Blister-Packing of 2 mg Buprenorphine Monoproduct as a Patient-Centered Method of Microdosing for Buprenorphine Induction

Abstract

I read with interest the article by De Aquino et al. [1]. Buprenorphine microdosing is gaining favor as an alternative method for the induction of opioid-dependent patients receiving buprenorphine products for the treatment of opioid use disorder [1, 2]. Recent articles have described in-hospital regimens and an outpatient regimen that employed microdosing as a means of induction while receiving full opioid agonists [3–5], and a randomized controlled trial is currently underway [6]. Originally described as the ‘Bernese method’, this strategy aims to lessen or prevent the required period of moderate opioid withdrawal that has traditionally been advised to patients as a means of buprenorphine induction [7]. The increasing presence of fentanyl in street-acquired drug products, and its slower pharmacokinetic properties, may be making traditional induction more difficult [8]. Regimens for buprenorphine microinduction have generally required patients to follow very specific dosing instructions. In an attempt to make microinduction a more feasible option for our patients within a busy community practice, we worked with two local community pharmacies to create a blister-pack regimen, which we nickname a ‘buprenorphine microdosing starter pack’. The instructions for the blister pack, detailed below, have been programmed into our EPIC Hyperspace electronic medical record as a ‘favorite’ order, allowing this regimen to be ordered with one click. This is based on the microdosing regimen described by Randhawa et al. [9] We called two local community pharmacies to inquire whether blister packing was available for patients. We then forwarded the Randhawa et al. reference to these pharmacies and worked to create a blister-pack regimen that was consistent with the regimen described therein. Challenges included the fact that very small buprenorphine dose products (e.g. BelbucaTM) are only US FDA-approved for chronic pain and not for the treatment of opioid use disorder. As such, we worked with the smallest available dose of buprenorphine monoproduct, the 2 mg tablet, and developed this blister pack regimen using a 7×4 standard weekly packaging system.