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Archambault L, Bertrand K, Martel MO, Bérubé M, Belhouari S, Perreault M. The current state of knowledge on care for co-occurring chronic pain and opioid use disorder: A scoping review. J Clin Nurs 2024. [PMID: 38532646 DOI: 10.1111/jocn.17139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 03/11/2024] [Accepted: 03/18/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND AND AIMS Opioid use disorder often co-occurs with chronic pain but assessment and treatment of these co-occurring disorders is complex. This review aims to identify current treatments and delivery models for co-occurring chronic pain and opioid use disorder (OUD) documented in the scientific literature. DESIGN Scoping review. METHODS The review was conducted in six databases in June 2022 (no time limit): CINAHL, PsycINFO, Web of Science, Cochrane, PubMed and Embase. The PRISMA-ScR checklist was used to guide reporting. RESULTS Forty-seven publications addressing the issue of co-occurring chronic pain and OUD management were included. Randomized controlled trials provide evidence for the effectiveness of opioid agonist treatments (OAT) such as methadone or buprenorphine/naloxone, as well as for combining OAT with Mindfulness-Oriented Recovery Enhancement or cognitive behavioural therapy. A number of other pharmacological treatments (opioid and nonopioid), nonpharmacological treatments (e.g. physiotherapy) and service delivery models (e.g. simultaneous treatment of comorbidities, interdisciplinary and interprofessional collaboration) are also underlined. In most cases, authors recommend a combination of strategies to meet patient needs. CONCLUSIONS The scoping review reveals gaps in evidence-based knowledge to effectively care for co-occurring chronic pain and OUD, but several experts recommend the uptake of known 'best' practices such as integrated treatment of the multiple biopsychosocial dimensions of the co-occurring disorders as well as collaborative interdisciplinary work. CLINICAL RELEVANCE Improving services is dependent on alleviating barriers such as working in silos, the costs associated with nonpharmacological treatments, and the double stigma associated with pain in people with a substance use disorder.
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Affiliation(s)
- Léonie Archambault
- Université de Sherbrooke and Douglas Research Center, Montréal, Quebec, Canada
- Institut universitaire sur les dépendances, Direction de l'enseignement universitaire et de la recherche, CIUSSS du Centre-Sud-de-l'Île-de-Montréal, Montréal, Quebec, Canada
| | - Karine Bertrand
- Institut Universitaire Sur les dépendances and Community Health Science Dept., Université de Sherbrooke, Longueuil, Quebec, Canada
| | - Marc O Martel
- Faculty of Dentistry & Department of Anesthesiology, McGill University, Montréal, Quebec, Canada
| | - Mélanie Bérubé
- Faculté Des Sciences infimières, Université Laval, Quebec City, Quebec, Canada
| | | | - Michel Perreault
- Douglas Research Center and Dept. of Psychiatry, McGill University, Montréal, Quebec, Canada
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2
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Rattanavong M, Kwan D, Jorgenson D, Landry E, Marwah R, Halpape K. Low-dose Initiation of Buprenorphine/naloxone for the Management of Chronic Non-cancer Pain in Patients on Long-term Opioid Therapy: A Case Series. Can J Pain 2024; 8:2310811. [PMID: 38571889 PMCID: PMC10989697 DOI: 10.1080/24740527.2024.2310811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 01/23/2024] [Indexed: 04/05/2024]
Abstract
Background Buprenorphine may provide superior analgesia to full opioid agonist therapy and reverse the effects of opioid-induced hyperalgesia, while having a favorable safety profile and fewer adverse effects, in chronic non-cancer pain treatment. Low-dose initiation of buprenorphine is a useful strategy for patients on long-term opioid therapy because it avoids the need for moderate opioid withdrawal required for traditional buprenorphine initiations. However, there are few published reports of low-dose initiation regimens in the setting of chronic pain. Aims The aim of the study was to describe a case series of individuals living with chronic pain who were transitioned from long-term full opioid agonist therapy onto sublingual buprenorphine/naloxone using low-dose initiation regimens. Methods This study is a retrospective case series that included all patients who received care at an outpatient chronic pain clinic and were scheduled for low-dose initiation of buprenorphine/naloxone between March 2020 and December 2022. Data were collected through a retrospective review of electronic medical records and results were analyzed using descriptive statistics. Results Eighteen patients underwent transitions from their baseline opioids onto buprenorphine/naloxone using a low-dose initiation regimen. Of those patients, 17 successfully completed the initiation (94.44%), 12 experienced adverse effects during the initiation (66.67%), with only one patient requiring treatment discontinuation, and all adverse effects resolved once maintenance doses of buprenorphine/naloxone were established. The mean Clinical Global Impression-Improvement score after initiation was 2 (1-5). Conclusion Low-dose initiation is an effective approach to transition patients with chronic non-cancer pain from long-term opioid therapy to buprenorphine/naloxone without major complications or worsening pain.
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Affiliation(s)
- Maya Rattanavong
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Donica Kwan
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Derek Jorgenson
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Eric Landry
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Radhika Marwah
- Family Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Katelyn Halpape
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
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3
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Ito S, Welsh M, Bockman C, Dale R, Pilkington D, Peperzak K. Outpatient cross-titration to buprenorphine for chronic pain: A retrospective analysis. J Opioid Manag 2023; 19:543-554. [PMID: 38189196 DOI: 10.5055/jom.0839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Abstract
OBJECTIVE To determine the effectiveness and safety of the University of Washington's buprenorphine cross-titration protocol for chronic pain in the outpatient setting. METHODS Retrospective chart review was performed on 150 patients transitioned from full µ-opioid agonist therapy to buprenorphine using the University of Washington Medical Center Pain Clinic's cross-titration protocol between September 1, 2020, and December 31, 2021, in an outpatient setting. Primary outcome was to determine the percentage of patients who completed the cross-titration and continued buprenorphine without full µ-opioid agonists 4 weeks after completion. Secondary outcomes included final buprenorphine dose, days needed to complete cross-titration, deviation rates from the protocol, and opioid-related adverse events. RESULTS Fifteen of 31 (48.4 percent) included patients successfully converted to buprenorphine. Median duration of successful cross-titration was 29 days (interquartile range 19-57). Average end-titration dose for patients on buprenorphine/naloxone sublingual films was 7.9 ± 5.7 mg/day, while for buprenorphine transdermal (TD) patches, it was 11.9 ± 4.8 mcg/h. Morphine equivalent daily dose (MEDD) prior to induction varied widely. All patients transitioned to TD buprenorphine were taking ≤30 mg MEDD. Patients previously taking >120 mg MEDD stabilized on 8-16 mg/day buprenorphine. Most common reasons for cross-titration failure were inadequate pain control and intolerable adverse effects. DISCUSSION The University of Washington's buprenorphine cross-titration protocol for chronic pain was successful in about half of included patients undergoing conversion from chronic full µ-opioid agonist therapy and generally well tolerated. Clinical responses were widely variable, and many required slower taper and higher end-titration buprenorphine dose than anticipated. Although protocols provide structure for cross-titration, each course should be monitored closely and individualized.
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Affiliation(s)
- Satoru Ito
- Department of Pharmacy Services, University of Washington Medicine, Seattle, Washington
| | - Mackenzie Welsh
- Department of Pharmacy Services, University of Washington Medicine, Seattle, Washington
| | - Christina Bockman
- Department of Pharmacy Services, University of Washington Medicine, Seattle, Washington
| | - Rebecca Dale
- Department of Anesthesia and Pain Medicine, University of Washington Center for Pain Relief, Seattle, Washington
| | - David Pilkington
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington
| | - Katherin Peperzak
- Department of Anesthesia and Pain Medicine, University of Washington Center for Pain Relief, Seattle, Washington
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4
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Murray JP, Pucci G, Weyer G, Ari M, Dickson S, Kerins A. Low dose IV buprenorphine inductions for patients with opioid use disorder and concurrent pain: a retrospective case series. Addict Sci Clin Pract 2023; 18:38. [PMID: 37264449 DOI: 10.1186/s13722-023-00392-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Accepted: 05/19/2023] [Indexed: 06/03/2023] Open
Abstract
BACKGROUND Hospitalizations are a vital opportunity for the initiation of life-saving opioid agonist therapy (OAT) for patients with opioid use disorder. A novel approach to OAT initiation is the use of IV buprenorphine for low dose induction, which allows patients to immediately start buprenorphine at any point in a hospitalization without stopping full agonist opioids or experiencing significant withdrawal. METHODS This is a retrospective case series of 33 patients with opioid use disorder concurrently treated with full agonist opioids for pain who voluntarily underwent low dose induction at a tertiary academic medical center. Low dose induction is the process of initiating very low doses of buprenorphine at fixed intervals with gradual dose increases in patients who recently received or are simultaneously treated with full opioid agonists. Our study reports one primary outcome: successful completion of the low dose induction (i.e. transitioned from low dose IV buprenorphine to sublingual buprenorphine-naloxone) and three secondary outcomes: discharge from the hospital with buprenorphine-naloxone prescription, self-reported pain scores, and nursing-assessed clinical opiate withdrawal scale (COWS) scores over a 6-day period, using descriptive statistics. COWS and pain scores were obtained from day 0 (prior to starting the low dose induction) to day 5 to assess the effect on withdrawal symptoms and pain control. RESULTS Thirty patients completed the low dose induction (30/33, 90.9%). Thirty patients (30/33, 90.9%) were discharged with a buprenorphine prescription. Pain and COWS scores remained stable over the course of the study period. Mean COWS scores for all patients were 2.6 (SD 2.8) on day 0 and 1.6 (SD 2.6) on day 5. Mean pain scores for all patients were 4.4 (SD 2.1) on day 0 and 3.5 on day 5 (SD 2.1). CONCLUSIONS This study found that an IV buprenorphine low dose induction protocol was well-tolerated by a group of 33 hospitalized patients with opioid use disorder with co-occurring pain requiring full agonist opioid therapy. COWS and pain scores improved for the majority of patients. This is the first case series to report mean daily COWS and pain scores over an extended period throughout a low dose induction process.
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Affiliation(s)
- John P Murray
- Department of Medicine, University of Chicago, 5841 S Maryland Ave, Chicago, IL, 60637, USA.
| | - Geoffrey Pucci
- Department of Pharmacology, University of Chicago, 5841 S Maryland Ave, Chicago, IL, 60637, USA
| | - George Weyer
- Department of Medicine, University of Chicago, 5841 S Maryland Ave, Chicago, IL, 60637, USA
| | - Mim Ari
- Department of Medicine, University of Chicago, 5841 S Maryland Ave, Chicago, IL, 60637, USA
| | - Sarah Dickson
- Department of Medicine, University of Chicago, 5841 S Maryland Ave, Chicago, IL, 60637, USA
| | - Angela Kerins
- Department of Pharmacology, University of Chicago, 5841 S Maryland Ave, Chicago, IL, 60637, USA
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5
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Azar P, Mathew N, Mahal D, Wong JSH, Westenberg JN, Schütz CG, Greenwald MK. Developing A Rapid Transfer from Opioid Full Agonist to Buprenorphine: "Ultrarapid Micro-Dosing" Proof of Concept. J Psychoactive Drugs 2023; 55:94-101. [PMID: 35152847 DOI: 10.1080/02791072.2022.2039814] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Buprenorphine/naloxone has been shown to be effective for treating opioid use disorder (OUD). However, the traditional method of induction requires a patient to be in moderate-to-severe withdrawal, which is challenging, time-consuming, and a common reason for leaving against medical advice. Induction strategies that minimize the severity and duration of patient discomfort while enabling patients to reach therapeutic doses during short hospital admissions can mitigate difficulties when inducing a patient on buprenorphine/naloxone. This case-series illustrates two patients with OUD using illicit fentanyl, who were successfully started on buprenorphine/naloxone using 24-hour and 6-hour micro-dosing induction protocol. During induction, the patients were up-titrated to a therapeutic dose through ultrarapid micro-dosing with ongoing use of short-acting opioids. Both patients reached therapeutic doses experiencing minimal levels of withdrawal. This case-series is a proof of concept for the use of a buprenorphine/naloxone ultrarapid micro-induction protocol for inpatients with OUD. By reducing the length of induction and precluding the need for withdrawal, this method offers several advantages over previously published inductions protocols and can improve the accessibility of buprenorphine/naloxone to patients with OUD.
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Affiliation(s)
- Pouya Azar
- Complex Pain and Addiction Services, Vancouver General Hospital, Vancouver, BC, Canada.,Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | - Nickie Mathew
- Complex Pain and Addiction Services, Vancouver General Hospital, Vancouver, BC, Canada.,Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada.,Department of the Provincial Health Services Authority, BC Mental Health & Substance Use Services, Provincial Health Services Authority, BC, Canada
| | - Daljeet Mahal
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | - James S H Wong
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | - Jean N Westenberg
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | - Christian G Schütz
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada.,Department of the Provincial Health Services Authority, BC Mental Health & Substance Use Services, Provincial Health Services Authority, BC, Canada
| | - Mark K Greenwald
- Department of Psychiatry and Behavioral Neurosciences, School of Medicine, and Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI, USA
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6
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MacAusland-Berg J, Wiebe A, Marwah R, Halpape K. Successful conversion from butorphanol nasal spray to buprenorphine/naloxone using a low-dose regimen to assist with opioid tapering in the setting of chronic pain and migraine management in an older adult patient: A case report. Can J Pain 2022; 6:135-141. [PMID: 36017357 PMCID: PMC9397438 DOI: 10.1080/24740527.2022.2090911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background Butorphanol is marketed as a treatment for migraines; however, evidence suggests that the harms of its use exceed the benefits. The short half-life of butorphanol places patients at high risk for opioid dependence and makes tapering a challenge. Buprenorphine/naloxone has unique pharmacological properties that are beneficial in chronic pain treatment. At this time there is limited published data on the use of micro-dosing initiation regimens in patients with chronic pain, especially in older adult patients. Aims This article presents the case of an older adult patient for whom a buprenorphine/naloxone micro-dosing regimen was successfully utilized to aid discontinuation of butorphanol nasal spray, assist with opioid tapering, and manage chronic pain. Methods This case took place in an outpatient setting while the patient was receiving care from an interprofessional chronic pain service. The electronic medical record was reviewed to obtain a summary of the case data. Informed patient consent was obtained. Results We present a case of an older adult patient who had been using butorphanol nasal spray for migraine and general pain management for over 20 years. The risks of ongoing use of butorphanol (i.e., inter-dose-related pain, opioid dependence, possible opioid-induced hyperalgesia, and fall risk) no longer exceeded any perceived benefit. The patient was successfully transitioned onto sublingual buprenorphine/naloxone using a micro-dosing regimen. Conclusions This case provides an example of the potential benefit buprenorphine/naloxone can have for patients with chronic pain and previous opioid exposure, especially older adults at risk of central adverse effects of opioids.
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Affiliation(s)
- Joshua MacAusland-Berg
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Amy Wiebe
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Radhika Marwah
- USask Chronic Pain Clinic, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
- Family Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Katelyn Halpape
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
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7
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K K A, E J M, D M S. Factors that distinguish opioid withdrawal during induction with buprenorphine microdosing: a configurational analysis. Addict Sci Clin Pract 2022; 17:55. [PMID: 36195895 PMCID: PMC9531395 DOI: 10.1186/s13722-022-00336-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 09/12/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Novel buprenorphine dosing strategies have emerged with an aim to transition patients from opioid agonists to buprenorphine without prerequisite opioid withdrawal. We applied a configurational approach to a subset of data from our earlier systematic review to answer the following question: when patients received a buprenorphine initiation strategy aimed to eliminate prerequisite withdrawal, what factors consistently distinguished patients that experienced withdrawal during the initiation process from patients that did not? METHODS From the 24 cases identified by our systematic review, we included cases that were treated using buprenorphine microdosing strategies (oral or transdermal), cases with opioid use disorder, and cases that fully transitioned to buprenorphine without continuing the full opioid agonist. Configurational analysis was used to identify combinations of patient and regimen level factors that uniquely distinguished cases experiencing withdrawal during induction. RESULT Fourteen cases were included in our analysis, of which 9 experienced opioid withdrawal symptoms. Three factors were involved in explaining both the presence and absence of withdrawal symptoms: history of heroin use, history of methadone use, and duration of overlap between buprenorphine and the full opioid agonist during induction. For the presence of withdrawal symptoms, the addition of a fourth factor "buprenorphine starting dose" resulted in a model with perfect consistency and coverage; for the absence of withdrawal symptoms, the addition of a fourth factor "induction duration" similarly resulted in a model with perfect consistency and 80% coverage. CONCLUSION Application of configurational methods allowed synthesis of case reports identified through a systematic review.
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Affiliation(s)
- Adams K K
- University of Connecticut School of Pharmacy, 69 N Eagleville Rd Unit 3092, Storrs, CT, 06269, USA
| | - Miech E J
- Regenstrief Institute, Center for Health Services Research, IN, USA
| | - Sobieraj D M
- University of Connecticut School of Pharmacy, 69 N Eagleville Rd Unit 3092, Storrs, CT, 06269, USA.
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8
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Development of an intravenous low-dose buprenorphine initiation protocol. Drug Alcohol Depend 2022; 237:109541. [PMID: 35753281 DOI: 10.1016/j.drugalcdep.2022.109541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 06/15/2022] [Accepted: 06/15/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Buprenorphine is a life-saving treatment for opioid use disorder (OUD). Low-dose initiation (LDI) is an emerging buprenorphine initiation strategy that circumvents barriers associated with standard initiation. This study aims to describe tolerability and completion of LDI using intravenous (IV) buprenorphine and to define dosing protocols in a cohort of patients hospitalized in an urban academic hospital. METHODS Data was collected via retrospective chart review for IV buprenorphine LDI cases initiated between September 1, 2020 and February 28, 2021. Cases were excluded if diagnostic criteria for OUD was not met, Clinical Opiate Withdrawal Scale (COWS) scores were not recorded, or sublingual (SL) buprenorphine was given within 24 h before IV buprenorphine. Completion of LDI and COWS data were assessed for all cases. Cases were categorized based on adherence to a dosing strategy and LDI indication, including OUD and acute pain, non-prescribed fentanyl exposure, and transition from methadone. RESULTS Seventy-two cases were identified, and thirteen cases were excluded, leaving 59 cases in the population. Of these cases, 72.9% (43/59) tolerated LDI, and 91.5% (54/59) completed buprenorphine initiation. Forty-four (44/59, 75%) cases were adherent. Median duration of LDI within the adherent group was 23.7 h (IQR 22.8-27.0), 37.1 h (IQR 36.2-40.9), and 48.8 h (IQR 47.0-52.4) for the "rapid," "moderate," and "slow" dosing strategies, respectively. CONCLUSIONS IV buprenorphine LDI was tolerated and completed in a majority of patients. Dosing protocols allowed for rapid transition to sublingual buprenorphine. Acute pain or recent methadone or fentanyl exposure may inform IV LDI dosing strategy selection.
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9
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Spreen LA, Dittmar EN, Quirk KC, Smith MA. Buprenorphine initiation strategies for opioid use disorder and pain management: A systematic review. Pharmacotherapy 2022; 42:411-427. [PMID: 35302671 PMCID: PMC9310825 DOI: 10.1002/phar.2676] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 03/04/2022] [Accepted: 03/05/2022] [Indexed: 12/17/2022]
Abstract
Buprenorphine possesses many unique attributes that make it a practical agent for adults and adolescents with opioid use disorder (OUD) and/or acute or chronic pain. Sublingual buprenorphine has been the standard of care for treating OUD, but its use in pain management is not as clearly defined. Current practice guidelines recommend a period of mild‐to‐moderate withdrawal from opioids before transitioning to buprenorphine due to its ability to displace full agonists from the μ‐opioid receptor. However, this strategy can lead to negative physical and psychological outcomes for patients. Novel initiation strategies suggest that concomitant administration of small doses of buprenorphine with opioids can avoid the unwanted withdrawal associated with buprenorphine initiation. We aim to systematically review the buprenorphine initiation strategies that have emerged in the last decade. Embase, PubMed, and Cochrane Databases were searched for relevant literature. Studies were included if they were published in the English language and described the transition to buprenorphine from opioids. Data were collected from each study and synthesized using descriptive statistics. This review included 7 observational studies, 1 feasibility study, and 39 case reports/series which included 924 patients. The strategies utilized between the literature included traditional initiation (47.9%), microdosing with various buprenorphine formulations (16%), and miscellaneous methods (36.1%). Traditional initiation and microdosing initiation were compared in the data synthesis and analysis; miscellaneous methods were omitted given the high variability between methods. Overall, 95.6% of patients in the traditional initiation group and 96% of patients in the microdosing group successfully rotated to sublingual buprenorphine. Initiation regimens can vary widely depending on patient‐specific factors and buprenorphine formulation. A variety of buprenorphine transition strategies are published in the literature, many of which were effective for patients with OUD, pain, or both.
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Affiliation(s)
- Lauren A Spreen
- Department of Pharmacy Services, University of Michigan Health, Ann Arbor, Michigan, USA.,University of Michigan College of Pharmacy, Ann Arbor, Michigan, USA
| | - Emma N Dittmar
- University of Michigan College of Pharmacy, Ann Arbor, Michigan, USA
| | - Kyle C Quirk
- Department of Palliative Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Michael A Smith
- Department of Pharmacy Services, University of Michigan Health, Ann Arbor, Michigan, USA.,University of Michigan College of Pharmacy, Ann Arbor, Michigan, USA
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10
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Martell JP, Konakanchi JS, Sethi R. Treating opioid use disorder with rapid micro induction technique of sublingual buprenorphine/naloxone in an outpatient setting—a case report. J Addict Dis 2022; 40:439-443. [DOI: 10.1080/10550887.2021.1996153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Jose Perez Martell
- Department of Psychiatry and Behavioral Sciences, University of Kansas Health System, Kansas City, Kansas, USA
| | - Jaya Sri Konakanchi
- School of Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Roopa Sethi
- Department of Psychiatry and Behavioral Sciences, University of Kansas Health System, Kansas City, Kansas, USA
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11
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Quirk K, Stevenson M. Buprenorphine Microdosing for the Pain and Palliative Care Clinician. J Palliat Med 2022; 25:145-154. [PMID: 34978915 DOI: 10.1089/jpm.2021.0378] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Buprenorphine (BUP) can be a safe and effective alternative to traditional opioids for many patients with chronic pain. For patients on higher doses of opioids, rotation to BUP is complicated by the requirement of an opioid-free interval or withdrawal during the transition. Microdosing inductions, in which BUP is gradually titrated, while full agonist opioids are continued, are a viable alternative to traditional inductions. The objective of this article is to review the current literature on BUP microdosing induction, with a focus on patients using opioids for pain. A literature review of the PubMed database was performed in the United States on articles published from inception to May 2021. A total of 34 publications were included. The most commonly utilized microdosing strategy involved administering divided doses of sublingual (SL) products marketed for opioid use disorder treatment, with 25 (73.5%) articles reporting use of partial SL tablets or films (ranging from 1/8 to 1/2 of a 2 mg product) at some point during the induction. Transdermal patches, low-dose SL BUP available in Europe, intravenous BUP, and buccal BUP have also been used. Beyond the products used, the speed of the microinduction, setting, final BUP dosing, and management of concomitant full agonists vary widely in the literature. Microdosing regimens should be individualized based on local guidelines and patient-specific factors. Further studies comparing the safety and efficacy of different protocols are warranted.
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Affiliation(s)
- Kyle Quirk
- Department of Palliative Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Maximillian Stevenson
- Department of Palliative Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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12
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Abstract
Low dose buprenorphine initiation, is an alternative method of initiating buprenorphine in which the starting dose is very low and gradually increased to therapeutic levels over a period of days. This method takes advantage of slow displacement of the full opioid agonist from mu-opioid receptors, avoiding the need for a person with opioid use disorder to experience opioid withdrawal symptoms before initiating buprenorphine, while also minimizing the risk of precipitated opioid withdrawal. With this initiation method, full opioid agonists can be continued as buprenorphine is initiated, expanding the population to which buprenorphine can be offered. To date, the literature on low dose initiation is primarily case-based but rapidly growing. While evidence emerges, guidance for the use of low dose initiation is clearly desired and urgently needed in the context of an increasingly risky and contaminated opioid drug supply, particularly with high potency synthetic opioids, driving overdose deaths. Despite limited evidence, several principles to guide low dose initiation have been identified including: (1) choosing the appropriate clinical situation, (2) initiating at a low buprenorphine dose, (3) titrating the buprenorphine dose gradually, (4) continuing the full opioid agonist even if it is nonmedical, (5) communicating clearly with frequent monitoring, (6) pausing or delaying buprenorphine dose changes if opioid withdrawal symptoms occur, and (7) prioritizing care coordination. We review a practical approach to low dose initiation in hospital-based and outpatient settings guided by the current evidence.
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13
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Wilson CG, Aarons L, Augustijns P, Brouwers J, Darwich AS, De Waal T, Garbacz G, Hansmann S, Hoc D, Ivanova A, Koziolek M, Reppas C, Schick P, Vertzoni M, García-Horsman JA. Integration of advanced methods and models to study drug absorption and related processes: An UNGAP perspective. Eur J Pharm Sci 2021; 172:106100. [PMID: 34936937 DOI: 10.1016/j.ejps.2021.106100] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 12/14/2021] [Accepted: 12/16/2021] [Indexed: 01/09/2023]
Abstract
This collection of contributions from the European Network on Understanding Gastrointestinal Absorption-related Processes (UNGAP) community assembly aims to provide information on some of the current and newer methods employed to study the behaviour of medicines. It is the product of interactions in the immediate pre-Covid period when UNGAP members were able to meet and set up workshops and to discuss progress across the disciplines. UNGAP activities are divided into work packages that cover special treatment populations, absorption processes in different regions of the gut, the development of advanced formulations and the integration of food and pharmaceutical scientists in the food-drug interface. This involves both new and established technical approaches in which we have attempted to define best practice and highlight areas where further research is needed. Over the last months we have been able to reflect on some of the key innovative approaches which we were tasked with mapping, including theoretical, in silico, in vitro, in vivo and ex vivo, preclinical and clinical approaches. This is the product of some of us in a snapshot of where UNGAP has travelled and what aspects of innovative technologies are important. It is not a comprehensive review of all methods used in research to study drug dissolution and absorption, but provides an ample panorama of current and advanced methods generally and potentially useful in this area. This collection starts from a consideration of advances in a priori approaches: an understanding of the molecular properties of the compound to predict biological characteristics relevant to absorption. The next four sections discuss a major activity in the UNGAP initiative, the pursuit of more representative conditions to study lumenal dissolution of drug formulations developed independently by academic teams. They are important because they illustrate examples of in vitro simulation systems that have begun to provide a useful understanding of formulation behaviour in the upper GI tract for industry. The Leuven team highlights the importance of the physiology of the digestive tract, as they describe the relevance of gastric and intestinal fluids on the behaviour of drugs along the tract. This provides the introduction to microdosing as an early tool to study drug disposition. Microdosing in oncology is starting to use gamma-emitting tracers, which provides a link through SPECT to the next section on nuclear medicine. The last two papers link the modelling approaches used by the pharmaceutical industry, in silico to Pop-PK linking to Darwich and Aarons, who provide discussion on pharmacometric modelling, completing the loop of molecule to man.
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Affiliation(s)
- Clive G Wilson
- Strathclyde Institute of Pharmacy & Biomedical Sciences, Glasgow, U.K.
| | | | | | | | | | | | | | | | | | | | - Mirko Koziolek
- NCE Formulation Sciences, Abbvie Deutschland GmbH & Co. KG, Germany
| | | | - Philipp Schick
- Department of Biopharmaceutics and Pharmaceutical Technology, Center of Drug Absorption and Transport, University of Greifswald, Germany
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14
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Irwin M, Gunther W, Keefer P, Saul D, Singh SA, Wright J, Smith MA. Buprenorphine for Chronic Pain in a Pediatric Patient With Sickle-Cell Disease. J Pain Symptom Manage 2021; 62:1086-1091. [PMID: 33864846 DOI: 10.1016/j.jpainsymman.2021.04.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 03/29/2021] [Accepted: 04/05/2021] [Indexed: 12/23/2022]
Affiliation(s)
- Madison Irwin
- University of Michigan College of Pharmacy, Ann Arbor, Michigan; Michigan Medicine, Department of Pharmacy Services, Ann Arbor, Michigan
| | - William Gunther
- University of Michigan Medical School, Department of Geriatric and Palliative Medicine, Ann Arbor, Michigan
| | - Patricia Keefer
- University of Michigan Medical School, Department of Internal Medicine and Pediatrics, Ann Arbor, Michigan
| | - D'Anna Saul
- University of Michigan Medical School, Department of Internal Medicine and Pediatrics, Ann Arbor, Michigan
| | - Sharon A Singh
- University of Michigan Medical School, Department of Hematology/Oncology, and Pediatrics, Ann Arbor, Michigan
| | - Jennifer Wright
- Michigan Medicine, Pediatric Palliative Care Service, Ann Arbor, Michigan
| | - Michael A Smith
- University of Michigan College of Pharmacy, Ann Arbor, Michigan; Michigan Medicine, Department of Pharmacy Services, Ann Arbor, Michigan.
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Short communication: Systematic review on effectiveness of micro-induction approaches to buprenorphine initiation. Addict Behav 2021; 114:106740. [PMID: 33352498 DOI: 10.1016/j.addbeh.2020.106740] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 11/10/2020] [Accepted: 11/12/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND/OBJECTIVES Micro-induction is a novel buprenorphine induction approach that seeks to avoid withdrawal and minimize precipitated withdrawal, both barriers to standard inductions. We aimed to synthesize evidence on micro-induction effectiveness, and regimens described. METHODS We searched scientific databases and grey literature for studies including adolescents or adults with opioid use disorder who received buprenorphine micro-induction. Study selection, data extraction and quality assessments occurred in duplicate. We narratively synthesized results. RESULTS We screened 4,752 citations and included 19 case studies/series and one feasibility study (n = 57 patients; mean age 38 years [SD 12.0]; 57.9% male [33/57]). Studies described 26 regimens; starting and maintenance doses ranged from 0.03 to 1.0 mg, and 8 to 32 mg, respectively. We calculated rate of increase to 8 mg. All patients achieved the desired maintenance dose. Among 54 patients in whom precipitated withdrawal was not reported, mean increases were 1.36 mg/day (SD 0.41). For three patients in whom precipitated withdrawal was specifically reported, mean increase was 1.17 mg/day (SD 0.11). All studies were low quality. DISCUSSION Described regimens are highly variable. Inconsistent reporting, selection bias, and poor quality evidence limit conclusions regarding optimal dosing, and patient characteristics and clinical settings in which micro-induction is likely beneficial. CONCLUSIONS This systematic review provides the most up-to-date synthesis on buprenorphine micro-induction regimens. Rigorous studies evaluating effectiveness and safety of micro-induction, and patient and clinical factors influencing its success, are needed.
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16
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Wong JSH, Nikoo M, Westenberg JN, Suen JG, Wong JYC, Krausz RM, Schütz CG, Vogel M, Sidhu JA, Moe J, Arishenkoff S, Griesdale D, Mathew N, Azar P. Comparing rapid micro-induction and standard induction of buprenorphine/naloxone for treatment of opioid use disorder: protocol for an open-label, parallel-group, superiority, randomized controlled trial. Addict Sci Clin Pract 2021; 16:11. [PMID: 33579359 PMCID: PMC7881636 DOI: 10.1186/s13722-021-00220-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 01/23/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Buprenorphine/naloxone (Suboxone) is a current first-line treatment for opioid use disorder (OUD). The standard induction method of buprenorphine/naloxone requires patients to be abstinent from opioids and therefore experience withdrawal symptoms prior to induction, which can be a barrier in starting treatment. Rapid micro-induction (micro-dosing) involves the administration of small, frequent does of buprenorphine/naloxone and removes the need for a period of withdrawal prior to the start of treatment. This study aims to compare the effectiveness and safety of rapid micro-induction versus standard induction of buprenorphine/naloxone in patients with OUD. METHODS This is a randomized, open-label, two-arm, superiority, controlled trial comparing the safety and effectiveness of rapid micro-induction versus standard induction of buprenorphine/naloxone for the treatment of OUD. A total of 50 participants with OUD will be randomized at one Canadian hospital. The primary outcome is the completion of buprenorphine/naloxone induction with low levels of withdrawal. Secondary outcomes are treatment retention, illicit drug use, self-reported drug use behaviour, craving, pain, physical health, safety, and client satisfaction. DISCUSSION This is the first randomized controlled trial to compare the effectiveness and safety of rapid micro-induction versus standard induction of buprenorphine/naloxone. This study will thereby generate evidence for a novel induction method which eliminates substantial barriers to the use of buprenorphine/naloxone in the midst of the ongoing opioid crisis. Trial registration ClinicalTrials.gov, NCT04234191; date of registration: January 21, 2020; https://clinicaltrials.gov/ct2/show/NCT04234191.
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Affiliation(s)
- James S H Wong
- Addictions and Concurrent Disorders Research Group, Institute of Mental Health, Department of Psychiatry, The University of British Columbia, 430-5950, David Strangway Building, Vancouver, BC, V6T 1Z3, Canada.
| | - Mohammadali Nikoo
- Addictions and Concurrent Disorders Research Group, Institute of Mental Health, Department of Psychiatry, The University of British Columbia, 430-5950, David Strangway Building, Vancouver, BC, V6T 1Z3, Canada
| | - Jean N Westenberg
- Addictions and Concurrent Disorders Research Group, Institute of Mental Health, Department of Psychiatry, The University of British Columbia, 430-5950, David Strangway Building, Vancouver, BC, V6T 1Z3, Canada
| | - Janet G Suen
- Addictions and Concurrent Disorders Research Group, Institute of Mental Health, Department of Psychiatry, The University of British Columbia, 430-5950, David Strangway Building, Vancouver, BC, V6T 1Z3, Canada
| | - Jennifer Y C Wong
- Addictions and Concurrent Disorders Research Group, Institute of Mental Health, Department of Psychiatry, The University of British Columbia, 430-5950, David Strangway Building, Vancouver, BC, V6T 1Z3, Canada
| | - Reinhard M Krausz
- Addictions and Concurrent Disorders Research Group, Institute of Mental Health, Department of Psychiatry, The University of British Columbia, 430-5950, David Strangway Building, Vancouver, BC, V6T 1Z3, Canada
| | - Christian G Schütz
- Behavioral Reward Affect + Impulsivity Neuroscience Lab, Institute of Mental Health, Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | - Marc Vogel
- Division of Addictive Disorders, University of Basel Psychiatric Hospital, Wilhelm Klein-Strasse 27, 4002, Basel, Switzerland
| | - Jesse A Sidhu
- Department of Psychiatry, University of British Columbia & Vancouver General Hospital, Vancouver, BC, Canada
| | - Jessica Moe
- Department of Emergency Medicine, University of British Columbia & Vancouver General Hospital, Vancouver, BC, Canada
- BC Centre for Disease Control, Provincial Health Services Authority, Vancouver, BC, Canada
| | - Shane Arishenkoff
- Department of Medicine, University of British Columbia & Vancouver General Hospital, Vancouver, BC, Canada
| | - Donald Griesdale
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia & Vancouver General Hospital, Vancouver, BC, Canada
| | - Nickie Mathew
- Department of Psychiatry, University of British Columbia & Vancouver General Hospital, Vancouver, BC, Canada
- BC Mental Health & Substance Use Services, Provincial Health Services Authority, Vancouver, BC, Canada
| | - Pouya Azar
- Department of Psychiatry, University of British Columbia & Vancouver General Hospital, Vancouver, BC, Canada
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17
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Buchheit BM, Joslin T, Turner HN, Wong TE. Ambulatory microdose induction of buprenorphine-naloxone in two adolescent patients with sickle cell disease. Pediatr Blood Cancer 2021; 68:e28766. [PMID: 33111401 DOI: 10.1002/pbc.28766] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 09/24/2020] [Accepted: 10/02/2020] [Indexed: 11/07/2022]
Abstract
Sickle cell disease (SCD) is a hematologic disorder defined by presence of sickle-shaped red blood cells that can occlude blood vessels and cause tissue ischemia and pain. Treating SCD pain adequately and safely is difficult given today's opioid climate. Buprenorphine-naloxone has been described as an alternative option to treat chronic pain in the adult literature; however, it historically required discontinuation of full-agonist opioids before initiation, resulting in opioid withdrawal. Herein we present two adolescents with SCD who successfully weaned off large doses of full-agonist opioids by using microdose induction of buprenorphine-naloxone in clinic, without experiencing significant opioid withdrawal. Ambulatory microdose induction may remove hurdles that otherwise would discourage patients from trying this regimen while still controlling pain safely.
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Affiliation(s)
- Bradley M Buchheit
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon
- Department of Medicine, Division of General Internal Medicine and Geriatrics, Section of Addiction Medicine, Oregon Health & Science University, Portland, Oregon
| | - Timothy Joslin
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon
| | - Helen N Turner
- Department of Anesthesiology and Perioperative Medicine, Oregon Health & Science University, Portland, Oregon
| | - Trisha E Wong
- Division of Pediatric Hematology/Oncology and Department of Pathology, Oregon Health & Science University, Portland, Oregon
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18
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Ahmed S, Bhivandkar S, Lonergan BB, Suzuki J. Microinduction of Buprenorphine/Naloxone: A Review of the Literature. Am J Addict 2020; 30:305-315. [DOI: 10.1111/ajad.13135] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 11/17/2020] [Accepted: 11/26/2020] [Indexed: 11/30/2022] Open
Affiliation(s)
- Saeed Ahmed
- Department of Addiction Psychiatry Boston University Medical Center Boston Massachusetts
- VA Boston Healthcare System Massachusetts
| | - Siddhi Bhivandkar
- Department of Psychiatry St. Elizabeth's Medical Center Boston Massachusetts
| | - Brady B. Lonergan
- Department of Psychiatry Brigham and Women's Hospital Boston Massachusetts
- Harvard Medical School Boston Massachusetts
| | - Joji Suzuki
- Department of Psychiatry Brigham and Women's Hospital Boston Massachusetts
- Harvard Medical School Boston Massachusetts
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19
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Irwin M, Petersen KS, Smith MA. Rapid Buprenorphine Induction for Cancer Pain in Pregnancy. J Palliat Med 2020; 24:1257-1262. [PMID: 33275857 DOI: 10.1089/jpm.2020.0524] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Most patients with cancer-related pain are managed using opioids; cancer-related pain in the setting of pregnancy can be challenging to address owing to risk to the fetus associated with in utero opioid exposure. Buprenorphine is a unique opioid with potential benefits over other opioids for use in pregnancy and is often used for management of cancer-related pain in nonpregnant adults. There are limited data on cancer-related pain management in pregnant patients and no data supporting the use of buprenorphine for cancer-related pain in pregnant patients. This case describes a rapid buprenorphine induction using a microdosing regimen in a pregnant patient and highlights the potential of buprenorphine for cancer-related pain in this population.
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Affiliation(s)
- Madison Irwin
- Department of Pharmacy Services, Michigan Medicine, Ann Arbor, Michigan, USA.,University of Michigan College of Pharmacy, Ann Arbor, Michigan, USA
| | - Ketti S Petersen
- Department of Family Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Michael A Smith
- Department of Pharmacy Services, Michigan Medicine, Ann Arbor, Michigan, USA.,University of Michigan College of Pharmacy, Ann Arbor, Michigan, USA
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20
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Marwah R, Coons C, Myers J, Dumont Z. [Not Available]. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2020; 66:891-894. [PMID: 33334955 PMCID: PMC7745932 DOI: 10.46747/cfp.6612891] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Objective To raise awareness of alternative techniques that can facilitate buprenorphine-naloxone treatment for opioid use disorder. Sources of information PubMed was searched for articles using the terms buprenorphine, buprenorphine/naloxone, micro-dosing, opioid agonist therapy, and induction. Other relevant guidelines, presentations, and resources were consulted. Main message Buprenorphine-naloxone is the first-line option for opioid agonist therapy owing to its superior safety profile compared with methadone. The uptake of this potentially life-saving drug has been limited by unfamiliarity and prescribing restrictions, but perhaps the biggest barrier is the prerequisite that patients be in moderate to severe withdrawal before initiation. An induction option that does not require withdrawal or immediate cessation of current opioid use, termed microdosing, is an appealing choice for patients and a practical approach that can be used by a broader array of practitioners, ultimately increasing access to buprenorphine-naloxone. Family physicians play an important role in the current opioid crisis by helping patients transition to opioid agonist therapy. Conclusion Microdosing is a safe and easy-to-implement regimen that can be used in a variety of practice settings with the help of community pharmacists. This article provides an overview of microdosing and serves as a guide to starting and maintaining treatment.
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Affiliation(s)
- Radhika Marwah
- Staff physician with the Interprofessional Pain and Addictions Recovery Clinic at the Centre for Addiction and Mental Health in Toronto, Ont
| | - Caitlin Coons
- Pharmacist with the Saskatchewan Health Authority in Regina.
| | - Jacqueline Myers
- Lead Pharmacist of the Opioid Stewardship Program with the Saskatchewan Health Authority
| | - Zack Dumont
- Manager of Clinical Pharmacy Services with the Saskatchewan Health Authority
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21
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Marwah R, Coons C, Myers J, Dumont Z. [Not Available]. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2020; 66:e302-e306. [PMID: 33334964 PMCID: PMC7745943 DOI: 10.46747/cfp.6612e302] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Objectif Sensibiliser les médecins de famille aux autres techniques pouvant faciliter le traitement par buprénorphine-naloxone dans les cas de trouble lié à l’utilisation d’opioïdes. Sources d’information Une recherche d’articles a été effectuée dans PubMed à l’aide des mots-clés anglais buprenorphine, buprenorphine/naloxone, microdosing, opioid agonist therapy et induction. D’autres lignes directrices, présentations et ressources ont également été consultées. Message principal L’association buprénorphine-naloxone est l’option de première intention pour le traitement par agoniste des récepteurs opioïdes en raison de son profil d’innocuité supérieur à celui de la méthadone. L’adoption de ce médicament pouvant sauver des vies est limitée par le manque de connaissances et par les restrictions en matière de prescription, mais le plus grand obstacle est probablement le fait que le patient doit être en sevrage modéré à sévère avant d’instaurer le traitement. Une option d’induction qui n’exige pas le sevrage ni l’arrêt immédiat de l’usage actuel d’opioïdes, appelé microdosage, est un choix qui plaît aux patients et une approche pratique pouvant être utilisée par un plus grand éventail de praticiens, facilitant ainsi l’accès à la buprénorphine-naloxone. Les médecins de famille jouent un rôle important dans l’actuelle crise des opioïdes en aidant les patients à faire la transition vers le traitement par agoniste des récepteurs opioïdes. Conclusion Le microdosage est un schéma thérapeutique sécuritaire et facile à administrer, qui peut être utilisé dans une gamme de contextes avec l’aide des pharmaciens communautaires. Le présent article présente un survol du microdosage et sert de guide pour instaurer et maintenir le traitement.
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Affiliation(s)
- Radhika Marwah
- Médecin membre du personnel à la Clinique interprofessionnelle de traitement de la douleur et des dépendances du Centre de toxicomanie et de santé mentale à Toronto, en Ontario
| | - Caitlin Coons
- Pharmacienne à la Saskatchewan Health Authority à Regina.
| | - Jacqueline Myers
- Pharmacienne en chef de l'Opioid Stewardship Program à la Saskatchewan Health Authority
| | - Zack Dumont
- Gestionnaire des services de pharmacie clinique à la Saskatchewan Health Authority
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22
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Brar R, Fairbairn N, Sutherland C, Nolan S. Use of a novel prescribing approach for the treatment of opioid use disorder: Buprenorphine/naloxone micro-dosing - a case series. Drug Alcohol Rev 2020; 39:588-594. [PMID: 32657496 PMCID: PMC7919736 DOI: 10.1111/dar.13113] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 04/07/2020] [Accepted: 05/05/2020] [Indexed: 01/13/2023]
Abstract
INTRODUCTION AND AIMS Buprenorphine/naloxone is an evidence-based treatment for opioid use disorder, but an identified limitation is the period of required opioid abstinence prior to induction on the medication. 'Micro-dosing', or using incrementally increasing doses of buprenorphine/naloxone over time, may be a way to overcome this challenge as it can be done in parallel with the ongoing use of other opioids (either illicit or prescribed). DESIGN AND METHODS A retrospective case series (January to December 2018) was completed of seven participants who underwent buprenorphine/naloxone induction using micro-dosing at two outpatient addiction clinics in Vancouver, Canada. RESULTS Seven participants completed a 7-day buprenorphine/naloxone micro-dosing protocol. Prior to and during the induction, one participant was prescribed methadone, three were prescribed slow release oral morphine and three used only illicit fentanyl. Participants were prescribed sublingual buprenorphine/naloxone: 0.5 mg once daily (day 1), 0.5 mg twice daily (BID; day 2), 1 mg BID (day 3), 2 mg BID (day 4), 3 mg BID (day 5), 4 mg BID (day 6) and 12 mg once daily (day 7). On day 7, all prescribed or illicit full opioid agonists were discontinued. Buprenorphine/naloxone was subsequently titrated to a daily dose of between 12 and 32 mg. All patients reported success with buprenorphine/naloxone induction with no precipitated withdrawal. DISCUSSION AND CONCLUSIONS Buprenorphine/naloxone micro-dosing may offer a promising alternative approach for successful induction for individuals with opioid use disorder who desire treatment with buprenorphine/naloxone, and further research to determine effectiveness is warranted.
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Affiliation(s)
- Rupinder Brar
- British Columbia Centre on Substance Use, Vancouver, Canada
- Department of Family Practice, University of British Columbia, Vancouver, Canada
| | - Nadia Fairbairn
- British Columbia Centre on Substance Use, Vancouver, Canada
- Department of Medicine, University of British Columbia, St. Paul’s Hospital, Vancouver, Canada
| | - Christy Sutherland
- British Columbia Centre on Substance Use, Vancouver, Canada
- Department of Family Practice, University of British Columbia, Vancouver, Canada
| | - Seonaid Nolan
- British Columbia Centre on Substance Use, Vancouver, Canada
- Department of Medicine, University of British Columbia, St. Paul’s Hospital, Vancouver, Canada
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23
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Rozylo J, Mitchell K, Nikoo M, Durante SE, Barbic SP, Lin D, Mathias S, Azar P. Case report: Successful induction of buprenorphine/naloxone using a microdosing schedule and assertive outreach. Addict Sci Clin Pract 2020; 15:2. [PMID: 31941547 PMCID: PMC6964069 DOI: 10.1186/s13722-020-0177-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 01/04/2020] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND The requirement for moderate withdrawal prior to initiation can be a barrier to buprenorphine/naloxone induction. CASE PRESENTATION We aimed to use a microdosing regimen to initiate regular dosing of buprenorphine/naloxone in a high-risk patient with a history of failed initiations due, in part, to withdrawal symptoms. Using an assertive outreach model and a buprenorphine/naloxone microdosing schedule, we initiated treatment of an individual's opioid use disorder. There was a successful buprenorphine/naloxone microdosing induction as the team reached a therapeutic dose of buprenorphine/naloxone. Including the induction period, the medication was used consistently for 4 weeks. CONCLUSIONS A microdosing schedule can be used to induce a patient onto buprenorphine/naloxone with no apparent withdrawal; gradually reducing illicit substance use. This case report builds on previous literature, highlighting ways to minimize barriers to induction of buprenorphine/naloxone, using a microdosing schedule and assertive outreach. Given the safety profile of buprenorphine and its potential to be a lifesaving intervention, a larger study of microdosing is indicated.
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Affiliation(s)
| | - Keren Mitchell
- University of British Columbia, Vancouver, BC, Canada
- Inner City Youth Program, Providence Health Care, Vancouver, BC, Canada
- Foundry, Providence Health Care, Vancouver, BC, Canada
- St Paul's Hospital, Vancouver, BC, Canada
| | - Mohammadali Nikoo
- University of British Columbia, Vancouver, BC, Canada
- Addiction and Concurrent Disorders Group, Institute of Mental Health, University of British Columbia, Vancouver, BC, Canada
| | - S Elise Durante
- Inner City Youth Program, Providence Health Care, Vancouver, BC, Canada
- Foundry, Providence Health Care, Vancouver, BC, Canada
| | - Skye P Barbic
- University of British Columbia, Vancouver, BC, Canada
- Inner City Youth Program, Providence Health Care, Vancouver, BC, Canada
- Foundry, Providence Health Care, Vancouver, BC, Canada
- St Paul's Hospital, Vancouver, BC, Canada
- Centre for Health Evaluation and Outcome Sciences, Vancouver, BC, Canada
- Department of Occupational Science and Occupational Therapy, University of British Columbia, Vancouver, BC, Canada
| | - Daniel Lin
- University of British Columbia, Vancouver, BC, Canada
- Inner City Youth Program, Providence Health Care, Vancouver, BC, Canada
- Foundry, Providence Health Care, Vancouver, BC, Canada
- St Paul's Hospital, Vancouver, BC, Canada
| | - Steve Mathias
- University of British Columbia, Vancouver, BC, Canada
- Inner City Youth Program, Providence Health Care, Vancouver, BC, Canada
- Foundry, Providence Health Care, Vancouver, BC, Canada
- St Paul's Hospital, Vancouver, BC, Canada
- Centre for Health Evaluation and Outcome Sciences, Vancouver, BC, Canada
| | - Pouya Azar
- University of British Columbia, Vancouver, BC, Canada.
- Inner City Youth Program, Providence Health Care, Vancouver, BC, Canada.
- Foundry, Providence Health Care, Vancouver, BC, Canada.
- St Paul's Hospital, Vancouver, BC, Canada.
- Vancouver General Hospital, DHCC, Floor 8-2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada.
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