Dr. Bob's Psychopharmacology Tips

Opioid detoxification with buprenorphine

Date: Sun, 21 Jan 1996 06:56:00 -0500
From: Robert_Swift_MD@brown.edu (Robert Swift MD)
Subject: Opioid detoxification with buprenorphine

We have been using buprenorphine for opioid detoxification in patients with chronic pain on a routine basis. Although classified pharmacologically as a "mixed agonist-antagonist", agonist properties tend to predominate at low doses and antagonist properties at higher doses (above 16 mg per day). Buprenorphine is highly potent and has high affinity for mu opioid receptors. It will gradually displace opioid agonists, but since it has agonist properties itself, the patients usually experience little if any withdrawal.

We usually start patients on subcutaneous buprenorphine 0.1 mg to 0.3 mg every 4-6 hours, immediately after stopping the opiates. According to the PDR, 0.3 mg buprenorphine is equivalent to 10 mg morphine. The dose is adjusted as necessary and patients are maintained for 2-3 days at a stable buprenorphine dose. It is then tapered over several days.

Buprenorphine is now being evaluated for long-term maintenance treatment in opioid dependence. In the setting of a structured treatment program, daily dosing of buprenorphine is effective in the maintenance treatment of narcotics addicts. There is some evidence that buprenorphine may also reduce cocaine use.

In the experimental maintenance treatment programs, buprenorphine doses usually range from 4 mg per day to up to 16 mg per day, administered sublingually, since the medication is not effective orally. (These tablets are not yet commercially available.) Advantages of buprenorphine include a milder withdrawal syndrome upon discontinuation and less potential for abuse, as agonist effects diminish at higher doses. Opioid dependent patients may be started on 2 to 4 mg buprenorphine per day immediately after opiates are discontinued, and the dose of buprenorphine titrated to 8 to 16 mg over several days. Even long term methadone maintenance patients have been switched to buprenorphine over 2-3 days with minimal withdrawal apparent.

Useful references:

Kosten TR, Morgan C, Kleber HD. Phase II clinical trials of buprenorphine: detoxification and induction onto naltrexone. NIDA Res Monogr 1992; 121:101-19.

Stine SM, Kosten TR. Use of drug combinations in treatment of opioid withdrawal. J Clin Psychopharmacol 1992 Jun; 12(3):203-9.

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