(20) Low-Dose Buprenorphine Induction Protocols for Co-Occurring Pain and Opioid Use Disorders

Background & Introduction: For patients with an opioid use disorder who also have pain management needs, buprenorphine is an appropriate treatment. However, there is a gap between patients identified as who could benefit and those who receive the medication (Bhatraju, et al). While there is growing literature to support the initiation of buprenorphine products during inpatient hospitalizations prior to discharge, our study specifically focused on an acute care trauma setting where high levels of pain medications are often necessary for symptomatic relief. This is typically due to high tolerance secondary to long-standing substance use and the severe nature of the physical injuries sustained by the patient population. Given all of this, it is beneficial to introduce buprenorphine during admission to treat both the acute pain and the substance use. However, given buprenorphine’s partial agonist properties, it can also precipitate withdrawal. Historically, perceived barriers such as waiting for the patient to be in severe withdrawal or waiting for any full opioid agonists to wash out inhibited the early introduction of buprenorphine as part of the treatment plan (Bhatraju, et al). By introducing buprenorphine through small doses, known as low-dose inductions, withdrawal symptoms can be minimized and patients can receive appropriate treatment (Jablonski, et al).

Methods: The study was an IRB-approved retrospective cohort analysis of patients admitted to an inpatient acute care trauma service at a level 1 academic hospital located in a city with a known history of extensive illicit opioid use. The patients reviewed were admitted between May 1, 2022 to January 31, 2023. Patients were identified based on medication administration records (MAR); any patient admitted to the inpatient shock trauma center between the aforementioned dates and who also received IV buprenorphine as per the MAR were included in the study. Various outcomes were evaluated including whether or not the patient completed the low-dose induction (defined by a transition to oral Suboxone prior to hospital discharge), the duration of the low-dose induction (defined as the length of time from the first dose of IV buprenorphine to the first dose of oral Suboxone), hospital length of stay (LOS), and the dosage of the buprenorphine prescription at the time of hospital discharge. Opioid requirements based on any full opioid agonist medications the patients received were also assessed and measured in oral morphine equivalents (OME). They were measured at 3 different time points: prior to the induction, at the conclusion of the induction, and at hospital discharge.

Results: A total of 36 patients, based on the screening criteria, were evaluated during the study period. The median age was 39 years old with the majority of patients identifying as male (n=24, 66.7%), and Caucasian (n=19, 52.8%). The majority of the patients were admitted due to a wound or soft tissue infection (n=13, 36.1%) , followed by blunt trauma (n=12, 33.3%) and penetrating trauma (n=8, 22.2%). 26 patients (72%) were not on any form of medication for opioid use disorder (MOUD) prior to their hospital admission. The baseline opioid requirement, measured in oral morphine equivalents, for the entire cohort was 117.5 mg. Out of the original 36 patients reviewed in the study, a total of 29 patients (80.6%) successfully completed the low-dose induction process and were transitioned from IV buprenorphine to oral Suboxone prior to hospital discharge. The median duration of the low-dose induction was 36 hours, and the median hospital length of stay was 9 days. Among the 29 patients who successfully completed the low-dose induction process, the median opioid requirement prior to the induction, at the end of the induction, and at hospital discharge (in OME) were 117.5 mg, 85 mg and 50 mg respectively. 26 patients (72%) were discharged with a Suboxone prescription with a median dose of 16 mg total daily. A total of 15 patients (41.7%) were discharged with a short supply of PRN opioid medication; the median dose of these prescriptions was 50 mg daily, as mentioned above.

Conclusion & Discussion: Our findings demonstrated that utilizing a low-dose buprenorphine induction protocol resulted in the successful transition to oral Suboxone as both a form of pain management and as medication for the treatment of opioid use disorder in a trauma population. It also allowed for lower doses of full opioid agonists, if any, to be prescribed at the time of hospital discharge. Low-dose induction protocols present a great opportunity to increase the utilization of MOUD in high-risk populations by allowing patients to initiate treatment for their substance use diagnosis prior to following-up in an outpatient setting, which helps to mitigate the risk of return to use. Some limitations to consider include that this study specifically focused on patients admitted to an acute care trauma service, which led to a smaller sample size. More significant findings may be obtained by looking at all patients, regardless of admission service, who received IV buprenorphine as part of a low-dose induction protocol. Another limitation is that we did not look at outpatient follow-up for the patients who successfully transitioned to oral Suboxone prior to discharge. When considering the long-term benefits of Suboxone, it would be useful to observe how many patients continued taking the medication.

References: 1. Bhatraju, E. P., Klein, J. W., Hall, A. N., Chen, D. R., Iles-Shih, M., Tsui, J. I., & Merrill, J. O. (2021). Low dose buprenorphine induction with full agonist overlap in hospitalized patients with opioid use disorder: A retrospective cohort study. Journal of Addiction Medicine, 16(4), 461–465. https://doi.org/10.1097/adm.0000000000000947.

2. Button, D., Hartley, J., Robbins, J., Levander, X. A., Smith, N. J., & Englander, H. (2021). Low-dose buprenorphine initiation in hospitalized adults with opioid use disorder: A retrospective cohort analysis. Journal of Addiction Medicine, 16(2). https://doi.org/10.1097/adm.0000000000000864.

3. Jablonski, L. A., Bodnar, A. R., & Stewart, R. W. (2022). Development of an intravenous low-dose buprenorphine initiation protocol. Drug and Alcohol Dependence, 237, 109541. https://doi.org/10.1016/j.drugalcdep.2022.109541.

4. Murray, J. P., Pucci, G., Weyer, G., Ari, M., Dickson, S., & Kerins, A. (2023). Low dose IV buprenorphine inductions for patients with opioid use disorder and concurrent pain: A retrospective case series. Addiction Science & Clinical Practice, 18(1). https://doi.org/10.1186/s13722-023-00392-z.