A Novel Intravenous Buprenorphine Micro-Infusion Strategy: Application in Critical Care and Opioid Use Disorder

Buprenorphine (BUP), a partial mu-opioid receptor (MOR) agonist, is an effective analgesic and is standard-of-care for treating opioid use disorder (OUD). Transitioning from full MOR agonists to stable BUP dosing can be challenging as some patients experience BUP-precipitated opioid withdrawal (BPOW) due to its ability to displace full MOR agonists. To improve patient tolerability low-dose BUP initiation protocols deliver small, progressively escalating BUP doses, allowing gradual displacement of other opioids and replacement with BUP. We describe a case series using a novel intravenous BUP "micro-infusion" protocol for rapid medication transition with no patients meeting the operational criteria for BPOW.

A retrospective case series of patients who received an 8-hour 1200 mcg BUP infusion (150 mcg/hr) and one (or more) sublingual BUP doses after medical or nonmedical full MOR agonist administration. Variables included demographic characteristics, presence of OUD, opioid medications, BUP continuation/prescription fill rates, and evidence of BPOW based on Clinical Opiate Withdrawal Scale (COWS) scores.

Of 23 patients included, 8 presented with current OUD (34.8%) and 15 were treated with full MOR agonists for analgesia (65.2%) before BUP micro-infusion. There were no instances of BPOW. Among the 8 patients with OUD, 5 (62.5%) continued sublingual BUP and filled their prescription for BUP upon discharge.

Overall, the 8-hour intravenous 1200 mcg BUP micro-infusion protocol was well-tolerated with no clinically apparent cases of BPOW and similar rates of continued sublingual BUP treatment post-discharge among patients with OUD compared with other low-dose BUP initiation protocols.