Importance of Communication in Buprenorphine Initiation | APhA 2025
Haley Pals, PharmD, BCPP, and Thomas Franko, PharmD, discussed the best approaches in the use of buprenorphine for treating patients with SUD.
Educating patients and allowing them to feel comfortable are significantly important in optimizing buprenorphine doses for those experiencing substance use disorder (SUD), according to a presentation at the American Pharmacists Association 2025 Annual Meeting and Exposition.1
“Buprenorphine is used in medication-assisted treatment to help people reduce or quit their use of heroin or other opiates, such as pain relievers like morphine,” according to the University of Arkansas for Medical Sciences Psychiatric Research Institute.2 “Approved for clinical use in October 2002 by the FDA, buprenorphine represents the latest advance in medication-assisted treatment (MAT). Medications such as buprenorphine, in combination with counseling and behavioral therapies, provide a whole-patient approach to the treatment of opioid dependency. When taken as prescribed, buprenorphine is safe and effective.”
Buprenorphine has become a key component in combatting the opioid epidemic, which is heightened in the US but has shown recent signs of slowing down. From 2021 to 2022, the US saw its first year-to-year decrease in opioid overdoses—now referred to as opioid-induced respiratory depression (OIRD)—since the year 2018. These improvements could be owed to the increased use of buprenorphine nationwide, leading to the current debate on the initiation of its use among opioid users and patients with SUD.
Buprenorphine has become a key component in combatting the opioid epidemic. | image credit: syahrir / stock.adobe.com
READ MORE: Pharmacy Buprenorphine Programs Can Increase OUD Treatment Access, But Barriers Limit Engagement
In a session titled Grand Ole Debate on Hot Topics in Pain and SUD, Haley Pals, PharmD, BCPP, and Thomas Franko, PharmD, explored the 2 most notable options for buprenorphine initiation: low-dose or traditional introduction of buprenorphine.
“The way in which [traditional initiation] is manifested is that buprenorphine has a much higher affinity,” explained Franko.1 “It is going to death-grip that new receptor a lot stronger than a full new opioid like oxycodone, heroin, or fentanyl potentially could. The way in which we do traditional is you've got to wait until that full new opioid is starting to leave the system.”
As Franko mentioned, traditional or standard buprenorphine initiation involves patients first completely stopping the use of opioids, forcing them into at least a “moderate” period of withdrawal before initiating the agent.1,3 Traditional initiation has been the standard of treatment for people with SUD because of its ability to help them avoid precipitated withdrawal caused by buprenorphine. Also, the timing of traditional initiation at the point of patients stopping their opioid use has been known to improve patients’ use of illicit substances.
However, traditional buprenorphine initiation still forces patients to withdrawal from using opioids at some point. While this approach may not exacerbate their withdrawal symptoms via precipitation, Pals chimed in to discuss the benefits of low-dose initiation and how patients may gravitate toward this approach.
“The concept here is that we can avoid that risk of precipitated withdrawal if we just go slower,” said Pals. “So of course, if you go too quickly with that buprenorphine, you are going to precipitate withdrawal. So just don't do that. If we just go slow enough and take our time to allow this to sneak in the background, we don't have to have that patient experience any withdrawal, because they're humans and we don’t want them to have to go through that.”
The differences between low-dose and traditional initiation may be simple, but they can make a crucial impact in patient experiences for those trying to treat their SUD. As Pals stated, the greatest benefit of low-dose initiation for buprenorphine treatment is its ability to avoid any type of withdrawal. With this approach’s focus on avoiding withdrawal, it may present the safest and most viable option for patients with SUD.
However, the data and evidence are not necessarily robust when it comes to low-dose initiation.
“At the end of the day, is it really worth it to go with the low-dose method?” said Franko. “In reality, the data is still kind of sketchy. It's still new and very much in its infancy, but there's pros and cons to it, like we're discussing. There is no standardized approach.”
Ultimately, the evidence supporting low-dose initiation is not yet there for it to be considered the standard approach for all patients. However, it has been introduced as a viable option. And with multiple options, as well as Pals and Franko’s patient-first approach to ensuring those using buprenorphine are comfortable with initiation, it’s most important to have open communication with patients and to educate them. To yield the best outcomes, it’s best to allow patients to choose which approach they are comfortable with.
“It all comes down to educating our patients on those risks and allowing them to accept [their initiation approach]. Everyone is so different of what they feel comfortable with, and I'll never know that unless I'm talking with them, explaining, and educating what that looks like either way. No matter what you do decide to use or tell your patients about, they need to know both sides, and they need to know the risks and benefits of both approaches. There's no right way [for] what your patient feels comfortable with,” concluded Pals.1
