Induction onto Buprenorphine utilizing transdermal patches over 24-48 hours: IPPAS method
Pouya Rezazadeh Azar, Victor W. Li, James Wong, Alaa Al Hawamdeh, Adam ChodkiewiczLecture Hall 221 (ESA West)
Introduction/Objectives:
Opioid agonist treatment (OAT) is essential for managing opioid use disorder (OUD), with buprenorphine being a preferred treatment due to its safer profile. However, its partial agonism at the mu-opioid receptor can lead to precipitated withdrawal, complicating the induction process. Innovative protocols have been developed to minimize withdrawal during induction. Our team previously reported two successful cases of fentanyl-related OUD transitioning to buprenorphine using a transdermal buprenorphine patch protocol over 48 hours.
Methods:
We conducted a retrospective chart review of 76 inpatients consented and treated with one of three transdermal buprenorphine induction protocols from January 2022 to November 2023. Each protocol involved staggered applications of 20 μg/h buprenorphine patches over 48 hours (6 patches every 24 hours), 24 hours (6 patches every 12 hours), or 8 hours (4 patches every 8 hours). Patients also received oral hydromorphone (16–32 mg) every 2 hours as needed for withdrawal symptoms. After induction, patients transitioned to full-dose sublingual or injectable buprenorphine, and all patches were removed. Withdrawal symptoms were monitored throughout the process.
Results:
Of the 76 patients, 28 were included in the primary outcome analysis. 48 were excluded due to insufficient COWS scores. Of the 28, 21 successfully transitioned to buprenorphine without significant withdrawal. Two patients did not complete the induction, opting for methadone, detox, or leaving against medical advice. 7 cases had elevated COWS scores, but expert review confirmed these were not due to precipitated withdrawal, likely due to insufficient opioid agonist PRNs. The highest recorded COWS score was 15 (range 10–15).
Conclusions:
This study demonstrates that high-tolerance patients, particularly those using fentanyl, can transition to buprenorphine with minimal withdrawal. This approach eliminates the need for withdrawal prior to induction, simplifies dosing, reduces nursing workload, and shortens the induction period. Further research in larger cohorts is needed to confirm its efficacy and safety, which could improve treatment outcomes and retention if validated.