Simplified rapid low-dose buprenorphine induction method for individuals using fentanyl: a case series

Among individuals with opioid use disorder using fentanyl, standard initial doses (2-4 mg) of buprenorphine may precipitate withdrawal, often preventing successful induction. Rapid low-dose induction is an emerging approach designed to mitigate this risk. This study describes a simplified rapid low-dose buprenorphine induction protocol in facilitating treatment initiation among patients presenting to an outpatient clinic.

This case series includes chart review data from nine patients with opioid use disorder treated at an outpatient substance use clinic who were initiated on buprenorphine-naloxone maintenance therapy. All had recent fentanyl use confirmed by UDS. Patients were instructed to follow a simplified induction protocol consisting of 1 mg of buprenorphine-naloxone, via 1/8th of an 8 - 2 mg sublingual film, administered at home hourly for 8 h, followed by maintenance dosing of 8 mg twice daily. Patients were advised to wait at least 24 h since last fentanyl use prior to initiating the induction protocol. Successful induction was defined as being on maintenance treatment at a follow-up appointment one week later.

Of the nine patients who began the rapid low-dose induction protocol, seven successfully transitioned to buprenorphine-naloxone maintenance by the 7-day follow-up. Two patients did not return for follow-up.

In this case series, the simplified rapid low-dose buprenorphine induction protocol was well-tolerated and 77.8% of patients using fentanyl were able to successfully initiate buprenorphine-naloxone maintenance. Benefits of this protocol are use of a single, standard dose of buprenorphine-naloxone, rapid induction timeline over only 8 h, and simple patient instructions.