Rapid Low-dose Buprenorphine Initiation for Hospitalized Patients with Opioid Use Disorder

Introduction Low-dose buprenorphine initiation allows patients to start buprenorphine for treatment of opioid use disorder (OUD) while continuing full-agonist opioids. This strategy is beneficial for hospitalized patients who may have acute pain and are not able to tolerate withdrawal. However, most protocols require 7-10 to complete, which may create barriers in patients with shorter or unpredictable lengths of stay. Objective This cohort study examined the efficacy and feasibility of a rapid low-dose buprenorphine initiation protocol in the hospital setting. Methods We performed a retrospective cohort study of hospitalized patients with OUD (diagnosed by DSM-5 criteria) seen by an addiction medicine consult service at a single academic medical center who started buprenorphine via a rapid low-dose initiation between November 2021 and May 2022. Patients were prospectively tracked using an electronic registry, and data were abstracted from the electronic health record. Results Twenty-four patients underwent rapid low-dose initiation during the study period. All patients received full-agonist opioids before starting buprenorphine. Thirteen (54%) patients reported using fentanyl, with 5 patients reported endorsing use within 48 hours preceding buprenorphine initiation. Nineteen (79%) patients completed initiation with an average time to completion of 72 hours. Among patients who reported fentanyl use in the 48 hours before starting buprenorphine, 60% completed initiation and 40% elected to transition to methadone. No patients experienced precipitated withdrawal. Conclusions Rapid low-dose buprenorphine initiation provides a feasible and well-tolerated alternative to traditional and slower low-dose initiations for hospitalized patients.