Doses Of Buprenorphine Research Articles

Adapting low-dose buprenorphine induction to meet patient needs: A pilot study

IntroductionLow-dose buprenorphine induction (LDBI) has been proposed to initiate buprenorphine in patients who are taking full opioid agonists in order to limit the risk of precipitated withdrawal. The objective of this study was to understand how real-world patient-specific adjustments in LDBI protocols impacted success rates in buprenorphine conversion. MethodsThis case series identified patients seen by the Addiction Medicine Consult Service at UPMC Presbyterian Hospital who were started on LDBI with transdermal buprenorphine followed by sublingual buprenorphine-naloxone between April 20, 2021, and July 20, 2021. The primary outcome was successful induction of sublingual buprenorphine. Characteristics of interest included total morphine milligram equivalents (MME) in the 24 hours prior to induction, MME during each day of induction, total time of induction, and final daily maintenance buprenorphine dose. ResultsOf the 21 patients included for analysis, 19 (91%) successfully completed LDBI and converted to a maintenance buprenorphine dose. Median (IQR) opioid analgesia utilization in the 24 hours prior to induction was 113 MME (63–166 MME) in the converted group and 83 MME (75–92 MME) in the group that did not convert. ConclusionsTransdermal buprenorphine patch followed by sublingual buprenorphine-naloxone resulted in a high success rate for LDBI. Patient-specific adjustments may be considered in order to effect a high success rate of conversion.

Association Between Buprenorphine Treatment Gaps, Opioid Overdose, and Health Care Spending in US Medicare Beneficiaries With Opioid Use Disorder

Nonadherence to buprenorphine may increase patient risk of opioid overdose and increase health care spending. Quantifying the impacts of nonadherence can help inform clinician practice and policy. To estimate the association between buprenorphine treatment gaps, opioid overdose, and health care spending. This longitudinal case-control study compared patient opioid overdose and health care spending in buprenorphine-treated months with treatment gap months. Individuals who were US Medicare fee-for-service beneficiaries diagnosed with opioid use disorder who received at least 1 two-week period of continuous buprenorphine treatment between 2010 and 2017 were included. Analysis took place between January 2010 and December 2017. A gap in buprenorphine treatment in a month lasting more than 15 consecutive days. Opioid overdose and total, medical, and drug spending (combined patient out-of-pocket and Medicare spending). Of 34 505 Medicare beneficiaries (17 927 [520%] male; 16 578 [48.1%] female; mean [SD] age, 49.5 [12.7] years; 168 [0.5%] Asian; 2949 [8.5%] Black; 2089 [6.0%] Hispanic; 266 [0.8%] Native American; 28 525 [82.7%] White; 508 [1.5%] other race), 11 524 beneficiaries (33.4%) experienced 1 or more buprenorphine treatment gaps. Treatment gap beneficiaries, compared with nontreatment gap beneficiaries, were more likely to be younger, be male, have a disability, and be Medicaid dual-eligible while less likely to be White, close to a buprenorphine prescriber, and treated with buprenorphine monotherapy (ie, buprenorphine hydrochloride). Beneficiaries were 2.89 (95% CI, 2.20-3.79) times more likely to experience an opioid overdose during buprenorphine treatment gap months compared with treated months. During treatment gap months, spending was $196.41 (95% CI, $110.53-$282.30) more than in treated months. Patients who continued to take buprenorphine dosages of greater than 8 mg/d and 16 mg/d were 2.61 and 2.84 times more likely to overdose in a treatment gap month, respectively, while patients taking buprenorphine dosages of 8 mg/d or less were 3.62 times more likely to overdose in a treatment gap month (maintenance of >16 mg/d: hazard ratio (HR), 2.64 [95% CI, 1.80-3.87]; maintenance of >8 mg/d: HR, 2.84 [95% CI, 2.13-3.78]; maintenance of ≤8 mg/d: HR, 3.62 [95% CI, 1.54-8.50]). Buprenorphine monotherapy was associated with greater risk of overdose and higher spending during treatment gaps months than buprenorphine/naloxone. Medicare patients treated with buprenorphine between 2010 and 2017 had a lower associated opioid overdose risk and spending during treatment months than treatment gap months.

How do I interpret and use quantitative buprenorphine and norbuprenorphine urine levels?

Confirmatory testing of urine samples can be useful in outpatient settings where buprenorphine dosing is not directly observed. But retaining and engaging the patient in effective treatment should be the ultimate goals of testing.

Experience and response to a randomised controlled trial of extended-release injectable buprenorphine versus sublingual tablet buprenorphine and oral liquid methadone for opioid use disorder: protocol for a mixed-methods evaluation

IntroductionOpioid use disorder (OUD) is a debilitating and persistent disorder. The standard-of-care treatment is daily maintenance dosing of sublingual buprenorphine (BUP-SL) or oral methadone (MET). Monthly, extended-release, subcutaneous injectable buprenorphine...

57 Buprenorphine Initiation for Pregnant Patients With Opioid Use Disorder: A Multicenter Observational Study of California Bridge Sites

57 Buprenorphine Initiation for Pregnant Patients With Opioid Use Disorder: A Multicenter Observational Study of California Bridge Sites

Buprenorphine Initiation in the Era of High-potency Synthetic Opioids: A Call for Community-based Participatory Research to Help Learning Health Systems Provide Precision Medicine for Opioid Use Disorder.

High-potency synthetic opioids and adulterants have saturated the US opioid supply, heightening risk to people who use drugs and creating challenges to buprenorphine initiation. As buprenorphine is an essential component of a response to the opioid crisis, a robust evidence base is urgently needed. Rapid research, in partnership with people who use drugs and using community-based participatory research practices to ensure trust, shared goals, and an absence of adverse consequences, should be conducted to help identify the factors associated with successful and failed inductions. Among factors to be considered include detailed assessment of substances used, amount of substances used, time between last use and buprenorphine induction, withdrawal severity at time of buprenorphine induction, dose of buprenorphine, impact of buprenorphine on withdrawal severity, and perhaps even genotypic information. Successful conduct of these efforts in learning health systems can help us move toward precision medicine for opioid use disorder.

Sublingual buprenorphine/naloxone treatment is not affected by OPRM1 A118G and BDNF Va66Met polymorphisms, but alters the plasma beta-endorphin and BDNF levels in individuals with opioid use disorder

The study aimed to examine the genetic contribution to buprenorphine (BUP) treatment in individuals with opioid use disorder (OUD), with a specific focus on BDNF and OPRM1 genes. A total of 113 controls and 111 OUD patients receiving sublingual BUP/naloxone were enrolled. OPRM1 A118G and BDNF Val66Met polymorphisms were investigated by PCR-FRLP. Plasma BDNF and beta-endorphin levels were assessed by ELISA kits in both groups. Blood BUP levels were measured by LC-MS/MS and normalized with daily BUP dose (BUP/D). OPRM1 A118G and BDNF Val66Met polymorphisms didn’t have an effect on plasma beta-endorphin and BDNF levels in OUD patients, respectively. Interestingly, OUD patients had significantly higher plasma BDNF and lower beta-endorphin levels compared to the controls (p < 0.001). A negative and significant correlation between plasma BUP/D and BDNF levels was found. Age onset of first use was associated with OPRM1 A118G polymorphism. The findings indicated that sublingual BUP/naloxone may increase plasma BDNF levels, but may decrease beta-endorphin levels in individuals with OUD. Plasma BDNF level seemed to be decreased in a BUP/D concentration-dependent manner.

Buprenorphine & methadone dosing strategies to reduce risk of relapse in the treatment of opioid use disorder

BackgroundAlthough there is consensus that having a “high-enough” dose of buprenorphine (BUP-NX) or methadone is important for reducing relapse to opioid use, there is debate about what this dose is and how it should be attained. We estimated the extent to which different dosing strategies would affect risk of relapse over 12 weeks of treatment, separately for BUP-NX and methadone. MethodsThis was a secondary analysis of three comparative effectiveness trials. We examined four dosing strategies: 1) increasing dose in response to participant-specific opioid use, 2) increasing dose weekly until some minimum dose (16 mg BUP, 100 mg methadone) was reached, 3) increasing dose weekly until some minimum and increasing dose in response to opioid use thereafter (referred to as the “hybrid strategy”), and 4) keeping dose constant after the first 2 weeks of treatment. We used a longitudinal sequentially doubly robust estimator to estimate contrasts between dosing strategies on risk of relapse. ResultsFor BUP-NX, increasing dose following the hybrid strategy resulted in the lowest risk of relapse. For methadone, holding dose constant resulted in greatest risk of relapse; the other three strategies performed similarly. For example, the hybrid strategy reduced week 12 relapse risk by 13 % (RR: 0.87, 95 %CI: 0.83–0.95) and by 20 % (RR: 0.80, 95 %CI: 0.71–0.90) for BUP-NX and methadone respectively, as compared to holding dose constant. ConclusionsDoses should be targeted toward minimum thresholds and, in the case of BUP-NX, raised when patients continue to use opioids.

Do patients addicted to fentanyl need higher doses of methadone or buprenorphine?

With most medical conditions, such as high blood pressure, there are many choices of medications. For opioid use disorder (OUD), there are three: methadone, buprenoprhine, and naltrexone, and because of issues with naltrexone—patients don't want it, induction requires a week opioid‐free first—that leaves methadone and buprenorphine. The question in the illicit fentanyl era is: Which medication works best for patients addicted to high levels of high potency opioids like fentanyl? ADAW asked top experts in the field and found out that there is no cookie‐cutter recipe; that people with OUD, just like people with high blood pressure, need individualized care. On top of that, many people with OUD have severe other problems and need comprehensive care, regardless of what medication is chosen.

Lower buprenorphine elimination rate constant is associated with lower opioid use

BackgroundOpioid craving is suggested to correlate with the rate of reduction in buprenorphine (BUP) plasma levels. No studies explored Buprenorphine elimination rate constant (BUP EL.R) as a predictor of opioid use or retention in BUP treatment.MethodsAnalysis was performed using data from a randomized controlled trial of 141 adults with opioid use disorder (OUD) randomized to Incentivized Adherence and Abstinence monitoring (I-AAM; experimental (n = 70) and treatment-as-usual; control (n = 71). In the I-AAM, structured access to unsupervised BUP doses was provided up to 28 days contingent of adherence measured by Therapeutic Drug Monitoring and abstinence by Urinary Drug Screens (UDS). In contrast, the treatment-as-usual (control) provided unstructured access to unsupervised doses was provided for up to 14 days considering UDS results. The primary outcome was percentage negative UDS. The secondary outcome, retention in treatment, was continuous enrollment in the study and analysis was via intention-to-treat. Significant bivariate correlations with the outcomes were adjusted for group allocation.ResultsA significant negative correlation between BUP EL.R and percentage negative opioid screens (Pearson correlation coefficient − 0.57, p < 0.01) was found. After adjusting for trial group, BUP EL.R was shown to be an independent predictor of percentage negative opioid screens (Standardized Beta Coefficient − 0.57, 95% CI − 221.57 to − 97.44, R2 0.322).ConclusionBUP EL.R predicted 32.2% of the variation in percentage negative opioid UDS and may serve as a potential promising tool in precision medicine of BUP treatment. Higher buprenorphine elimination is associated with higher positive opioid urine screens during treatment.Trial registrationISRCTN41645723 retrospectively registered on 15/11/2015.

Do buprenorphine doses and ratios matter in medication assisted treatment adherence.

IntroductionBuprenorphine (BUP), generally prescribed as buprenorphine/naloxone, is a key component of medication-assisted treatment (MAT) to manage opioid use disorder. Studies suggest higher doses of BUP increase treatment adherence. Routine urine drug screens (UDS) assist in monitoring MAT adherence via measurement of excreted BUP and its metabolite, norbuprenorphine (NBP). The clinical significance between BUP/NBP concentrations and their ratios for assessing adherence and substance use is not well-described.MethodsWe conducted a single-center, retrospective chart review of 195 clients age ≥18 years enrolled in a local MAT program from August 2017 to February 2021. Demographics, BUP doses, prescription history, and UDS results were collected. Participants were divided based on MAT adherence (<80% vs ≥80%) and median total daily dose (TDD) of BUP (≥16 mg vs <16 mg) in addition to pre- and post-COVID-19 cohorts.ResultsMedian BUP/NBP urinary concentrations were significantly correlated with MAT adherence (P < .0001 for each) and a reduced percentage of positive UDS for opioids (P = .0004 and P < .0001, respectively) but not their ratios. Median TDD of BUP ≥16 mg (n = 126) vs <16 mg (n = 68) was not correlated with MAT adherence (P = .107) or incidence of nonprescription use (P = .117). A significantly higher incidence of UDS positive for opiates (P = .049) and alcohol (P = .035) was observed post-COVID-19.DiscussionClients appearing adherent to MAT who had higher concentrations of urinary BUP/NBP demonstrated a reduced incidence of opioid-positive UDS independent of the BUP dose prescribed. An increase in opioid- and alcohol-positive UDSs were observed during the COVID-19 pandemic.

Postoperative respiratory depression in patients on sublingual buprenorphine: a retrospective cohort study for comparison between postoperative continuation and discontinuation of buprenorphine

BackgroundWe tested the hypothesis that patients who continued buprenorphine postoperatively experience postoperative respiratory depression less frequently than those who discontinued buprenorphine.MethodsThis is a retrospective cohort study of patients who were on buprenorphine preoperatively. The primary outcome was postoperative respiratory depression as defined by respiratory rate < 10/minute, oxygen saturation (SpO2) < 90%, or requirement of naloxone for 48 h postoperatively. The secondary outcome was the composite of postoperative respiratory complications. The associations between postoperative buprenorphine continuation and respiratory depression and respiratory complications were estimated using separate multivariable logistic regression models, including demographic, intraoperative characteristics, and preoperative buprenorphine dose as covariates.ResultsPostoperative buprenorphine continuation was not associated with postoperative respiratory depression (adjusted odds ratio (OR), 1.11, 95% confidence interval (CI), 0.61 to 1.99, P=0.72). In subanalysis stratified by the preoperative buprenorphine dose, buprenorphine continuation was not associated with postoperative respiratory depression either when preoperative buprenorphine dose was high (≥16 mg daily) or low (<16 mg daily). Postoperative buprenorphine continuation was associated with lower incidence of postoperative respiratory complications (adjusted OR, 0.43, 95% CI, 0.21 to 0.86, P=0.02).ConclusionsContinuing buprenorphine was not associated with respiratory depression, but it was associated with a lower incidence of respiratory complications.

How to be self-reliant in the context of stigma? The dilemma of people who inject drugs in Vietnam

Integration of substance use disorder (SUD) treatment and HIV care can increase antiretroviral therapy coverage among people with opioid use disorder (OUD). However, implementation of integrated treatment models remains limited. Stigma towards people with OUD poses a barrier to initiation of, and adherence to, HIV treatment. We sought to understand the extent of stigma towards SUD and HIV among people with OUD in Vietnam, and the effect of stigma on integrated OUD and HIV treatment services utilization. Between 2013 and 2015, we conducted in-depth interviews with 43 patients and 43 providers at 7 methadone clinics and 8 HIV clinics across 4 provinces in Vietnam. We used thematic analysis with a mixed deductive and inductive approach at the semantic level to analyze key topics. Two main themes were identified: (1) Confidentiality concerns about HIV status make patients reluctant to receive integrated care at HIV clinics, given the requirements for daily buprenorphine dosing at HIV clinics. (2) Provider stigma existed mostly toward people with OUD and seemed to center on the belief that substance use causes a deterioration in one’s morals, and was most frequently manifested in the form of providers’ apprehensive approach towards patients. Concerns regarding stigmatization may cause patients to feel reluctant to receive treatment for both OUD and HIV at a single integrated clinic. Interventions to reduce stigma at the clinic and policy levels may thus serve to improve initiation of and adherence to integrated care.

Case Report: Buprenorphine-precipitated fentanyl withdrawal treated with high-dose buprenorphine

Background: Buprenorphine, a partial agonist of the mu-opioid receptor, is an increasingly prescribed medication for maintenance treatment of opioid use disorder. When this medication is taken in the context of active opioid use, precipitated withdrawal can occur, leading to acute onset of opioid withdrawal symptoms. Fentanyl complicates use of buprenorphine, as it slowly releases from body stores and can lead to higher risk of precipitated withdrawal. Objectives: Describe the successful management of buprenorphine precipitated opioid withdrawal from fentanyl with high doses of buprenorphine. We seek to highlight how no adverse effects occurred in this patient and illustrate his stable transition to outpatient treatment. Case report: We present the case of a patient with severe opioid use disorder who presented in moderately severe opioid withdrawal after taking non-prescribed buprenorphine-naloxone which precipitated opioid withdrawal from daily fentanyl use. He was treated with high doses of buprenorphine, 148 mg over the first 48 hours, averaging 63 mg per day over four days. The patient reported rapid improvement in withdrawal symptoms without noted side effects and was able to successfully taper to 16 mg twice daily by discharge. Conclusions: This case demonstrates the safety and effectiveness of buprenorphine at high doses for treatment of precipitated withdrawal. While other options include symptomatic withdrawal management, initiating methadone or less researched options like ketamine, utilizing buprenorphine can preserve or re-establish confidence in this life-saving medication. This case also increases the previously documented upper boundary on buprenorphine dosing for withdrawal and should provide additional confidence in its use.

Characterizing the Clinical use of a Novel Video-assisted Dosing Protocol With Secure Medication Dispensers to Reduce Barriers to Opioid Treatment.

Distance and travel costs to opioid treatment programs (OTPs), especially in rural communities, are barriers to treatment for opioid use disorder. Retention rates at 12 months in our OTP are 55% (range 53%-61%).We piloted a novel treatment platform utilizing a video directly observed therapy (VDOT) smartphone app and a secure medication dispenser to support adherence with take-home doses of methadone or buprenorphine while enabling patients to maintain prosocial activities, reduce time and cost of travel, and increase retention. Participants (n¼58) were adults in a Vermont OTP. Inclusion criteria included travel hardship, access to Wi-Fi or cellular network, and having an iPhone 4S or Android 4.0 or greater. Patients received a dispenser, VDOT app, clinic dispensed medication, counseling, and urine drug testing. Chart reviews assessed VDOT compliance, engagement in prosocial activities, travel costs and time savings, and treatment disposition/retention. Project-associated costs were examined. Of the 15,831 expected videos, 15,581 (98.4%) were received and only 10 (0.063%) showed signs of medication noncompliance with 1 (0.0064%) showing an overt attempt at diversion. About 93% of participants engaged in prosocial activities, travel time and costs were reduced 86%, median cost saved $72 weekly, median travel time saved 5.5 hours weekly and 98% of participants were in treatment 12 months later. VDOT participants using dispensers showed high levels of medication ingestion integrity, had favorable clinical stability, and lower travel time and costs. These findings suggest that using VDOT with dispensers may hold promise as an innovative platform for supporting medication adherence.

Association of Counseling and Psychotherapy on Retention in Medication for Addiction Treatment Within a Large Medicaid Population.

Buprenorphine/naloxone is an effective medication for the treatment of opioid use disorder. Unlike methadone, which can only be dispensed in federally waived clinics and which must be combined with specific psychosocial treatment, buprenorphine can be dispensed by individual prescribers who have completed an 8-hour training program, with no requirement that patients receive concomitant psychotherapy. The objective of this study is to quantify the association of counseling and psychotherapy on retention in treatment. We also examine the effect of buprenorphine dosage on retention. We examined a cohort of 4987 members of a not-for-profit managed care organization serving Medicaid members in 41 counties in Pennsylvania. This cohort was selected from all members who had a full year without any medication for opioid use disorder followed by initiation of treatment with buprenorphine/naloxone in 2016 to 2017 and who remained Medicaid eligible for at least 80% of the following 2 years. Outcomes were estimated using inverse probability weighted propensity scores. The addition of counseling and psychotherapy within the first 8 weeks of treatment was associated with greater total retention in treatment and there was a dose-response relationship. A 16 mg/d or greater dose of buprenorphine was also associated with greater retention. These results provide support for an integrated approach to treating people with an opioid use disorder, through a combination of buprenorphine pharmacotherapy and targeted counseling and psychotherapy within the first 2 months of treatment.

Patients on Buprenorphine Formulations Undergoing Surgery.

To review the pharmacology of buprenorphine, the evolution of buprenorphine dosing recommendations, and the current literature regarding its recommendations for the perioperative period. There is a consensus that for all surgeries, buprenorphine should be continued throughout the perioperative period. If the surgery is a minimal to mild pain surgery, no dose adjustment is needed. There is no clear consensus regarding moderate to severe pain. With all surgeries, multimodal analgesia should be utilized, with regional anesthesia when possible. Patients taking buprenorphine should continue their buprenorphine perioperatively; whether to decrease or maintain dosing is up for debate. Multimodal analgesia should also be used throughout the perioperative period, and communication between the patient and all provider teams is of the utmost importance to provide adequate analgesia during the perioperative period, as well as to arrange safe analgesia upon discharge.

Assessment of Intraoperative Hemodynamics and Recovery Characteristics in Pediatric Patients Receiving Buprenorphine and Propofol Anesthesia for Cleft Palate Surgery: A Prospective Observational Study.

Children with cleft palate are usually operated on before 18 months of age. Cleft palate surgery demands stable hemodynamic parameters, a bloodless surgical field, and an awake and pain-free child after surgery. We aimed to study the anesthesia technique using buprenorphine and propofol for cleft palate surgery. The design involves prospective observational study. The study was conducted at a tertiary care hospital. After the Institutional Ethics Committee approval, 42 patients aged 6 months to 12 years undergoing cleft palate surgery were enrolled. Anesthesia induction commenced with sevoflurane or propofol 3 mg.kg-1. After intubation, buprenorphine 3 μg.kg-1 was given, and propofol infusion was started at 2-8 mg.kg-1.h-1. Hemodynamic parameters, awakening time, and surgeon's satisfaction score were noted. After extubation, pain score, emergence agitation (EA) score, sedation score, recovery score, and adverse events were noted. All statistical analyses were performed using the 20.0 version of the Statistical Package for the Social Science (SPSS) software program. Continuous data were summarized as mean and standard deviation, and were analyzed using a two-sided Student's unpaired t-test. Categorical data were represented using frequencies and proportions. The single dose of buprenorphine with propofol infusion started immediately postintubation causes a significant decrease in heart rate after 1 h. This contributed to a favorable operative field, increasing the surgeon's satisfaction score. In the recovery room, patients were essentially pain-free till 2.5 h after surgery, with only one patient requiring rescue analgesia. Furthermore, 90% of patients showed a smooth and calm recovery with no EA. The Steward's recovery score remained high throughout without any complication. In cleft palate surgeries, a single-dose buprenorphine 3 μg.kg-1 and propofol maintenance infusion 2-8 mg.kg-1.h-1 were effective in maintaining hemodynamic parameters and a bloodless surgical field and managing postoperative pain with a good recovery profile.

Effects of Buprenorphine Dose and Therapeutic Engagement on Illicit Opiate Use in Opioid Use Disorder Treatment Trials.

The impact of agonist dose and of physician, staff and patient engagement on treatment have not been evaluated together in an analysis of treatment for opioid use disorder. Our hypotheses were that greater agonist dose and therapeutic engagement would be associated with reduced illicit opiate use in a time-dependent manner. Publicly-available treatment data from six buprenorphine efficacy and safety trials from the Federally-supported Clinical Trials Network were used to derive treatment variables. Three novel predictors were constructed to capture the time weighted effects of buprenorphine dosage (mg buprenorphine per day), dosing protocol (whether physician could adjust dose), and clinic visits (whether patient attended clinic). We used time-in-trial as a predictor to account for the therapeutic benefits of treatment persistence. The outcome was illicit opiate use defined by self-report or urinalysis. Trial participants (N = 3022 patients with opioid dependence, mean age 36 years, 33% female, 14% Black, 16% Hispanic) were analyzed using a generalized linear mixed model. Treatment variables dose, Odds Ratio (OR) = 0.63 (95% Confidence Interval (95%CI) 0.59–0.67), dosing protocol, OR = 0.70 (95%CI 0.65–0.76), time-in-trial, OR = 0.75 (95%CI 0.71–0.80) and clinic visits, OR = 0.81 (95%CI 0.76–0.87) were significant (p-values < 0.001) protective factors. Treatment implications support higher doses of buprenorphine and greater engagement of patients with providers and clinic staff.

Buprenorphine initiation strategies for opioid use disorder and pain management: A systematic review.

Buprenorphine possesses many unique attributes that make it a practical agent for adults and adolescents with opioid use disorder (OUD) and/or acute or chronic pain. Sublingual buprenorphine has been the standard of care for treating OUD, but its use in pain management is not as clearly defined. Current practice guidelines recommend a period of mild‐to‐moderate withdrawal from opioids before transitioning to buprenorphine due to its ability to displace full agonists from the μ‐opioid receptor. However, this strategy can lead to negative physical and psychological outcomes for patients. Novel initiation strategies suggest that concomitant administration of small doses of buprenorphine with opioids can avoid the unwanted withdrawal associated with buprenorphine initiation. We aim to systematically review the buprenorphine initiation strategies that have emerged in the last decade. Embase, PubMed, and Cochrane Databases were searched for relevant literature. Studies were included if they were published in the English language and described the transition to buprenorphine from opioids. Data were collected from each study and synthesized using descriptive statistics. This review included 7 observational studies, 1 feasibility study, and 39 case reports/series which included 924 patients. The strategies utilized between the literature included traditional initiation (47.9%), microdosing with various buprenorphine formulations (16%), and miscellaneous methods (36.1%). Traditional initiation and microdosing initiation were compared in the data synthesis and analysis; miscellaneous methods were omitted given the high variability between methods. Overall, 95.6% of patients in the traditional initiation group and 96% of patients in the microdosing group successfully rotated to sublingual buprenorphine. Initiation regimens can vary widely depending on patient‐specific factors and buprenorphine formulation. A variety of buprenorphine transition strategies are published in the literature, many of which were effective for patients with OUD, pain, or both.