5 instances of precipitated withdrawal in the pilot group. There was no statistically significant difference in mean discharge time after protocol initiation between the pilot and control groups (P = 0.60). Most patients surveyed described a positive experience with LDB induction.

Conclusion: Hospitalization is a critical time to initiate buprenorphine for patients with opioid use disorder. Our data adds to the growing evidence that LDB induction is feasible for patients taking methadone and short-acting opioid agonists, and that a more rapid induction protocol is generally well-tolerated by patients although precipitated withdrawal is a risk. Finally, our rapid induction protocol did not seem to increase hospital length of stay compared with traditional induction.

FIGURE 1.

Baseline antithrombotic treatment prescriptions in the Eastern European and global populations. ^aThe denominator for Eastern Europe is the total number of eligible patients in the Eastern European population (N = 1341). The denominator for the global population is the total number of eligible patients in the global population (N = 21,300). Tx, treatment; VKA, vitamin K antagonist.

FIGURE 2.

Baseline DOAC prescription dosage in the Eastern European and global populations. ^aThe denominators are all eligible patients (ie, the ns shown per treatment group). No patients in Eastern Europe were prescribed or treated with edoxaban. ^bDabigatran standard dose (150 mg BID), lower dose (110/75 mg BID); rivaroxaban standard dose (20 mg QD), lower dose (15/10 mg QD); apixaban standard dose (5 mg BID), lower dose (2.5 mg BID); edoxaban standard dose (60 mg QD), lower dose (30 mg QD); “other” doses were any dose that did not fit under the definitions of standard or lower doses per treatment. BID, twice daily; DOAC, direct oral anticoagulants; QD, once daily.

FIGURE 3.

Incidence rates of important clinical outcomes during 3 years of treatment with dabigatran versus VKA in Eastern Europe versus the global population. Each n denotes the number of patients with events. Results are shown for all eligible patients treated with dabigatran and VKA in Eastern Europe (N = 498 and N = 466, respectively) and globally (N = 3807 and N = 4788, respectively), that is, excluding a few patients with a prescription but not treated. ^aStroke, systemic embolism, myocardial infarction, life-threatening bleed, vascular death CI, confidence interval; VKA, vitamin K antagonist.

FIGURE 4.

Probability of persistence with dabigatran during 3 years of treatment in Eastern Europe versus the global population. Results are shown for all eligible patients treated with dabigatran and VKA in Eastern Europe (N = 498 and N = 466, respectively) and globally (N = 3807 and N = 4788, respectively), that is, excluding a few patients with a prescription but not treated. CI, confidence interval; VKA, vitamin K antagonist.