Buprenorphine Microdosing Cross Tapers: A Time for Change

Microdosing buprenorphine to transition patients from full-agonist opioids avoids the withdrawal and pain that typically require 12 or more hours of opioid abstinence. Evidence shows this cross-taper strategy is safe and effective, and it is already used across the United States. The authors argue that national prescribing guidelines and buprenorphine training should recognize this approach, and that the FDA should approve transdermal buprenorphine for opioid use disorder while manufacturers produce lower-dose sublingual formulations. They conclude that buprenorphine microdosing cross-tapers should become the new standard of care.

Study at a glance

Abstract

Buprenorphine is a partial opioid agonist that is Food and Drug Administration (FDA) approved to treat chronic pain and opioid use disorder (OUD). The national prescribing guidelines in the United States (US) recommend that patients transitioning from full opioid agonists to buprenorphine first undergo 12 or more hours of active opioid withdrawal, in order to avoid buprenorphine-precipitated opioid withdrawal. This opioid-free period imposes a significant barrier for many patients. Evidence is accumulating that using microdoses of buprenorphine to cross taper from full-agonist opioids to buprenorphine is a safe and effective way to avoid opioid withdrawal and uncontrolled pain. This microdose cross-tapering strategy is already being used across the US. The US prescribing guidelines and buprenorphine training would benefit from acknowledging this new approach. Additionally, to facilitate this strategy, the FDA should approve transdermal buprenorphine formulations for OUD and manufacturers could produce lower dose formulations of sublingual buprenorphine. The time has come for us to embrace buprenorphine microdosing cross tapers as a new standard of care.