Transdermal buprenorphine patch-facilitated induction of sublingual buprenorphine in hospitalized patients receiving full agonist opioids: a retrospective cohort study

Treatment with buprenorphine is challenging to initiate in hospitalized patients receiving full agonist opioids because of the risk of precipitated opioid withdrawal. We describe clinical outcomes of precipitated withdrawal, incidence and rate of buprenorphine prescription at discharge in hospitalized patients undergoing transdermal buprenorphine patch-facilitated buprenorphine induction while receiving full agonist opioids. This is a retrospective chart review of hospitalized patients in a single academic healthcare system who were started on sublingual buprenorphine for opioid use disorder using a transdermal buprenorphine patch low-dose initiation strategy with overlapping full agonist opioids. The primary outcome was incidence of precipitated opioid withdrawal among those who received at least one dose of sublingual buprenorphine following low-dose initiation. Discharge with a prescription for sublingual buprenorphine was a secondary outcome. Of 288 unique patient encounters with inpatient buprenorphine patch use, 68 met eligibility criteria for inclusion and five of 68 (7.4%, 95% CI: 2.4-16.3%) experienced precipitated opioid withdrawal. Sixty-seven of 68 (99%) patients were discharged with a buprenorphine prescription including 100% of those with precipitated withdrawal. There were no significant associations between incidence of precipitated withdrawal and oral morphine equivalents received prior to sublingual buprenorphine induction, age, sex, history of liver disease, dose or duration of transdermal buprenorphine patch. This study supports growing evidence that a transdermal buprenorphine patch-facilitated buprenorphine initiation strategy in hospitalized patients receiving full agonist opioids is well-tolerated. Limitations include its retrospective chart review methodology and incomplete data available to fully characterize precipitated withdrawal. Transdermal buprenorphine-facilitated low dose buprenorphine initiation in hospitalized patients receiving full agonist opioids was well-tolerated in the majority of patients, with 7.4% (95% CI: 2.4-16.3%) developing precipitated withdrawal.