Why Does Fentanyl Addiction Make Buprenorphine Therapy Difficult?
Starting buprenorphine treatment can be a challenging process for those attempting to recover from fentanyl addiction. While buprenorphine is an effective medication for opioid use disorder (OUD), it also carries risks if not initiated properly. One major concern is precipitated withdrawal. These are severe withdrawal symptoms that can occur when buprenorphine displaces other opioids from receptors. For people transitioning from potent opioids like fentanyl, precipitated withdrawal is especially likely if buprenorphine doses are started too high.
To help mitigate this risk, induction protocols have been developed that involve starting with very low doses of buprenorphine and gradually increasing over time. This is known as microdosing induction. The goal is to slowly accumulate buprenorphine in the body while avoiding abruptly displacing fentanyl.
In this article, I will explore the 7 different microdosing approaches I provide my patients for safer buprenorphine therapy for fentanyl addiction. If you are not one of my patients, please read this post for informational purposes only and then seek the help of a qualified medical professional who can assist you. Reading or listening to this article does not establish a doctor-patient relationship.
What Does It Mean to Be In Opioid Withdrawal?
Opioid withdrawal occurs when opioid receptors in the brain and body become unoccupied. This leads to symptoms ranging from mild like restlessness and sweating, to severe like muscle cramps, diarrhea, and vomiting. As more receptors become unoccupied, withdrawal symptoms increase in severity.
Microdosing buprenorphine aims to relieve these symptoms by partially filling the unoccupied opioid receptors. The goal is to occupy just enough receptors to reduce withdrawal discomfort without causing a precipitated withdrawal.
Precipitated withdrawal happens when opioids are suddenly and completely removed from opioid receptors. This abrupt receptor vacancy triggers rapid onset of withdrawal symptoms.
Suboxone (buprenorphine/naloxone) can be used with these microdosing protocols. While Suboxone contains naloxone, only about 2% of the naloxone is absorbed into the bloodstream. This is too low to cause precipitated withdrawal if using Suboxone for microdosing buprenorphine.
The key points are that microdosing gradually occupies vacant opioid receptors to ease withdrawal symptoms. And the small amount of naloxone in Suboxone will not cause issues when used for microdosing.
Microdosing Buprenorphine Induction Protocol
The basic idea behind microdosing induction is to give very small, incremental doses of buprenorphine over time instead of starting with a full dose right away. This helps the medication gradually build up in the body's opioid receptors without causing a precipitated withdrawal.
With microdosing, the goal is to reach a target dose through careful titration. For instance, a patient may start with 1-2mg of buprenorphine on day 1, and slowly work up to 6-8mg by day 3 or 4. This is done by administering 0.5-1mg dose adjustments every few hours. By steadily ramping up the dosage over days rather than hours, there is less chance of buprenorphine ejecting opioids from occupied mu receptors.
Every method presented here assumes that you have stopped using fentanyl. The longer you go without using fentanyl, the safer these protocols will be. Patients follow an individualized schedule under close provider guidance. Dose changes are based on how they feel - their withdrawal symptoms and comfort level. Overall, microdosing has been shown to improve treatment retention and the induction experience.
Low Dose Buprenorphine Induction
Low dose induction follows a similar principle of starting with smaller than normal doses of buprenorphine and gradually increasing over time. However, rather than microdoses, low dose protocols use higher doses such as 1-2mg as the starting amount.
On the first day, the patient may be prescribed 1-2mg of buprenorphine every few hours, slowly titrating up to 6-8mg total by the end of the first day. The provider closely monitors for withdrawal symptoms and makes dose adjustments accordingly.
On the second day, the dose can be further raised to 12-16mg total, split into 3 or 4 smaller doses throughout the day. The final target dose is typically 16mg and is maintained moving forward.
While not quite as gradual as microdosing, low dose induction still minimizes risks compared to full dose starts. It provides a moderate rate of increase, while allowing close monitoring and symptom-guided adjustments.
Gradual Buprenorphine Induction
This approach involves taking an extended period of time - generally 5-7 days - to very slowly induct buprenorphine. The dose is increased incrementally each day at a cautious pace.
For example, a sample schedule may be:
Day 1: 2mg
Day 2: 4mg
Day 3: 6mg
Day 4: 8mg
Day 5: 10mg
Day 6: 12mg
Day 7: 16mg (target dose)
As you can see, the dose rises gradually, by small amounts each day. This prevents sudden spikes in occupancy and avoids precipitated withdrawal.
With gradual induction, the person is closely monitored, including assessments for withdrawal symptoms and side effects. The schedule can be adjusted based on comfort level.
While lengthier than other methods, a slow steady introduction can provide a smooth transition onto buprenorphine therapy for some patients. It eases the body and brain into stability.
Symptom-Guided Buprenorphine Induction
With this approach, buprenorphine doses are adjusted based specifically on the individual patient's reported withdrawal symptoms and cravings. There is close monitoring and modifications are made rapidly in response to feedback.
For example, if a patient reports persisting withdrawal symptoms, the next dose increase may be moved up or the amount raised slightly. If symptoms seem well-controlled, the schedule is maintained or slowed.
The provider tailors the induction plan day-by-day even hour-by-hour based on the patient's needs. This allows personalization and flexibility compared to standardized schedules.
Symptom-guided induction requires very frequent interaction and assessment. But the benefit is doses are truly customized to the patient's comfort level for an optimal induction experience.
Buprenorphine Titration Protocol
This induction approach involves establishing a pre-determined titration schedule with systematically increasing doses over several days. The timing of each incremental dose rise is fixed rather than adjusted based on symptoms.
A sample titration protocol may be:
Day 1: 0.5mg every 4 hours up to a 2mg total dose
Day 2: 1mg every 4 hours up to a 4mg total dose
Day 3: 2mg every 4 hours up to an 8mg total dose
Day 4: 2mg every 4 hours up to a 12mg total dose
The intervals between dose increases are shorter initially, then taper off as the target dose nears.
While not as responsive as symptom-guided titration, this fixed schedule allows for close monitoring at steadily progressing increments. Patients still receive support for withdrawal or medication side effects as needed.
Quarter Buprenorphine Method
With this approach, the total target buprenorphine dose for the first day is divided into 4 equal "quarters." Each quarter dose is separated by a set amount of time, allowing for gradual accumulation.
For example, if the day one goal is 8mg total:
First quarter: 2mg
Second quarter (ex. 4 hours later): 2mg
Third quarter (4 hours later): 2mg
Fourth quarter: 2mg
This would add up to the 8mg total day one dose, steadily administered in 4 increments. On day two, the patient may take two 4mg doses, separated by 6-8 hours. The quarters method eases in buprenorphine effects while monitoring outcomes.
Hourly Buprenorphine Dosing Method
With this microdosing approach, incremental doses of buprenorphine are given every 1-2 hours over the first day of induction. Doses are around 0.5-1mg each.
For example, the patient receives 1mg of buprenorphine hourly for the first 6-8 hours. The total amount administered depends on their response and withdrawal management.
This very gradual method allows for close provider monitoring between doses. Dose adjustments can rapidly be made based on the patient's symptoms and comfort level.
Compared to less frequent dosing schedules, hourly administration provides tighter control over buprenorphine levels and opioid receptor occupancy rates during the delicate induction phase.
While labor intensive, hourly dosing optimizes safety and relief by avoiding large fluctuations. It offers a smooth transition onto the medication.
The Dr. Pierre Buprenorphine Microdosing Protocol
Most likely, this is the protocol we discussed during our appointment. I prefer a symptom based protocol because it establishes many safety measures. I recommend that you wait up to 48 hours after your last use of fentanyl before starting the buprenorphine. Allowing yourself to enter withdrawal means that there are unoccupied opioid receptors ready to accept buprenorphine. I typically prescribe clonidine and gabapentin to help you tolerate the withdrawal as long as possible.
When you can no longer tolerate the withdrawals or 48 hours have been reached, it is time to start. Using the 2mg buprenorphine tablet I prescribed, cut them into quarters (0.5mg). Take 0.5mg every 4 hours. You should notice that each time you take the quarter tablet, your symptoms are gradually getting better. As long as your symptoms continue to slowly improve, you can continue taking 0.5mg every 4 hours. The following are the daily goals:
Day 1: 0.5mg every 4 hours up to 2mg total dose. (Use a quarter of the 2 mg tablet)
Day 2: 1mg every 4 hours up to 6mg total dose. (use half of the 2 mg tablet)
Day 3: 2mg every 4 hours up to an 8mg total dose. (use the whole 2 mg tablet)
Day 4: 4mg every 4 hours up to a 16mg total dose. (Use half of the 8mg tablet)
Day 5: You are done with the transition, follow the instructions for your full dose.
For my patients, please contact my office if you have any questions or concerns about any protocol we discussed during our appointment.
Key Takeaways
Buprenorphine therapy for fentanyl addiction can be daunting due to risks like precipitated withdrawal. However, microdosing protocols such as the approaches discussed in this post can facilitate safer, more comfortable initiation.
While standard induction starts with higher doses, microdosing focuses on incremental increases from 0.5-2mg up to a therapeutic level. This allows buprenorphine to slowly accumulate and stabilize.
Symptom monitoring, dose adjustments, and a gradual schedule are key across protocols. More research is still needed to optimize techniques.
Overall, microdosing enables safer transition onto buprenorphine maintenance therapy. Patients should consult their healthcare provider about the induction method most appropriate for their needs. With careful adherence to a customized protocol, buprenorphine can be an invaluable medication for overcoming fentanyl addiction.
About the author:
Dr. Harold Pierre is a board-certified anesthesiologist and addiction medicine specialist with over 20 years of experience. He is board-certified by the American Board of Anesthesiology and the American Board of Preventive Medicine.
This article provides general information about buprenorphine induction protocols and does not constitute medical or treatment advice. The information is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Please consult with a qualified healthcare provider for advice regarding your specific medical condition. Do not attempt to self-administer buprenorphine without medical oversight.
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