Direct Induction of Buprenorphine Extended-Release: A Case Report

Area of Science:

• Addiction Medicine
• Pharmacology
• Clinical Therapeutics

Background:

• Buprenorphine is a safer alternative for opioid use disorder (OUD) due to its partial opioid agonist activity, reducing respiratory depression risk.
• Initiating buprenorphine in active opioid users carries a risk of precipitated withdrawal, often managed with slow titration strategies.
• Current buprenorphine induction methods can be lengthy, potentially reducing patient adherence and increasing healthcare costs.

Purpose of the Study:

• To describe a case illustrating a buprenorphine induction strategy that avoids precipitated withdrawal.
• To explore a novel method for buprenorphine initiation in severe opioid use disorder.

Main Methods:

• A 55-year-old male with severe OUD and fentanyl use received a 300 mg subcutaneous buprenorphine depot injection without prior stabilization.
• The patient was concurrently administered oral hydromorphone equivalents as needed over the initial 6 hours post-injection.
• Withdrawal symptoms were monitored using the Clinical Opiate Withdrawal Scale (COWS).

Main Results:

• The patient experienced mild withdrawal symptoms (maximum COWS score of 7) within 6 hours, despite receiving additional full opioid agonists.
• Over the subsequent 18 hours, with no further full opioid agonist administration, withdrawal symptoms significantly decreased (maximum COWS score of 1).
• This suggests successful buprenorphine induction without severe precipitated withdrawal.

Conclusions:

• Subcutaneous buprenorphine depot elution alongside as-needed full opioid agonists may represent a viable strategy to prevent precipitated withdrawal.
• This approach could improve the accessibility and acceptability of buprenorphine treatment for OUD.
• Further research is warranted to confirm the replicability and efficacy of this induction method.