initiate buprenorphine when patient develops mild withdraw symptoms
- related: opioid management inpatient
- tags: #literature #icu
Ideally, the clinician would prescribe the combination product buprenorphine-naloxone, as the naloxone would reduce the potential for misuse.
Importantly, buprenorphine should not be prescribed to patients whose opioid receptors are still occupied by full-agonist opioids, because buprenorphine has a higher affinity for mu opioid receptors than other opioids and may precipitate withdrawal. Therefore, initiation of buprenorphine for the indication of OUD requires patients to be abstinent from opioids until they start to develop mild to moderate symptoms of opioid withdrawal, usually 12 to 24 hours without opioids, although longer in the case of some ER/LA opioids such as methadone. At that point, buprenorphine can be initiated and will ameliorate the withdrawal symptoms by binding to the mu receptors. The dose is titrated until withdrawal symptoms are controlled.
Although other initiation protocols are used in specific circumstances, such as low-dose initiation (often in low milligram doses; i.e., 0.25 mg) while the patient is still taking a full-agonist opioid, these protocols are not as well established and should generally only be considered under the supervision of a clinician experienced in the pharmacologic management of OUD.
The following infographic outlines the steps for initiating buprenorphine. More detailed information can be found in the Buprenorphine Quick-Start Guide from the Substance Abuse and Mental Health Services Administration (SAMHSA).
If pharmacotherapy is indicated to control this patient’s pain, then a nonopioid analgesic such as acetaminophen or a nonsteroidal anti-inflammatory drug would be preferred. Although venlafaxine and gabapentin can be helpful in treating neuropathic pain and can be useful nonopioid analgesics, they would not be indicated in this patient who only has very mild pain symptoms.
Clonidine is an alphas adrenergic agonist used to treat symptoms of opioid withdrawal. In this case, the patient does not appear to be currently experiencing withdrawal symptoms. Even if he were, initiating buprenorphine would be a better option than prescribing clonidine, because buprenorphine would treat not only his withdrawal symptoms but also his OUD
Clonazepam would be a high-risk medication in this patient. Concurrent use of benzodiazepines and opioids is associated with an elevated risk for respiratory depression, and this patient is at risk of misusing the benzodiazepine given his experience with opioids.1