AANA February 2026 Journal Course: Optimizing Buprenorphine Induction: Updated Approaches in Opioid Use Disorder Management-AANA Journal: Optimizing Buprenorphine Induction: Updated Approaches in Opioid Use Disorder Management

AANA Journal: Optimizing Buprenorphine Induction: Updated Approaches in Opioid Use Disorder Management

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This article from the AANA Journal (February 2026) provides an in-depth review of updated approaches to buprenorphine induction for opioid use disorder (OUD) management. Buprenorphine, favored over methadone for its safety profile—such as a ceiling effect on respiratory depression and lower abuse potential—has become a first-line medication for OUD treatment. However, initiating buprenorphine is challenging because traditional guidelines require patients to be in mild-to-moderate withdrawal before starting to avoid precipitated withdrawal due to buprenorphine's partial agonist activity at μ-opioid receptors.<br /><br />To overcome barriers posed by prerequisite withdrawal, two alternative induction methods have emerged: microdosing and bridging. Microdosing involves administering low, subtherapeutic doses of buprenorphine while continuing full opioid agonists, allowing gradual receptor occupancy and minimizing withdrawal. This method can be done outpatient with low monitoring needs and typically spans up to 7 days. Bridging involves stopping the full agonist and using transdermal buprenorphine patches or short opioid-free intervals before starting sublingual buprenorphine, facilitating a faster transition (2-4 days) but requiring inpatient monitoring due to a higher potential for withdrawal during opioid abstinence.<br /><br />The article reviews buprenorphine’s pharmacology, highlighting its unique receptor activities, including μ-opioid full agonism with ceiling respiratory effects, κ-opioid antagonism (which may reduce dysphoria and depression), and slow receptor dissociation contributing to prolonged effects and reduced abuse liability. New formulations such as 7-day injectable buprenorphine (CAM2038) show promise for streamlined induction without prior sublingual testing.<br /><br />Clinical considerations include perioperative pain management in buprenorphine-maintained patients and adjustments required owing to opioid tolerance. Regulatory changes have reduced prescribing barriers by eliminating the X-waiver, allowing any DEA-registered provider with Schedule III authority to prescribe buprenorphine following an 8-hour training.<br /><br />Despite evidence supporting alternative induction strategies, barriers remain, including provider knowledge gaps, stigma, insurance hurdles, and dosage form manipulation challenges. The authors emphasize the crucial role advanced practice nurses, particularly CRNAs, can play in expanding access to buprenorphine-assisted treatment, especially in underserved areas, through patient evaluation, induction, and monitoring.<br /><br />Overall, microdosing and bridging represent innovative, evidence-supported methods to optimize buprenorphine initiation by mitigating withdrawal symptoms and enhancing treatment retention, but further research is needed to establish standardized protocols and long-term efficacy.

Keywords

Buprenorphine induction

Opioid use disorder

Microdosing

Bridging

Buprenorphine pharmacology

Ceiling effect

Injectable buprenorphine

Perioperative pain management

X-waiver elimination

Advanced practice nurses