Rapid microinduction of buprenorphine/naloxone for opioid use disorder in a large safety net hospital: a retrospective case series

Background: Opioid overdose death is a public health crisis. Buprenorphine is a partial μ-opioid receptor agonist used for maintenance treatment of opioid dependence and significantly reduces mortality. Hospitalized patients with opioid use disorder requiring narcotics for pain control present clinical challenges such as adequately controlling pain, preventing withdrawal and early discontinuation of treatments (i.e., leaving against medical advice). Therefore, inducing these patients onto buprenorphine while hospitalized is difficult. A three-day rapid cross-titration of low dose buprenorphine from a full-opioid agonist is a hypothesized novel method that induces patients onto buprenorphine in the hospital setting.Objectives: To examine the utility of a three-day buprenorphine microinduction protocol in a large safety-net hospital.Methods: A retrospective chart review was conducted for 48 adult patients (27 female) with opioid use disorder (OUD) requiring pain management who underwent buprenorphine microinduction in the inpatient setting. The primary outcome for this study was the rate of successful inductions defined as: 1) completion of a full rapid three-day microinduction protocol without precipitated withdrawal and 2) reaching an adequate maintenance dose of buprenorphine for treatment of OUD, defined as a total dose of ≥ 8 mg of buprenorphine daily. Other outcomes of interest included pain and withdrawal symptoms during induction, rehospitalization and buprenorphine pickup from pharmacy.Results: Forty-one patients (27 female) underwent a rapid three-day microinduction. Thirty-six patients (87.8%) tolerated the cross-titration and successfully titrated to at least 8 mg/day buprenorphine. There were zero cases of precipitated withdrawal.Conclusions: These findings support the safety and feasibility of buprenorphine microinductions in hospitalized patients with OUD, pain, and complicated medical presentations. This strategy allows adequate pain control while simultaneously transitioning to buprenorphine within three days, leading to improved retention, safety, and comfort.