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CNS Drugs Jun 2019Opioid use disorder affects over 26 million individuals worldwide. There are currently three World Health Organization-recommended and US Food and Drug... (Review)
Review
Opioid use disorder affects over 26 million individuals worldwide. There are currently three World Health Organization-recommended and US Food and Drug Administration-approved medication treatments for opioid use disorder: the full opioid agonist methadone, the opioid partial agonist buprenorphine, and the opioid receptor antagonist naltrexone. We provide a review of the use of buprenorphine for the treatment of opioid use disorder and discuss the barriers, challenges, risks, and efficacy of buprenorphine treatment vs. other treatments. Although evidence from numerous studies has shown buprenorphine to be effective for the treatment of opioid use disorder, a majority of patients with opioid use disorder do not receive buprenorphine, or any other medical treatment. We review the different formulations of buprenorphine, including newer long-acting injectable formulations that may decrease the risk of diversion and improve adherence.
Topics: Buprenorphine; Humans; Medication Adherence; Narcotic Antagonists; Opiate Substitution Treatment; Opioid-Related Disorders; Substance Withdrawal Syndrome
PubMed: 31062259
DOI: 10.1007/s40263-019-00637-z -
Pain Medicine (Malden, Mass.) Apr 2020An expert panel convened to reach a consensus on common misconceptions surrounding buprenorphine, a Schedule III partial µ-opioid receptor agonist indicated for chronic... (Review)
Review
OBJECTIVE
An expert panel convened to reach a consensus on common misconceptions surrounding buprenorphine, a Schedule III partial µ-opioid receptor agonist indicated for chronic pain. The panel also provided clinical recommendations on the appropriate use of buprenorphine and conversion strategies for switching to buprenorphine from a full µ-opioid receptor agonist for chronic pain management.
METHODS
The consensus panel met on March 25, 2019, to discuss relevant literature and provide recommendations on interpreting buprenorphine as a partial µ-opioid receptor agonist, prescribing buprenorphine before some Schedule II, III, or IV options, perioperative/trauma management of patients taking buprenorphine, and converting patients from a full µ-opioid receptor agonist to buprenorphine.
RESULTS
The panel recommended that buprenorphine's classification as a partial µ-opioid receptor agonist not be clinically translated to mean partial analgesic efficacy. The panel also recommended that buprenorphine be considered before some Schedule II, III, or IV opioids in patients with a favorable risk/benefit profile on the basis of metabolic factors, abuse potential, and tolerability and that buprenorphine be continued during the perioperative/trauma period. In addition, switching patients from a full µ-opioid receptor agonist to buprenorphine should be considered with no weaning period at starting doses that are based on the previous opioid dose.
CONCLUSIONS
These recommendations provide a framework for clinicians to address most clinical scenarios regarding buprenorphine use. The overall consensus of the panel was that buprenorphine is a unique Schedule III opioid with favorable pharmacologic properties and a safety profile that may be desirable for chronic pain management.
Topics: Analgesics, Opioid; Buprenorphine; Chronic Pain; Drug Substitution; Humans; Practice Guidelines as Topic; Receptors, Opioid, mu
PubMed: 31917418
DOI: 10.1093/pm/pnz356 -
The American Journal on Addictions Jul 2021Buprenorphine's high-binding affinity as a partial µ-opioid agonist displaces preexisting full agonists causing precipitated withdrawal, which requires most individuals... (Review)
Review
BACKGROUND AND OBJECTIVES
Buprenorphine's high-binding affinity as a partial µ-opioid agonist displaces preexisting full agonists causing precipitated withdrawal, which requires most individuals starting buprenorphine to endure moderate withdrawal prior to induction to avoid precipitated withdrawal. A novel approach called microinduction has emerged to remove this prerequisite. Our aim is to review the literature on these alternative approaches.
METHODS
Using keywords including buprenorphine, buprenorphine/naloxone, transdermal buprenorphine, suboxone, microinduction, microdosing, rapid induction, buprenorphine-dosing protocol, the authors searched PubMed/Medline, EMBASE, PsycINFO, PsychARTICLES, and Scopus databases from the date of inception through April 30, 2020, which yielded 1726 results, which, in turn, after manual exclusion for irrelevant content and publication in languages other than English, generated a total of 18 papers.
RESULTS
On the basis of 18 papers included in this review, 63 patients were successfully transitioned to buprenorphine using different microdosing techniques, primarily in the inpatient setting. From the available data, patients were transitioned from a variety of opioids over a range of dosing without significant withdrawal, and initial doses ranged most frequently from 0.2 to 0.5 mg. While the timeframe for the various schedules ranged from 3 to 112 days, most transitioned over a period of 4 to 8 days, and most participants completed the cross titration at 8 to 16 mg.
DISCUSSION AND CONCLUSIONS
The growing literature demonstrates some initial promise for alternative induction models, specifically targeting patients averse to withdrawal, patients prescribed opioids for chronic pain, patients on high-dose methadone, and patients using illicit or pharmaceutical fentanyl.
SCIENTIFIC SIGNIFICANCE
This manuscript provides a review of the existing literature to help clinicians better understand the approaches to microdosing of buprenorphine in various clinical settings and populations. (Am J Addict 2020;00:00-00).
Topics: Buprenorphine; Drug Administration Schedule; Humans; Naloxone
PubMed: 33378137
DOI: 10.1111/ajad.13135 -
Current Treatment Options in Oncology Nov 2021Buprenorphine has unique and favorable pharmacological properties that make it useful in a variety of clinical scenarios. It has been recommended to consider... (Review)
Review
Buprenorphine has unique and favorable pharmacological properties that make it useful in a variety of clinical scenarios. It has been recommended to consider buprenorphine first-line opioid for chronic pain, especially in the elderly as it may be associated with less cognitive impairment, falls, sexual dysfunction, and sarcopenia when compared with schedule II opioids. It may be useful in patients with comorbid substance use disorder or non-medical opioid use, as there is less risk of misuse, euphoria and it may improve mood. When used to treat opioid use disorder, the training and waiver was recently waived for licensed practitioners with a DEA and any provider may prescribe buprenorphine. For many reasons outlined in this article, the popularity of using buprenorphine for analgesia continues to grow and a practitioner should consider this as an excellent and safe option for chronic pain.
Topics: Analgesics, Opioid; Buprenorphine; Chronic Pain; Humans; Pain Management
PubMed: 34791564
DOI: 10.1007/s11864-021-00910-8 -
Journal of Addiction Medicine 2019: Buprenorphine is an effective treatment for opioid use disorder. As a high-affinity, partial agonist for the mu-opioid receptor, buprenorphine suppresses opioid... (Review)
Review
: Buprenorphine is an effective treatment for opioid use disorder. As a high-affinity, partial agonist for the mu-opioid receptor, buprenorphine suppresses opioid withdrawal and craving, reduces illicit opioid use, and blocks exogenous opioid effects including respiratory depression. Other pharmacologic benefits of buprenorphine are its superior safety profile compared with full opioid agonists and its long half-life that allows daily or less-than-daily dosing. New and innovative buprenorphine formulations, with pharmacokinetic profiles that differ from the original tablet formulation, continue to be developed. These include higher bioavailability transmucosal tablets and films and also 6-month implantable and monthly injectable products. This growing array of available formulations allows more choices for patients and increased opportunity for clinicians to individualize treatment; thus, it is important for buprenorphine prescribers to understand these differences.
Topics: Analgesics, Opioid; Biological Availability; Buprenorphine; Buprenorphine, Naloxone Drug Combination; Drug Implants; Drug Interactions; Humans; Injections; Opioid-Related Disorders; Substance Withdrawal Syndrome; Tablets
PubMed: 30531584
DOI: 10.1097/ADM.0000000000000457 -
Anesthesiology Clinics Sep 2018As part of a national effort to combat the current US opioid epidemic, use of currently Food and Drug Administration-approved drugs for the treatment of opioid use... (Review)
Review
As part of a national effort to combat the current US opioid epidemic, use of currently Food and Drug Administration-approved drugs for the treatment of opioid use disorder/opioid addiction (buprenorphine, methadone, and naltrexone) is on the rise. To provide optimal pain control and minimize the risk of relapse and overdose, providers need to have an in-depth understanding of how to manage these medications in the perioperative setting. This article reviews key principles and discusses perioperative considerations for patients with opioid use disorder on buprenorphine, methadone, or naltrexone.
Topics: Buprenorphine; Humans; Methadone; Naltrexone; Opioid-Related Disorders; Pain Management; Perioperative Care
PubMed: 30092933
DOI: 10.1016/j.anclin.2018.04.002 -
Annals of Emergency Medicine May 2019
Review
Topics: Buprenorphine; Emergency Service, Hospital; Evidence-Based Medicine; Female; Humans; Male; Narcotic Antagonists; Opioid-Related Disorders; Practice Guidelines as Topic; Substance Withdrawal Syndrome
PubMed: 30616926
DOI: 10.1016/j.annemergmed.2018.11.032 -
Journal of General Internal Medicine Jun 2023
Topics: Humans; Buprenorphine; Narcotic Antagonists; Opiate Substitution Treatment
PubMed: 36988866
DOI: 10.1007/s11606-023-08038-1 -
Journal of Palliative Medicine Jul 2022
Topics: Buprenorphine; Humans; Opiate Substitution Treatment; Opioid-Related Disorders
PubMed: 35775892
DOI: 10.1089/jpm.2022.0170 -
Journal of Addiction Medicine Dec 2020Treatment with medications for opioid use disorder such as buprenorphine improves patient morbidity and mortality as well as treatment adherence, an important component... (Review)
Review
OBJECTIVES
Treatment with medications for opioid use disorder such as buprenorphine improves patient morbidity and mortality as well as treatment adherence, an important component of patient care. Buprenorphine is combined with naloxone to reduce misuse; and, when taken sublingually, naloxone is poorly absorbed. Urine testing for buprenorphine is a common way to monitor adherence. Some patients who want to appear adherent may directly tamper with their urine by adding buprenorphine to their urine to allow for the detection without ingestion. Practitioners may rely upon the concentration of buprenorphine and the metabolite, norbuprenorphine, and utilize the ratio of metabolite to parent compound (norbuprenorphine:buprenorphine - N:B ratio) to discern possible evidence of tampering; however, there remains debate as to what specific ratio may signify this practice. Testing for naloxone may also help determine if urine tampering occurred as only low naloxone concentrations are found in the urine when taken by a sublingual route.
METHODS
To determine a reliable N:B ratio that may be used to identify possible urine tampering by adding parent drug directly to urine, we examined 136,605 urine samples for quantitative concentrations of buprenorphine and norbuprenorphine by LC-MS/MS performed at a commercial laboratory. After identifying abnormal ratios (<0.02), we then compared them with naloxone concentrations and specimen validity testing, other markers that may coincide with specimen tampering of this type.
RESULTS
Correlating urinary buprenorphine and norbuprenorphine concentrations, we found 2 distinct patient populations, which could be distinguished by N:B ratios ranging from 0.01 to 0.2. In addition, while the distribution of urine naloxone concentrations itself did not demonstrate distinct populations, naloxone was able to further flag potential tampered specimens when combined with N:B ratios. Abnormal specimen validity testing was additionally found more commonly in cases with N:B ratios <0.02.
CONCLUSIONS
This comprehensive study compared N:B ratios with naloxone concentrations and specimen validity testing. This study suggests that a N:B ratio of <0.02 in concert with high naloxone concentrations (>1000 ng/ml) can help to identify potential cases of tampered urine samples.
Topics: Buprenorphine; Chromatography, Liquid; Humans; Naloxone; Tandem Mass Spectrometry
PubMed: 32530884
DOI: 10.1097/ADM.0000000000000676