Clinical Pharmacist-Led Low-Dose Buprenorphine Initiations (Microinductions): A Case Series

Buprenorphine is a semi-synthetic opioid approved for pain and opioid use disorder (OUD). A challenge in its initiation is the risk of precipitated withdrawal if a large sublingual buprenorphine dose is administered too soon after a full mu opioid receptor (MOR) agonist. This experience can be so discomforting that it might prevent further efforts to transition patients to an otherwise safe and effective treatment for OUD and/or chronic pain. Recent evidence supports a newer initiation method that may not carry as great of a risk, known as low-dose buprenorphine initiations (LDBI). While current literature demonstrates LDBIs in addiction medicine extensively, there is limited evidence detailing its use in pain, and even less detailing LDBIs led by clinical pharmacy practitioners. This case series describes five successful pharmacist-led LDBIs at a Veterans Affairs Medical Center (VAMC) among patients with chronic pain and/or OUD who required urgent transitions from their full MOR agonist to sublingual buprenorphine where a standard induction strategy would have been highly challenging and unrealistic. These cases demonstrate the versatility and clinical utility of LDBI across a variety of urgent clinical settings with unique baseline opioid regimens and continue to reinforce its possible role as a first-line induction strategy for buprenorphine.