High-Dose Buprenorphine Initiation: A Scoping Review

High-Dose Buprenorphine Initiation: A Scoping Review

Published: July/Aug 2024
Journal Article

Overview

This one-hour, on-demand, journal article-based activity presents a scoping review of the existing literature on the effectiveness and safety of high-dose buprenorphine initiation across fifteen studies across a range of health care settings.

The authors reviewed outcomes from 580 high-dose buprenorphine initiations to evaluate the safety and effectiveness of this initiation strategy. There were no reported events of fatal or nonfatal overdose or respiratory depression, although adverse event reporting was inconsistent in published reports. The preliminary nature of their discussion of the research findings on the high-dose buprenorphine initiation approach was acknowledged; they noted the limitations of their search strategy and some methodological limitations of the studies reviewed. They also suggest avenues for further investigation to confirm the safety, efficacy, and effectiveness of the high-dose buprenorphine initiation approach for a broader patient population and range of settings.

The target audience for this intermediate continuing education activity includes: physicians, nurse practitioners, PAs, pharmacists, and other clinicians, researchers, students, and policymakers.

This activity addresses the following ACGME Core Competencies: Patient Care, Medical Knowledge, Interpersonal and Communication Skills, Practice-Based Learning and Improvement, Professionalism, and Systems-Based Practice.

Article Abstract

Objectives: The aim of the study is to review and synthesize the literature on high-dose buprenorphine initiation (>12-mg total dose on day of initiation).

Methods: A scoping review of literature about high-dose buprenorphine initiation was conducted. MEDLINE, Embase, PsycINFO, and Cochrane Central were searched. Randomized controlled trials, prospective and retrospective cohort studies, and case studies/reports published in English before February 13, 2023, were included.

Results: Fifteen studies reporting outcomes from 580 high-dose buprenorphine initiations were included. Eight studies were in inpatient settings, 3 in emergency departments, 3 in outpatient settings, and 1 in a first-responder setting. Four studies reported high-dose initiations among individuals exposed to fentanyl. There were no reported events of fatal or nonfatal overdose or respiratory depression, although adverse event reporting was inconsistent in published reports. The most reported side effects with high-dose buprenorphine initiation were nausea or vomiting (n = 17) and precipitated withdrawal (n = 7). The most serious reported adverse event was hypotension requiring oral hydration (n = 2). Most studies reported improvements in subjective or objective withdrawal symptoms. The duration of follow-up ranged from none to 8 months.

Conclusions: High-dose buprenorphine initiation has not been associated with reported cases of overdose or respiratory depression. However, the current literature about high-dose buprenorphine is limited by inconsistent side effect reporting, limited power to detect rare safety events such as respiratory depression, limited follow-up data, and few comparison studies between high-dose and regular initiation protocols. Further prospective data are needed to evaluate the safety and effectiveness of this initiation strategy.

Learning Objectives

Upon completion, learners will be able to:

1. Evaluate the safety and effectiveness of high-dose buprenorphine initiation (>12-mg total dose on day of initiation) based on the findings in this review of existing data.
2. Consider possible limitations to the applicability of the findings to a given patient population and to specific settings.

Registration Rates

*Residents, Fellows-in-training, Interns, and Students must join ASAM to receive a discounted registration rate. Click here to become an ASAM member. National and Chapter membership dues apply. There is no charge for Students to become a Member, but verification of student status is required.

Membership Question?  Call ASAM at 1.301.656.3920, email us, or view the ASAM website for more information.

Refunds & Cancellations

All ASAM eLearning Center refund requests must be made in writing to education@asam.org within 90 days of purchase. Those requesting refunds for courses that are in progress will receive partial refunds or eLearning Center credit. Automatic full refunds will be made for any course with a live-course component that has been cancelled.

Open Registration: 08/01/2024 - 07/31/2027

Close Access Date: 08/31/2027

Course Instructions

1. Click on the Contents tab to begin this activity.
2. Click View Journal Article and read the journal article in its entirety. 
3. Click Complete Post Test to answer multiple choice questions. Participants will have 10 attempts to pass and must answer 2 out of 3 questions correctly.
4. Click Complete Evaluation to provide valuable activity feedback. Scroll down on all questions as there may be answer options that expand past the size of the window.
5. Click the button Claim Medical Credits in the box titled Claim Credits & Certificate. Choose the type of credit and click submit. Click the button View/Print Certificate to save or print your certificate. You can view/print your certificate at any time by visiting the ASAM eLearning Center, clicking Dashboard, and clicking Transcript/Achievements.

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Accreditation & Credits

Joint Accreditation Statement

In support of improving patient care, the American Society of Addiction Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Credits Available

• Physicians: 1 Credit(s)
• Pharmacology Hour(s): 1 Hour(s)
• Certified Counselors: NBCC Contact Hours Not offered

Maintenance of Certification (MOC)/Continuing Certification Program (CCP)

This activity is designed to meet the requirements for MOC/CCP for several primary physician boards and for state licensing CME requirements. MOC Credit is only reported and designated for ABA, ABP, ABIM, and ABS. By completing the online credit application and evaluation, the learner permits ASAM to report credits to the appropriate Board. Learn more.

• ABA MOCA 2.0®*: 1 Lifelong Learning | 1 Patient Safety
• ABIM MOC Points: 1 Medical Knowledge | 1 Patient Safety
• ABP MOC: 1 Lifelong Learning & Self-Assessment
• ABS Continuing Certification: 1 Accredited CME | 1 Self-Assessment

Additionally, this activity has been designed to satisfy the requirements of the following primary physician board certification requirements. Please confirm with your individual Board.

• American Board of Addiction Medicine (ABAM)
• American Board of Preventative Medicine (ABPM)
• American Board of Psychiatry and Neurology (ABPN)
• Royal College of Physicians and Surgeons of Canada (RCPSC)

Certificates for other professions

All participants may request a certificate of participation upon completion of the activity and an online evaluation confirming their participation. Learners are strongly advised to contact their professional licensing board or professional association to confirm this certificate will be accepted as evidence supporting continuing education requirements.

California Association for Drug/Alcohol Educators (CAADE)

This educational program is approved by CAADE: #CP40 999 1225.

California Association of DUI Treatment Centers (CADTP)

This educational program is approved by CADTP: #205.

California Consortium of Addiction Programs and Professionals (CCAPP)

This educational program is approved by CCAPP: #OS-20-330-1224.

Disclosure Information

In accordance with the disclosure policies of ASAM and Joint Accreditation, the effort is made to ensure balance, independence, objectivity, and scientific rigor in all accredited continuing education activities. These policies include identifying and mitigating all relevant financial relationships with ineligible companies for those involved in the creation and dissemination of accredited continuing education.

See the attached pdf for a list of disclosures.

  American Society of Addiction Medicine has been approved by NBCC as an Approved Continuing Education Provider, ACEP No. 7062. Programs that do not qualify for NBCC credit are clearly identified. American Society of Addiction Medicine is solely responsible for all aspects of the programs.

MOCA 2.0® is a trademark of the American board of Anesthesiology®.
This activity contributes to the patient safety CME requirement for Part II: Lifelong Learning and Self-Assessment of the American board of Anesthesiology's (ABA) redesigned Maintenance of Certification in Anesthesiology Program® (MOCA®), known as MOCA 2.0®. Please consult the ABA website, https://www.theaba.org/, for a list of all MOCA 2.0 requirements.

The complete list of disclosures and designation statements are linked below.