Managing Opioid Withdrawal Symptoms During the Fentanyl Crisis: A Review

Figures & data

Table 1 Low-Dose Buprenorphine Initiation Using Sublingual Buprenorphine

Day	Sublingual Buprenorphine	Full-Agonist Opioids
1	0.5 mg QD	Continue
2	0.5 mg BID	Continue
3	1 mg BID	Continue
4	2 mg BID	Continue
5	4 mg BID	Continue
6	4 mg TID	Continue
7+	8 mg BID	STOP

Note: Data from Cohen et al³⁶

Abbreviations: QD, once per day; BID, twice per day; TID, three times per day; +, and following days.

Table 2 Low-Dose Buprenorphine Initiation Using Transdermal Buprenorphine Without Concurrent Full-Agonist Opioid

Day	Transdermal Buprenorphine	Sublingual Buprenorphine
1	20 mcg/hr	–
2	20 mcg/hr	8 mg QD or BID
3	–	8 mg BID, up-titrate as needed

Note: Data from Baumgartner et al³⁷

Abbreviations: mcg/hr, micrograms per hour; QD, once per day; BID, twice per day.

Table 3 Comparison of Published Protocols Using Various Medications to Transition to Extended-Release Naltrexone (XR-NTX)

Rudolf et al^Citation64		Mannelli et al^Citation65,Citation66
Medication (Max Daily mg)	DAY	Oral Naltrexone	Sublingual Buprenorphine
Tizanidine (32 mg) Hydroxyzine (600 mg) Gabapentin (1500 mg)	1	0.25–0.5 mg	4 mg
	2	0.25–0.5 mg	2 mg
	3	0.5–1 mg	2 mg
	4	2–6 mg	–
–	5	3–15 mg	–
–	6	5–35 mg	–
–	7	13-50	-
–	8	XR-NTX	-

Notes: All protocols included other ancillary medications, such as dicyclomine, acetaminophen, naproxen, and loperamide.

Abbreviations: mg, milligram; et al, et alia.

Figure 1 Prisma Flow Diagram.

Cohen SM, Weimer MB, Levander XA, Peckham AM, Tetrault JM, Morford KL. Low Dose Initiation of Buprenorphine: a Narrative Review and Practical Approach. J Addict Med. 2022;16(4):399–406. doi:10.1097/ADM.0000000000000945

 PubMed Web of Science ®Google Scholar

Baumgartner K, Salmo E, Liss D, et al. Transdermal buprenorphine for in-hospital transition from full agonist opioids to sublingual buprenorphine: a retrospective observational cohort study. Clin Toxicol. 2022;60(6):688–693. doi:10.1080/15563650.2022.2028802

 PubMed Web of Science ®Google Scholar

Rudolf G, Walsh J, Plawman A, et al. A novel non-opioid protocol for medically supervised opioid withdrawal and transition to antagonist treatment. Am J Drug Alcohol Abuse. 2018;44(3):302–309. doi:10.1080/00952990.2017.1334209

 PubMed Web of Science ®Google Scholar

Mannelli P, Wu LT, Peindl KS, Swartz MS, Woody GE. Extended release naltrexone injection is performed in the majority of opioid dependent patients receiving outpatient induction: a very low dose naltrexone and buprenorphine open label trial. Drug Alcohol Depend. 2014;138:83–88. doi:10.1016/j.drugalcdep.2014.02.002

 PubMed Web of Science ®Google Scholar

Mannelli P, Swartz M, Wu LT. Withdrawal severity and early response to treatment in the outpatient transition from opioid use to extended release naltrexone. Am J Addict. 2018;27(6):471–476. doi:10.1111/ajad.12763

 PubMed Web of Science ®Google Scholar