Buprenorphine: Difference between revisions
 
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*Routes of Administration: Buccal, sublingual, intradermal, transdermal, IV, IM
*Routes of Administration: Buccal, sublingual, intradermal, transdermal, IV, IM
*Common Trade Names: Suboxone (buprenorphine + [[naloxone]]), Buprex
*Common Trade Names: Suboxone (buprenorphine + [[naloxone]]), Buprex
*Combined with naloxone to deter abuse. The naloxone has no effect when used as intended under the tongue. The naloxone is only active when abused by crushing/injection. Buprenorphine and buprenorphine/naloxone are interchangeable. Buprenorphine/naloxone is now generic in the USA.


==Adult Dosing==
==Adult Dosing==
Dosing for opioid withdraw. Patients must be in withdraw to start taking buprenorphine or buprenorphine can precipitate withdraw symptoms.
''Highly variable, dependent on individual. The below dosing is for the traditional induction, although there are also options including a micro-induction (low-dose induction) for patients not in opioid withdrawal or a high-dose induction.'' <ref> Weimer MB, Herring AA, Kawasaki SS, Meyer M, Kleykamp BA, Ramsey KS. ASAM Clinical Considerations: Buprenorphine Treatment of Opioid Use Disorder for Individuals Using High-potency Synthetic Opioids. J Addict Med. 2023 Jul 28. doi: 10.1097/ADM.0000000000001202. Epub ahead of print. PMID: 37505909. </ref>
*For [https://www.mdcalc.com/cows-score-opiate-withdrawal Clinical Opioid Withdrawal Scale] (COWS) >=8: 4mg, observe 45min, redose if COWS remains >=8. Then discharge home with 16 mg a day for 2 days if you are able to prescribe, other wise consider return to the ER on day 2 and 3 for a 16 mg dose per day.
===[[Opioid withdrawal]]===
*For Clinical Opioid Withdrawal Scale (COWS) 0-7: Do not dose in the ER. If you can prescribe consider unobserved home induction instructions available on paper <ref>A Guide for Patients Beginning Buprenorphine Treatment at Home https://medicine.yale.edu/edbup/quickstart/Home_Buprenorphine_Initiation_338574_42801_v1.pdf</ref><ref>A Patient’s Guide to Starting Buprenorphine at Home from ASAM https://www.asam.org/docs/default-source/education-docs/unobserved-home-induction-patient-guide.pdf</ref> and app<ref>Buprenorphine Home Induction  Apple App Store https://apps.apple.com/us/app/buprenorphine-home-induction/id1449302173</ref> <ref>Starting Buprenorphine from Google Play Store https://play.google.com/store/apps/details?id=com.amstonstudio.bup&hl=en_US&gl=US</ref>.
{{Suboxone protocol}}
 
*If sublingual tablets/films unavailable then intravenous/intramuscular formulation (dose 0.3-0.9 mg every 6-12 hours) has been used for opioid withdrawal in the ED<ref>Berg ML, et. al. Evaluation of the use of buprenorphine for opioid withdrawal in an emergency department. Drug Alcohol Depend. 2007 Jan 12;86(2-3):239-44. https://doi.org/10.1016/j.drugalcdep.2006.06.014. Epub 2006 Aug 22. PMID: 16930865.</ref> and hospitalized<ref>Welsh CJ, Suman M, Cohen A, et al. The use of intravenous buprenorphine for the treatment of opioid withdrawal in medically ill hospitalized patients. Am J Addict. 2002;11(2):135-40 https://doi.org/10.1080/105500490290087901</ref> patients.  
 
[[File:Buprenorphine in ED.png|thumb|NIH National Institute on Drug Abuse ED Buprenorphine algorithm<ref>https://d14rmgtrwzf5a.cloudfront.net/sites/default/files/algorithm.pdf</ref>]]


==Pediatric Dosing==
==Pediatric Dosing==
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==Special Populations==
==Special Populations==
*[[Drug Ratings in Pregnancy|Pregnancy Rating]]: C
*[[Drug Ratings in Pregnancy|Pregnancy Rating]]: C (but buprenorphine is preferred over methadone in pregnant patients due to neonatal outcomes)
*[[Lactation risk categories|Lactation risk]]: Infant risk has been demonstrated
*[[Lactation risk categories|Lactation risk]]: Infant risk has been demonstrated
*Hepatic dosing: reduce dose or do not use in moderate - severe impairment
*Hepatic dosing: reduce dose or do not use in moderate - severe impairment
*Renal dosing:  
*Renal dosing:


==Contraindications==
==Contraindications==
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==Comments==
==Comments==
*No DATA 2000 Waiver (aka X Waiver) required to administer within the ED for up to 72h (e.g. patient can come back to ED for daily dose for 3 days)<ref>https://www.drugabuse.gov/nidamed-medical-health-professionals/discipline-specific-resources/initiating-buprenorphine-treatment-in-emergency-department/frequently-asked-questions-about-ed-initiated-buprenorphine</ref>
*Combined with naloxone to deter abuse. The naloxone has no effect when used as intended under the tongue. The naloxone is only active when abused by crushing/injection. Buprenorphine and buprenorphine/naloxone are interchangeable. Buprenorphine/naloxone is now generic in the USA.
*The DATA 2000 Waiver (aka X Waiver) is no longer required <ref>https://www.drugabuse.gov/nidamed-medical-health-professionals/discipline-specific-resources/initiating-buprenorphine-treatment-in-emergency-department/frequently-asked-questions-about-ed-initiated-buprenorphine</ref>


==See Also==
==See Also==

Latest revision as of 09:24, 4 July 2024

Administration

  • Type: Opioid- maintenance therapy in opioid use disorder, rapid detox
  • Dosage Forms: injectable solution, sublingual tablet
  • Dosage Strengths: injectable solution: 0.3 mg/mL; sublingual tablet: 2, 8mg
  • Routes of Administration: Buccal, sublingual, intradermal, transdermal, IV, IM
  • Common Trade Names: Suboxone (buprenorphine + naloxone), Buprex

Adult Dosing

Highly variable, dependent on individual. The below dosing is for the traditional induction, although there are also options including a micro-induction (low-dose induction) for patients not in opioid withdrawal or a high-dose induction. [1]

Opioid withdrawal

  • For Clinical Opioid Withdrawal Scale (COWS) ≥8: give 4 to 8mg of Buprenorphine, observe 30 to 45min
    • Redose if COWS remains ≥8. Then discharge home with 16 mg a day to bridge until follow-up (an X-waiver is no longer required to prescribe buprenorphine).
  • For Clinical Opioid Withdrawal Scale (COWS) 0-7: Consider observing the patient until their COWS score is >8 for the standard buprenorphine induction.
    • Alternatively, you can prescribe consider unobserved home induction instructions available on paper [2][3] and app[4] [5].
  • If sublingual tablets/films unavailable then intravenous/intramuscular formulation (dose 0.3-0.9 mg every 6-12 hours) has been used for opioid withdrawal in the ED[6] and hospitalized[7] patients.
NIH National Institute on Drug Abuse ED Buprenorphine algorithm[8]

Pediatric Dosing

Variable

Special Populations

  • Pregnancy Rating: C (but buprenorphine is preferred over methadone in pregnant patients due to neonatal outcomes)
  • Lactation risk: Infant risk has been demonstrated
  • Hepatic dosing: reduce dose or do not use in moderate - severe impairment
  • Renal dosing:

Contraindications

  • Allergy to class/drug
  • SBO, paralytic ileus
  • Acute/severe asthma (if unmonitored), respiratory depression

Adverse Reactions

Serious

  • Hypotension, prolonged QT, MI
  • Respiratory depression
  • SBO
  • Hepatotoxicity
  • Stroke
  • Sedation, coma
  • Drug dependence or withdrawal

Common

  • Pruritus
  • Constipation, nausea, diarrhea, xerostomia
  • Dizziness, headache, somnolence
  • URI symptoms

Pharmacology

  • Half-life: 24-48 hours
  • Metabolism: Extensive hepatic, CYP3A4 substrate
  • Excretion: Mostly fecal, some renal

Mechanism of Action

  • Mixed opiate agonist-antagonist, partial mu-opioid agonist, kappa-opioid antagonist

Comments

  • Combined with naloxone to deter abuse. The naloxone has no effect when used as intended under the tongue. The naloxone is only active when abused by crushing/injection. Buprenorphine and buprenorphine/naloxone are interchangeable. Buprenorphine/naloxone is now generic in the USA.
  • The DATA 2000 Waiver (aka X Waiver) is no longer required [9]

See Also

References

  1. ↑ Weimer MB, Herring AA, Kawasaki SS, Meyer M, Kleykamp BA, Ramsey KS. ASAM Clinical Considerations: Buprenorphine Treatment of Opioid Use Disorder for Individuals Using High-potency Synthetic Opioids. J Addict Med. 2023 Jul 28. doi: 10.1097/ADM.0000000000001202. Epub ahead of print. PMID: 37505909.
  2. ↑ A Guide for Patients Beginning Buprenorphine Treatment at Home https://medicine.yale.edu/edbup/quickstart/Home_Buprenorphine_Initiation_338574_42801_v1.pdf
  3. ↑ A Patient’s Guide to Starting Buprenorphine at Home from ASAM https://www.asam.org/docs/default-source/education-docs/unobserved-home-induction-patient-guide.pdf
  4. ↑ Buprenorphine Home Induction Apple App Store https://apps.apple.com/us/app/buprenorphine-home-induction/id1449302173
  5. ↑ Starting Buprenorphine from Google Play Store https://play.google.com/store/apps/details?id=com.amstonstudio.bup&hl=en_US&gl=US
  6. ↑ Berg ML, et. al. Evaluation of the use of buprenorphine for opioid withdrawal in an emergency department. Drug Alcohol Depend. 2007 Jan 12;86(2-3):239-44. https://doi.org/10.1016/j.drugalcdep.2006.06.014. Epub 2006 Aug 22. PMID: 16930865.
  7. ↑ Welsh CJ, Suman M, Cohen A, et al. The use of intravenous buprenorphine for the treatment of opioid withdrawal in medically ill hospitalized patients. Am J Addict. 2002;11(2):135-40 https://doi.org/10.1080/105500490290087901
  8. ↑ https://d14rmgtrwzf5a.cloudfront.net/sites/default/files/algorithm.pdf
  9. ↑ https://www.drugabuse.gov/nidamed-medical-health-professionals/discipline-specific-resources/initiating-buprenorphine-treatment-in-emergency-department/frequently-asked-questions-about-ed-initiated-buprenorphine
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