A guide to using buprenorphine-naloxone microdosing as an induction method in opioid agonist therapy (OAT).

Author: Marie-Ève Goyer, Elise Schurter, Karine Hudon, Anne-Sophie Thommeret-Carrière, Yan Ferguson

Theme: Clinical Research Year: 2023

In Canada, opioid agonist therapy (OAT) is the first-line treatment for opioid use disorder and has been proven as an effective strategy to lower the incidence of hepatitis C and other drug-related harms in people who inject drugs. Buprenorphine/naloxone (BUP-SL) is one of the standard OAT options, but it recommended method of induction, which requires the patient to be in moderate to severe withdrawal before starting, can be challenging and therefore limits access to this treatment. However, in recent years there has been an increased interest from practitioners in the use of alternative induction methods such as microdosing. Despite indicated off-label, microdosing of BUP-SL consists of introducing repeated low doses of buprenorphine, in concomitance with the current full agonist opioids for a period of about 7-13 days. This Guide to Using Buprenorphine-naloxone Microdosing as an Induction Method aims to summarize clinical expertise to support clinicians in their practice.
Using a rigorous rapid review process, current literature has been collected from six medical databases and analysed by outcomes such as withdrawal symptoms, treatment retention, opioid and other substance use, quality of life, patient preference, acceptability, mental and physical health, cravings, adverse events, etc. 37 articles have been collected: 29 case reports, 3 cohort studies, 1 feasibility study, 4 literature reviews. Grey literature has also been summarised through a review of 13 clinical practice guidelines from Canada, USA and Europe. The guide was then developed with an Expert Review Committee composed of doctors, pharmacists and a nurse.
Available knowledge and clinical expertise have demonstrated BUP-SL microdosing induction to be feasible, and to allow patients to transfer from a full agonist opioid to a buprenorphine formulation with minimal withdrawal symptoms while still being administered both opioids during the process.

The guide presents BUP-SL microdosing induction characteristics, including general principles with detailed protocols, eligibility, contraindications, and precautions, as well as a prescription template, and an information guide to pharmacists and patients. The Guide to Using Buprenorphine-naloxone Microdosing as an Induction Method is one more step towards meeting people’s needs – offering more flexibility that could result in less drug-related harms while providing guidance to clinicians.

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