Episode 203: Microinduction and harm reduction in OUD.
Nathan Bui and Sanjay Reddy describe how to manage opioid use disorder (OUD) by using microinduction and harm reduction, strategies that are reshaping the way we treat opioid use disorder.
Written by Sanjay Reddy, OMSIV and Nathan Bui, OMSIV. Western University of Health Sciences, College of Osteopathic Medicine of the Pacific.
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Intro
Welcome to episode 203 of Rio Bravo qWeek, your weekly dose of knowledge.
Today, we’re tackling one of the biggest health challenges of our time: opioid use disorder, or OUD. Nearly every community in America has been touched by it: families, friends, even healthcare providers themselves.
For decades, treatment has been surrounded by barriers, painful withdrawals, stigma, and strict rules that often do more harm than good. Too many people who need help never make it past those walls. But here’s the hopeful part, new approaches are rewriting the story. They are less about rigid rules and more about meeting people where they are.
Two of the most promising strategies for treatment of OUD are buprenorphine microinduction and harm reduction. Let’s learn why these two connected strategies could change the future of addiction recovery.
Background information of treatment: The X-waiver (short for DATA 2000 waiver) was a special DEA requirement for prescribing buprenorphine for opioid use disorder. Doctors used to take extra training (8 hours) and apply for it. Then, they could prescribe buprenorphine to a very limited number of patients.
The X-waiverhelped regulate buprenorphine but also created barriers to access treatment to OUD. It was eliminated in January 2023 and now all clinicians with a standard DEA registration no longer need a waiver to prescribe buprenorphine for OUD.
Why buprenorphine?
Buprenorphine is one of the safest and most effective medications for opioid use disorder. It has some key attributes that make it both therapeutic and extremely safe:
1) As a partial agonist at mu-opioid receptors, it binds and provides enough partial stimulation to prevent cravings and withdrawal symptoms without producing strong euphoria associated with full agonists.
2) Because it has a strong binding affinity compared to full agonists, it easily displaces other opioids that may be occupying the receptor.
3) As an antagonist at kappa-opioid receptors, it contributes to improved mood and reduced stress-induced cravings.
4) The “ceiling effect”: increasing the dosage past a certain point does not produce a stronger opioid effect. This ceiling effect reduces the risk of respiratory depression and overdose, making it a safer option than full agonists.
5) It also had mild analgesic effects, reducing pain.
6) Long duration of action: The strong binding affinity and slow dissociation from the mu-opioid receptor are responsible for buprenorphine's long half-life of 24–60 hours. This prolonged action allows for once-daily dosing in medication-assisted treatment for OUD.
Induction vs microinduction:
The problem is, starting it—what’s called “induction”—can be really tough. Patients usually need to stop opioids and go through a period of withdrawal first.
Drugs like fentanyl, which can cause precipitated withdrawal —a sudden, severe crash may push people back to using opioids. Because buprenorphine binds so tightly to the mu-opioid receptor, it can displace other opioids, such as heroin or methadone. If buprenorphine is taken while a person still has other opioids in their system, it can trigger sudden and severe withdrawal symptoms.
Opioid withdrawal sign sand symptoms:
Opioid withdrawal symptoms are very uncomfortable; patients may even get aggressive during withdrawals. As a provider, once you meet one of these patients you never forget how uncomfortable and nasty they can be. The symptoms are lacrimation or rhinorrhea, piloerection "goose flesh," myalgia, diarrhea, nausea/vomiting, pupillary dilation, photophobia, insomnia, autonomic hyperactivity (tachypnea, hyperreflexia, tachycardia, sweating, hypertension, hyperthermia), and yawning.
Think about all the symptoms you run for COWS (Clinical Opiate Withdrawal Scale). It is estimated 85 % of opioid-using patients who inject drugs (PWID) reported opioid withdrawal. Fortunately, even though opioid withdrawal is very uncomfortable, it is not life-threatening (unlike alcohol or benzodiazepine withdrawal, which can be fatal).
Many patients who start the journey treating opioid use disorder experience “bumps in the road” --they avoid treatment or drop out early.
What is Microinduction?
Microinduction is a fairly new strategy started in Switzerland around 2016. It is also known as the “Bernese method” (named after the city of Bern, Switzerland).
With this method, instead of stopping opioids cold turkey, patients start with tiny doses of buprenorphine—fractions of a milligram. These doses gradually increase over several days while the patient continues their regular opioid use. While they begin this titer, they can continue use of the full agonist they were previously using–methadone, fentanyl, or heroin, while the buprenorphine begins to take effect.
Once the buprenorphine builds up to a therapeutic level, the full agonist is stopped. This method uses buprenorphine’s unique pharmacology to stabilize the brain’s opioid system without triggering those really nasty withdrawal symptoms.
Early studies and case reports suggest this is safe, tolerable, and effective method to do. Microinduction is changing the game, and it has been spreading quickly in North America.
Instead of forcing patients to stop opioids completely, the dose is slowly increased over the next three to seven days, while the patient keeps using their usual opioids.By the end of that week, the buprenorphine has built up to a therapeutic level and the full agonist is stopped. The difference is really dramatic. Instead of a painful crash into withdrawal, patients describe the process as a gentle step down, or a ramp instead of a cliff.
It’s a flexible method. It can be done in a hospital, a clinic, or even outpatient with good follow-up. Once a patient and doctor develop a strong relationship built on the principles of patient autonomy and patient-centered care, microinduction can be closely monitored on a monthly basis including televisits. Microinduction has been shown to help more patients stay in treatment.
The Role of Harm Reduction
Instead of demanding perfection, harm reduction focuses on best practices providers can implement to reduce risk and keep patients safe. Harm reduction can vary from providing naloxone to reverse overdoses, giving out clean syringes, or offering safer injection education.
It also means allowing patients to stay in treatment even if they keep using other substances, and tailoring care for groups like adolescents, parents, or people recently released from incarceration. Harm reduction says that instead of demanding perfection, let’s focus on progress. Instead of all-or-nothing, let’s devote resources to keeping people alive and safe.
As mentioned,an option is providing naloxone kits so overdoses can be reversed in the moment. Also, giving out clean syringes so the risk of HIV or hepatitis infection is reduced while injecting heroin. Another way to reduce harm is teaching safer injection practices so people can protect themselves until they’re ready for that next step in their treatment.
It also means keeping the doors open, even when patients slip. If someone is still using other substances, they still deserve care. And it means tailoring support for groups who oftentimes get left behind. For people like adolescents, parents balancing childcare, or people coming out of incarceration who are at the highest risk of overdose.
Harm reduction recognizes that recovery isn’t a straight line. It’s about meeting people where they are and walking with them forward.
Conclusion:
Microinduction is itself a harm reduction strategy. It lowers barriers by removing the need for painful withdrawal.When paired with a harm reduction culture in clinics, patients are more likely to enter care, stay engaged, and build trust with doctors for continued care.
Managing opioid use disorder is one of the greatest health challenges of our time. But solutions like buprenorphine microinduction and harm reduction strategies are reshaping treatment—making it safer, more humane, and more accessible. If we embrace these approaches, we can turn barriers into bridges and help more people find recovery.
Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you. Send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week!
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References:
- Bluthenthal, R. N., Simpson, K., Ceasar, R. C., Zhao, J., Wenger, L., & Kral, A. H. (2020). Opioid withdrawal symptoms, frequency, and pain characteristics as correlates of health risk among people who inject drugs. Drug and Alcohol Dependence, volume 211, 1 June 2020, 107932. https://doi.org/10.1016/j.drugalcdep.2020.107932.
- De Aquino, J. P., Parida, S., & Sofuoglu, M. (2021). The pharmacology of buprenorphine microinduction for opioid use disorder. Clinical Drug Investigation, 41 (5), 425–436. https://doi.org/10.1007/s40261-021-01032-7.
- Taylor, J. L., Johnson, S., Cruz, R., Gray, J. R., Schiff, D., & Bagley, S. M. (2021). Integrating harm reduction into outpatient opioid use disorder treatment settings. Journal of General Internal Medicine, 36 (12), 3810–3819. https://doi.org/10.1007/s11606-021-06904-4.
- Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/.
