This week, the Journal of Addiction Medicine published ASAM Clinical Considerations: Buprenorphine Treatment of Opioid Use Disorder (OUD) for Individuals Using High-Potency Synthetic Opioids (HPSOs), an expert consensus in response to evolving clinical questions in treatment of OUD with buprenorphine with emerging HPSOs and stimulants in the drug supply. Broadly, experts suggest individualized strategies for buprenorphine treatment. Specifically, experts overview two emerging strategies for buprenorphine initiation when standard initiation strategies do not apply:

1. Rapid high-dose buprenorphine initiation after opioid discontinuation (HDB), and
2. Low-dose buprenorphine with opioid continuation (LDB-OC). 

U.S. federal law is currently understood to prohibit a key component of the LDB-OC strategy, or medical prescription of full agonist opioids (FAO) during a multi-day dose escalation of buprenorphine, for all patients except those individuals (1) with pain transitioning from FAO to buprenorphine, (2) admitted to a hospital, or (3) enrolled in an opioid treatment program (OTP). Importantly, this current understanding of law creates unnecessary risk for patients and prescribers in many outpatient settings, as some prescribers are advising patients to continue using their own illicit opioids during buprenorphine dose escalation when the strategy is viewed as the least bad option for initiating lifesaving medication. 

The Clinical Considerations document also highlights that some individuals may need a higher dose of buprenorphine to stabilize, broader access to long acting injectable buprenorphine is needed to help some individuals, and access to methadone is essential for individuals who are not able to stabilize on buprenorphine.

While The ASAM National Practice Guideline (NPG) for the Treatment of Opioid Use Disorder cites a typical buprenorphine dose limit of 24 mg per day, high quality studies show improved treatment retention, reduced opioid use, and lack of adverse events at doses of buprenorphine 16-32 mg per day. Higher buprenorphine stabilization doses (>16 mg per day) and frequent dosing (2-4 times per day) may be needed during pregnancy to achieve consistent effective buprenorphine plasma levels and prevent opioid withdrawal between doses. Although some insurance plans or states may mandate a certain buprenorphine dose limitation, some patients may benefit from high buprenorphine doses during buprenorphine stabilization ( > 24 mg per day).

Read the full ASAM Clinical Considerations document for more specific information.

Read ASAM's Information Brief on Buprenorphine Dosing during Stabilization of OUD Involving HPSO.