Buprenorphine Microdosing for the Pain and Palliative Care Clinician

Microdosing induction of buprenorphine, in which the drug is gradually titrated while full agonist opioids are continued, offers a viable alternative to traditional inductions that require an opioid-free interval or withdrawal. This review of 34 publications found that the most common strategy involved administering divided doses of sublingual products marketed for opioid use disorder, with 73.5% of articles using partial tablets or films ranging from 1/8 to 1/2 of a 2 mg product. Transdermal patches, low-dose sublingual buprenorphine available in Europe, intravenous buprenorphine, and buccal buprenorphine have also been used. The speed of induction, setting, final dosing, and management of concomitant full agonists varied widely.

Study at a glance

Abstract

Buprenorphine (BUP) can be a safe and effective alternative to traditional opioids for many patients with chronic pain. For patients on higher doses of opioids, rotation to BUP is complicated by the requirement of an opioid-free interval or withdrawal during the transition. Microdosing inductions, in which BUP is gradually titrated, while full agonist opioids are continued, are a viable alternative to traditional inductions. The objective of this article is to review the current literature on BUP microdosing induction, with a focus on patients using opioids for pain. A literature review of the PubMed database was performed in the United States on articles published from inception to May 2021. A total of 34 publications were included. The most commonly utilized microdosing strategy involved administering divided doses of sublingual (SL) products marketed for opioid use disorder treatment, with 25 (73.5%) articles reporting use of partial SL tablets or films (ranging from 1/8 to 1/2 of a 2 mg product) at some point during the induction. Transdermal patches, low-dose SL BUP available in Europe, intravenous BUP, and buccal BUP have also been used. Beyond the products used, the speed of the microinduction, setting, final BUP dosing, and management of concomitant full agonists vary widely in the literature. Microdosing regimens should be individualized based on local guidelines and patient-specific factors. Further studies comparing the safety and efficacy of different protocols are warranted.