Ketamine-assisted buprenorphine initiation: a pilot case series.

Area of Science:

• Pharmacology
• Addiction Medicine
• Clinical Research

Background:

• Opioid use disorder (OUD) treatment is hindered by fear of opioid withdrawal.
• Buprenorphine initiation is often delayed due to concerns about spontaneous or buprenorphine-precipitated opioid withdrawal (BPOW).
• Ketamine has shown potential in managing BPOW, but its use in outpatient settings requires careful dosing to avoid dissociative effects.

Purpose of the Study:

• To explore the efficacy of low-dose, self-administered sublingual ketamine in facilitating buprenorphine initiation for ambulatory patients with OUD.
• To assess ketamine's role in mitigating withdrawal symptoms during the transition from fentanyl or methadone to buprenorphine.

Main Methods:

• Prescribed sublingual ketamine (16 mg per dose, 4-8 doses) to patients transitioning to buprenorphine who feared BPOW or were experiencing it.
• Monitored patients daily or near-daily, adjusting ketamine and buprenorphine dosages based on response.
• Included patients transitioning from illicit fentanyl and methadone.

Main Results:

• Ketamine was prescribed to 37 patients; 16 (43%) completed buprenorphine initiation.
• Of those who tried ketamine, 67% successfully initiated buprenorphine.
• Most patients reported reduced or eliminated withdrawal symptoms; 92% of the last 12 completers had 30-day retention.
• A protocol allowed four patients to initiate buprenorphine over four days with mild withdrawal.

Conclusions:

• Sub-dissociative ketamine facilitated outpatient buprenorphine initiation for most patients who tried it.
• Ketamine may reduce apprehension and lower barriers to buprenorphine treatment.
• Further research is needed to confirm findings and develop standardized protocols for diverse settings.