Rapid Induction of Buprenorphine Can Help Avoid Opioid Withdrawal

Individuals with opioid use disorder (OUD) can achieve therapeutic levels of buprenorphine using a single 4mg dose of buprenorphine-naloxone followed by an extended-release buprenorphine injection an hour later, according to a report in JAMA Psychiatry. Patients receiving this rapid induction (RI) strategy were more likely to return for their second buprenorphine injection than those who received standard induction (seven or more days of buprenorphine-naloxone prior to initial extended-release buprenorphine injection).

“Buprenorphine limits withdrawal symptoms and reduces overdose risk. This RI strategy would be particularly beneficial in settings requiring therapeutic buprenorphine levels of 2ng/mL or greater to be rapidly achieved and sustained,” wrote Rajinder Shiwach, M.D., of Insight Clinical Research in Desoto, Texas, and colleagues.

A total of 729 treatment-seeking patients with moderate or severe OUD were enrolled for this study, which was conducted from October 26, 2021, to January 19, 2024. Of this group, 474 patients (367 positive for fentanyl) were randomized to receive the RI strategy, while 255 (196 positive for fentanyl) received standard induction at 28 outpatient treatment centers in the United States and Canada. All participants met the criteria for high-risk opioid use by injecting opioids, using high doses of opioids, and/or using fentanyl.

The researchers found that 86.3% (n=409) of RI patients received the first extended-release injection compared with 59.2% (n=151) of standard induction patients. A total of 314 (66.2%) RI patients received the second extended-release injection one week later compared with 138 (54.1%) standard induction patients. This difference was primarily driven by fentanyl-positive patients, who had a 14.8% higher retention rate for the second extended-release injection following RI versus standard induction. There was no significant difference in occurrence of adverse events between patients in both groups.

“The ultimate goal of rapid induction is to reach a therapeutic buprenorphine concentration as soon as possible to manage OUD without inducing precipitated withdrawal that could jeopardize continued engagement in extended-release buprenorphine treatment,” wrote Shiwach and colleagues. “This regimen represents an important improvement in implementation of buprenorphine treatment for this serious, life-threatening condition.”

For related information, see the Psychiatric News article “Fighting the Opioid Crisis in the ED.”