24-48 h initiation by transdermal buprenorphine for the treatment of opioid use disorder in the inpatient setting: a retrospective chart review

Buprenorphine (Bup) is a first-line medication for opioid use disorder (OUD) that carries risk of precipitated withdrawal (PW) with ongoing need for rapid and effective initiation strategies. We report a novel approach to low-dose initiation using transdermal Bup patches (TD-Bup) and characterize the efficacy and tolerability of 24 h and 48 h TD-Bup initiation protocols for Bup as a medication for OUD (MOUD). We conducted a retrospective chart review using data extracted from paper and electronic medical records of adult inpatients with OUD admitted to Vancouver General Hospital between January 2022 and October 2023. Eligible patients were started on low-dose transdermal buprenorphine (TD-Bup) initiation protocols. The intervention involved sequenced application of TD-Bup patches reaching a total of 12 patches (240 µg/h) over 24 to 48 hours, with continuation of full opioid agonists. Protocol variants included: 6 patches q24h for 48 hours, 6 patches q12h for 24 hours, and 4 patches q8h for 24 hours. Primary outcomes were the rate of successful initiation onto therapeutic doses of sublingual or extended-release depot Bup, and the incidence of opioid withdrawal. Seventy five patients were identified. Fifty five (73%) were successfully initiated and discharged on Bup and the most common reasons for unsuccessful initiation were preference to switch to another medication for OUD (n = 11) and withdrawal (n = 6). There was no significant difference between the protocol variants for successful initiation (p = 0.191). Adverse events (agitation, increased pain, insomnia, pruritus) were reported in 5 dropouts. Only 28 patients had sufficient Clinical Opioid Withdrawal Scale (COWS) scores to allow for objective assessment of withdrawal, with the remainder evaluated from full chart review. Nineteen patients had COWS score elevation > 6 and/or any narrative documentation of withdrawal. Three patients were felt to represent probable PW. No relationships were found between withdrawals and protocol variant (p = 0.621) or successful initiation (p = 0.082). All-cause withdrawals were associated with self-directed discharges (p = 0.042). Rapid low-dose buprenorphine initiation with TD-Bup appears feasible with relatively low risk of withdrawals and PW, although a weakness is the vulnerability to underdosing patients with full opioid agonists resulting in opioid deficit withdrawal. Further prospective evaluation of d rapid low-dose buprenorphine initiation with TD-Bup against other evidence-based contemporary Bup MOUD initiations is warranted.