Effective Buprenorphine Initiation with Injectable Buprenorphine for Patients with Minimal-to-mild Opioid Withdrawal

Buprenorphine is a highly effective medication for opioid use disorder (OUD). Its partial opioid agonist properties require some consideration during initiation, particularly in the setting of highly potent synthetic opioids like fentanyl and fentanyl analogues. This non-randomized controlled trial studied the feasibility and acceptability of buprenorphine initiation with a seven-day extended-release buprenorphine injection for individuals with minimal-to-mild opioid withdrawal* treated in one of four US emergency departments.

• All patients (N=100) had positive urine drug test results for more than one opioid and negative for methadone; 70 percent tested positive for fentanyl and 39 percent tested positive for buprenorphine.
• Among patients with mild withdrawal (COWS 4–7; n=63), 6 percent experienced increased withdrawal following receipt of the injection; 3 percent experienced precipitated withdrawal.
• For patients with minimal withdrawal (COWS 0–3; n=37), 16 percent experienced increased withdrawal following receipt of the injection; 14 percent experienced precipitated withdrawal.
• Only individuals with fentanyl in their urine drug test experienced an increase in opioid withdrawal or precipitated opioid withdrawal.
• Most patients reported their overall experience with the treatment to be completely effective at seven days; 73 percent engaged in OUD treatment within seven days of receiving the injection.
• Adverse events occurred in 13 percent of patients, 5 percent requiring hospitalization; no opioid overdoses were reported within the 7 days of follow-up.

* Withdrawal was assessed via the Clinical Opiate Withdrawal Scale (COWS) with higher scores indicating increasing withdrawal.

Comments: This prospective trial is the first to describe the feasibility and acceptability of a buprenorphine seven-day injection for individuals with minimal-to-mild opioid withdrawal, including those exposed to fentanyl. It has high applicability and importance as a novel and safe initiation strategy for individuals with OUD with mild withdrawal at baseline. The findings also confirm prior guidance that it is safest to have some opioid withdrawal symptoms prior to buprenorphine initiation. Most importantly, this initiation strategy facilitated ongoing treatment engagement for OUD in most participants.

Melissa B. Weimer, DO, MCR

Reference: D’Onofrio G, Herring AA, Perrone J, et al. Extended-release 7-day injectable buprenorphine for patients with minimal to mild opioid withdrawal. JAMA Netw Open. 2024;7(7):e2420702.