Direct Induction of Buprenorphine Extended-Release: A Case Report

Buprenorphine has superior safety in opioid use disorder compared with alternatives due to its action as a partial opioid agonist, which limits its ability to cause respiratory depression. There is a risk of precipitated opioid withdrawal after buprenorphine exposure in someone using full opioid agonists. Buprenorphine induction strategies that avoid precipitated withdrawal remain a crucial component for starting buprenorphine in individuals actively using opioids. These strategies start with low doses of buprenorphine increasing over time, which may avoid precipitated withdrawal at the cost of an extended initiation period, potentially discouraging patients and increasing healthcare costs. A 55-year-old male with severe opioid use disorder and unregulated fentanyl use presented after an overdose, was admitted due to a cerebral venous sinus thrombosis and anemia (hemoglobin of 4.4 g/dL), and was given 300 mg of buprenorphine injection depot subcutaneously without any prior buprenorphine stabilization. Prior to injection, he was taking 30 mg of methadone and 96 mg of oral hydromorphone equivalents daily. Over the 6 hours after injection, he received another 272 mg oral hydromorphone equivalents and experienced a maximum Clinical Opiate Withdrawal Scale score of 7. Over the next 18 hours, he received no additional hydromorphone, and his Clinical Opiate Withdrawal Scale was a maximum of 1. This case illustrates a buprenorphine induction method without precipitated withdrawal by relying on the elution of buprenorphine from the subcutaneous depot alongside full agonist opioids that are given as needed. If these results are readily replicable, this approach may have significant implications for the accessibility and acceptability of buprenorphine for patients and providers.