Community based buprenorphine micro-induction in the context of methadone maintenance treatment and fentanyl – Case report

The micro-induction method of initiating buprenorphine is becoming a popular method for initiating buprenorphine in patients with Opioid Use Disorder, who are on full opioid agonists, either prescribed or non-prescribed, in order to avoid precipitated withdrawal. Given the rising concerns around illicit fentanyl use, this method of initiating buprenorphine has become another tool for clinicians to help patients with Opioid Use Disorder, even when multiple full opioid agonists are involved. While the process for initiating buprenorphine through this process is well studied, the characteristics of patients who are able to tolerate this initiation method in an outpatient setting is not.We present the cases of two patients with Opioid Use Disorder in a community-based methadone maintenance program in whom micro-induction methods were used to initiate buprenorphine without lowering the methadone dose. Both patients successfully transitioned to buprenorphine without precipitated withdrawal. One of the patients was also using fentanyl at the time of induction and was able to abstain from fentanyl use following the induction process.Initiating Buprenorphine using micro-induction strategies in a community based outpatient clinic in patients who are already on full opioid agonists is feasible, in these particular cases, the methadone dose or concurrent fentanyl use did not affect the outcome. We present the characteristics of the patient and the community clinic hoping that this helps more clinicians in replicating this induction strategy.