title: Use of microdoses for induction of buprenorphine treatment with overlapping full opioid agonist use: the Bernese method.
abstract: BACKGROUND
  Buprenorphine is a partial µ-opioid receptor agonist used for maintenance treatment of opioid dependence. Because of the partial agonism and high receptor affinity, it may precipitate withdrawal symptoms during induction in persons on full µ-opioid receptor agonists. Therefore, current guidelines and drug labels recommend leaving a sufficient time period since the last full agonist use, waiting for clear and objective withdrawal symptoms, and reducing pre-existing full agonist therapies before administering buprenorphine. However, even with these precautions, for many patients the induction of buprenorphine is a difficult experience, due to withdrawal symptoms. Furthermore, tapering of the full agonist bears the risk of relapse to illicit opioid use.
  
  
  METHODS
  We present two cases of successful initiation of buprenorphine treatment with the Bernese method, ie, gradual induction overlapping with full agonist use. The first patient began buprenorphine with overlapping street heroin use after repeatedly experiencing relapse, withdrawal, and trauma reactivation symptoms during conventional induction. The second patient was maintained on high doses of diacetylmorphine (ie, pharmaceutical heroin) and methadone during induction. Both patients tolerated the induction procedure well and reported only mild withdrawal symptoms.
  
  
  CONCLUSIONS
  Overlapping induction of buprenorphine maintenance treatment with full µ-opioid receptor agonist use is feasible and may be associated with better tolerability and acceptability in some patients compared to the conventional method of induction.
authors: Division of Addiction, University Psychiatric Services Bern, Bern, Switzerland.
authors: Robert
authors: R
authors: Hämmig
authors: Division of Substance Use and Addictive Disorders, University of Basel Psychiatric Hospital, Basel, Switzerland.
authors: Antje
authors: A
authors: Kemter
authors: Division of Substance Use and Addictive Disorders, University of Basel Psychiatric Hospital, Basel, Switzerland.
authors: Johannes
authors: J
authors: Strasser
authors: Division of Addiction, University Psychiatric Services Bern, Bern, Switzerland.
authors: Ulrich
authors: U
authors: von Bardeleben
authors: Division of Addiction, University Psychiatric Services Bern, Bern, Switzerland.
authors: Barbara
authors: B
authors: Gugger
authors: Division of Substance Use and Addictive Disorders, University of Basel Psychiatric Hospital, Basel, Switzerland.
authors: Marc
authors: M
authors: Walter
authors: Division of Substance Use and Addictive Disorders, University of Basel Psychiatric Hospital, Basel, Switzerland.
authors: Kenneth M
authors: KM
authors: Dürsteler
authors: Division of Substance Use and Addictive Disorders, University of Basel Psychiatric Hospital, Basel, Switzerland.
authors: Marc
authors: M
authors: Vogel
keywords: heroin; opiate; suboxone; substitution; subutex