Individualizing Buprenorphine: Low-dose Induction to Long-acting Injectables

In this episode of ASAM Practice Pearls, Dr. Stephen Taylor hosts Dr. Stephen Holt in a discussion about practical strategies for initiating and managing patients receiving low-dose buprenorphine and long-acting injectable (LAI) formulations. The conversation explores how to match induction approaches to individual patient needs, guidance on dosing, and ways to support ongoing use, cravings, or withdrawal symptoms. This episode offers listeners practical insights for implementing buprenorphine treatment strategies and expanding access to evidence-based care. ----more---- Looking for this episode's transcript? Download it HERE Get credit for listening! Claim your 0.5 CEs HERE Have an idea for a future episode? Share it with us at education@asam.org. Host Stephen M. Taylor, MD, MPH, DFAPA, DFASAM Dr. Stephen M. Taylor is ASAM's President and is board certified in general psychiatry, child and adolescent psychiatry, addiction psychiatry, and addiction medicine. With over 30 years of practice experience, Dr. Taylor is dedicated to helping adolescents and adults overcome addiction and co-occurring psychiatric disorders. He has served as the Medical Director of the NBA and NBPA Player Assistance and Anti-Drug Program for 16 years and is the Chief Medical Officer of Pathway Healthcare, which operates multiple outpatient addiction and mental health treatment offices across six states. Expert Stephen Holt, MD, MS, FACP, FASAM Dr. Stephen Holt has been an attending physician at Yale-New Haven Hospital since 2008 and is an Associate Professor of Medicine at Yale School of Medicine. He is the Director of the Yale Addiction Recovery Clinic and the Associate Program Director for Yale's Primary Care Internal Medicine Residency Program. He is board-certified in Addiction Medicine and Internal Medicine. He has published and lectures frequently on a variety of addiction medicine topics, and has won numerous teaching awards at the local, regional, and national levels. 📖 Show Segments 00:05 - Introduction  00:45 - Patient Case: Erratic use of Buprenorphine 02:23 - Deciding Between Traditional and Low-Dose Induction 05:27 - Direct-to-Inject Approach and Access Logistics 09:23 - Low-dose Induction Approach 10:38 - Considerations for Tailoring Buprenorphine Doses 12:37 - Candidates for LAI Formulations 14:16 - Initiating LAI Treatment 17:56 - Managing Ongoing Use and Breakthrough Symptoms on LAI 21:02 - Addressing Co-occurring Substance Use Disorders 23:05 - Practice Pearls 25:31 - Conclusion and Additional Learning Opportunity  📋 Key Takeaways Match your induction strategy to the patient: Patients using short-acting or predictable opioids can follow a traditional induction. For those taking predictable long-acting opioids or methadone, consider a low-dose induction. For patients with erratic use of buprenorphine or fentanyl, consider a direct-to-inject or high-dose induction approach. Low-dose induction reduces the risk of precipitated withdrawal: Start a patient with very small amounts of buprenorphine (e.g., 0.5 mg) while the patient continues using their opioid, then gradually increase their buprenorphine dose over approximately 6 days in the outpatient setting. Consider direct-to-inject LAI buprenorphine for patients with unstable use: LAI buprenorphine (especially 7-day formulations) allows a gradual receptor transition, reducing withdrawal risk and simplifying care for patients with unstable opioid use patterns. Proactively address logistical barriers to offering LAIs: Establish feasible workflows (e.g., specialty pharmacy or buy-and-bill) to reduce access barriers. Another option is to plan follow-up visits a few days later to administer the injection and use sublingual buprenorphine as a bridge, rather than trying to secure LAI same-day access upfront. Individualize LAI dosing based on patient use patterns and context: There's no perfect conversion from fentanyl to buprenorphine. Dosing decisions depend on opioid type, level of cravings, and environment. Patients using more than 2-3 bags of fentanyl per day may require the maximum dose of LAI buprenorphine, whereas lighter users may not. Offer LAI buprenorphine as a routine op