Buprenorphine Enhanced Taper Tolerability Evaluation Report (BETTER): A Case Series.

BACKGROUND Discontinuing sublingual buprenorphine (SL-BUP) has been identified by some patients as a potential outcome of success for opioid use disorder treatment. The process of tapering SL-BUP can be lengthy as unpleasant opioid withdrawal symptoms limit the pace of dose adjustments. Uncontrolled withdrawal symptoms pose a risk for return to illicit opioid use and more patient-centered options for tapering SL-BUP are needed. Previous case reports have identified using extended-release subcutaneous buprenorphine (ER-BUP) to minimize withdrawal symptoms as the dose self-decreases very gradually. Ideal dosing strategies, appropriate patient characteristics, and duration of buprenorphine release with the ER-BUP injection are not well described. PATIENT CASES We present 8 cases where a single 100 mg ER-BUP injection was administered to patients experiencing intolerable withdrawal symptoms during SL-BUP taper. Patients were taking between 2 and 6 mg SL-BUP daily prior to injection. Three patients experienced mild adverse effects the day after receiving injection, all of which were taking lower SL-BUP doses (2-3 mg). In the 12 months following injection, 3 patients experienced mild, but tolerable withdrawal symptoms at variable intervals. Two patients returned to taking SL-BUP and no patients returned to illicit opioid use. Buprenorphine urine toxicology showed elimination of buprenorphine occurred after 24 weeks. DISCUSSION Findings from these cases support current evidence-based guidance that ER-BUP tapering is better tolerated than traditional SL-BUP tapering. These patient cases and pharmacokinetic modeling of ER-BUP suggest that a target preinjection dose of 2 to 6 mg SL-BUP will minimize the risk of more severe adverse effects or withdrawal symptoms. Patients and providers should ensure that remission is well-established before initiating SL-BUP taper. A shared decision-making approach can help support patient autonomy and understanding safety risks of discontinuing SL-BUP. Future prospective studies with larger populations could further refine dosing strategies with various SL-BUP preinjection doses and newer ER-BUP formulations.