1/xx
* Calling all clinician’s caring for patients with substance use disorders *
What the heck is buprenorphine (bup) microdosing? – A Tweetorial

#MedTwitter

Have you ever microdosed a patient onto bup?

2/xx
Microdosing is a buprenorphine induction protocol that can be used while patients CONTINUE to take other full opioid receptor agonists (prescribed and non-prescribed) over a 7-day period. Interested? – Let’s review

3/xx
To start, it’s important to remember two key characteristics of buprenorphine
1) High affinity (it grabs the opioid receptor and kicks anything off in its path)
2) Partial agonist (only activates the mu receptor halfway)

4/xx
Practically what this means is that if you start buprenorphine while a full opioid agonist (ie heroin) is in your system, your body abruptly goes from full agonism -> partial agonism

This sudden shift is what causes PRECIPITATED WITHDRAWAL

(Ghosh, CJA, 2018)

5/xx
Trying to avoid precipitated withdrawal is why we wait until mild withdrawal starts or a COWS > 8, (when all the full agonists are gone) before starting buprenorphine

This is traditional induction

6/xx
But this can be challenging in some situations
-long acting opioid agonists like methadone (withdrawal takes longer or stopping increases risk of recurrence)
-acute pain requiring opioids where stopping isn’t possible right now
-possibly non-Rx fentanyl use

7/xx
Plus feeling withdrawal, precipitated or not, is terrible. So is there another way to start buprenorphine?

MICRODOSING

8/xx
The analogy that helped me understand microdosing (and precipitated withdrawal) is a car speeding down the highway

Full opioid agonists in your system are like a car speeding along at 100 MPH

9/xx
When you start buprenorphine with full agonists still in the gas tank, the car all of a sudden slows from 100 MPH-> 50MPH
That sudden sensation of stopping is what causes precipitated withdrawal

10/xx
Microdosing works by starting with tiny doses of buprenorphine (as low as 0.25-0.5mg daily or 1/8th -1/4th of a 2mg strip) and increasing over days to an effective dose

11/xx
For our car this means slowing down over days from
100MPH->90MPH->80MPH->70MPH->60MPH->50MPH

By gradually slowing there’s no sudden stopping and thus no withdrawal, precipitated or otherwise

12/xx
The most common way this is done is the BERNESE method first described here by Dr. Hämmig

https://www.thieme-connect.com/products/ejournals/abstract/10.1055/s-0030-1261914?lang=en

13/xx
Practically this is how it can be done (requires cutting up strips)

14/xx
In the hospital, it can be tricky to cut up buprenorphine strips. Luckily the amazing @DrMelissaWeimer and her colleagues have published a way around this using belbuca (buprenorphine microgram strips)

https://pubmed.ncbi.nlm.nih.gov/32960820/ 

15/xx
I’ve had success with this strategy in the hospital.
There are other methods to microdose including using buprenorphine patches but I have less experience with them.

Thanks to @CarolynAChan for editing this tweetorial and making it better!

Would love to hear from colleagues around the country and world about your experiences microdosing buprenorphine

@NanouTheNomad @jtetrault17 @DrMelissaWeimer @DrKimSue @DrSarahAxelrath @DrPoorman @YaleADM @RichBottner @DrSarahWakeman @ShadiNahvi @DrKristineTL @AyeshaAppaMD

Also thanks to my brother and MedEd pro @ACohenMD1 for looking it over too! Classic twin brother move to forget to show appreciation when it's deserved