Low-Dose Buprenorphine Initiation May Prevent Opioid Withdrawal in Some Patients
Just 7% of patients who received low-dose buprenorphine initiation (LDBI) for opioid use disorder (OUD) experienced clinically significant opioid withdrawal, according to an updated systematic review published in Addiction Science & Clinical Practice. Meanwhile, withdrawal at any level was reported in 54% of patients in case reports and 41% in single-arm observational studies.
“This finding suggests that LDBI strategies allow some patients to transition to buprenorphine with less withdrawal than with traditional dosing strategies and that some patients do not experience any withdrawal,” wrote corresponding author Kristin Waters, Pharm D, and coauthors from the University of Connecticut School of Pharmacy, Storrs, Connecticut. “These dosing strategies are an additional tool for clinicians in overcoming withdrawal-related barriers for their patients.”
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The systematic review focused on buprenorphine initiation strategies that omit prerequisite opioid withdrawal and updated results published in 2021. The latest search identified 44 additional articles published between April 2020 and August 2024, of which 31 were case reports or series involving 84 patients and 13 were single-arm observational studies involving 576 patients. Added to studies in original systematic review, the new studies brought the total number of included reports to 59, covering a total 682 patients compared with just 24 patients in the previous review.
“Our update includes nearly 30 times as many cases as our first systematic review. This illustrates that, despite the lack of prospective data to inform practices, clinicians continue to use and refine these strategies and practice with them will likely not abate,” the authors wrote. “As such, it is critical that there is support for prospective trials in this area of research.”
Although researchers described the quality of evidence as low, which limited their interpretation of the data, the review revealed several findings of interest. In addition to low rates of severe withdrawal with LDBI, the review found sublingual buprenorphine to be the most common initial form of buprenorphine used (55%). Buccal and intravenous forms did not appear in the original review; in the update, they were used in 18% and 14% of patients, respectively.
Finally, the most recent data showed an 81% transition rate to buprenorphine with or without full opioid agonists, down from an 87.5% rate of transition to buprenorphine monotherapy in the previous review.
“However, an 81% transition rate is clinically meaningful in the management of patients with OUD,” researchers wrote.
