Treat Opioid Use Disorder with Buprenorphine and Save Lives

Each year, more than 100,000 people lose their lives to drug overdose. Among these tragedies, opioid-related deaths are particularly preventable. We have the tools to reverse overdoses when they happen, effective public health strategies to prevent them, and, importantly, any prescribing clinician can offer immediate, lifesaving treatment with buprenorphine for those with opioid use disorder.

Opioid use disorder (OUD) is easily diagnosable and treatable, with highly effective medications that lead to favorable long-term outcomes. When treated effectively, recovery rates for OUD are better than those of many chronic conditions that providers routinely manage. Buprenorphine, a lifesaving medication approved for OUD treatment since 2002, is a Schedule III substance that can be prescribed by any practitioner with prescriptive authority, including physicians, nurse practitioners, and physician assistants. Importantly, no special training or licensure is required, and there are no patient limits. In Massachusetts, prescribers can now prescribe up to 90 days of buprenorphine at a time, which is a testament to the safety of this medication.

The evidence supporting buprenorphine is incredibly robust. Studies have shown that buprenorphine reduces mortality by more than 50%, improves remission rates from opioid use disorder, increases retention in treatment, lowers the risk of HIV transmission, and enhances overall health and quality of life. The strength of this evidence led to buprenorphine being added to the World Health Organization’s list of essential medications, alongside treatments like insulin and HIV medication. Providers can initiate buprenorphine treatment in any inpatient, emergency department, or ambulatory care setting. Even without other supports or clear follow-up, offering buprenorphine is generally safer than not, especially given the high risk of overdose associated with unregulated opioids such as fentanyl. Providing some form of beneficial intervention is always preferable to doing nothing, and even a three-day prescription can significantly increase the likelihood that a patient will connect with the next step in their treatment.

How does it work?

Buprenorphine is a partial opioid agonist. It works by binding to opioid receptors in the brain and partially activating them to eliminate withdrawal symptoms and reduce cravings. Buprenorphine also has a high binding affinity, meaning that it sticks tightly to opioid receptors, blocking them from being activated by other opioids. This mechanism prevents a person from experiencing the full effects of other opioids if they relapse and protects them from overdose. Buprenorphine can be administered daily as a sublingual or buccal medication, or as a weekly or monthly extended-release injection. It can be prescribed in the privacy of a healthcare provider’s office and filled at the pharmacy.

How do I prescribe it?

When prescribing buprenorphine, it's essential to instruct the patient to wait until they are in mild to moderate withdrawal before taking their first dose. This timing is an important indicator that the opioids previously used have left their system, allowing buprenorphine to bind to the opioid receptors without displacing another full opioid agonist. If taken too soon—before withdrawal symptoms begin— buprenorphine can cause precipitated withdrawal, a sudden and uncomfortable shift from full opioid effects to partial opioid effects due to the abrupt displacement of other opioids from the receptors. Patients can be safely begin buprenorphine at home after they begin experiencing withdrawal symptoms. To assist clinicians, an Epic SmartRx is available for writing an initial buprenorphine prescription.

For patients who have experienced precipitated withdrawal, are concerned about it, or cannot wait for withdrawal symptoms to occur—often a concern with fentanyl use—alternative initiation methods are available. One approach is a low-dose initiation, which involves administering very small doses of buprenorphine at first. Another option, once withdrawal has begun, is a high-dose initiation, providing a large dose of buprenorphine to get them feeling better soon. Clinicians who need guidance on these alternative protocols can place an e-consult or refer the patient to a Mass General Brigham Bridge Clinic.

Treat opioid use disorder with buprenorphine and save lives

Be part of someone's recovery. Treating opioid addiction with buprenorphine saves lives and increases the rate of recovery. Prescribing buprenorphine reduces mortality and increases recovery.

Logistics

• Most insurances cover buprenorphine.
• The usual daily dose for the sublingual formulation is between 16–24 mg.
• The most common sublingual formulation is buprenorphine-naloxone. The naloxone is inactive when taken sublingually and is included to prevent injection use.
• Prescribers must check the PDMP before prescribing.
• In Massachusetts, buprenorphine can be prescribed for up to 90 days at a time.
• There are no specific requirements for counseling, toxicology testing, laboratory tests, or treatment agreements; care should be individualized based on patient’s unique needs.
• Consider prescribing naloxone to any patient with a history of OUD, including those treated with buprenorphine.

What are the key points to remember?

• Buprenorphine is a lifesaving medication that any prescriber can offer.
• Buprenorphine can be started in any care setting.
• Taking beneficial action is always better than doing nothing. The default should be to start buprenorphine when someone with untreated OUD is being seen, rather than waiting for a specialist or referring elsewhere.
• When in doubt, use the Epic SmartRx to start buprenorphine.
• Mass General Brigham Bridge Clinics and e-consults are available to anyone, with or without a Mass General Brigham primary care provider, and can provide supportive consultation for clinicians.
• Patients can be referred for buprenorphine initiation at any Bridge Clinic and offered immediate care.