A 52-year-old man on disability, residing in supported housing, was admitted to a tertiary care hospital for acute kidney failure. His past medical history included hepatitis C, laparoscopic cholecystectomy for gallstones, left knee injury, and a previous nasal fracture. His substance use history included stimulant and opioid use disorders for 10 years, starting with daily cocaine and intermittent heroin use. Two years prior, he had transitioned to using unregulated fentanyl. Prior to admission, he was using 200 mg of intravenous and inhaled unregulated fentanyl per day. He had a past trial of methadone up to 80 mg daily, but discontinued treatment as he felt fentanyl helped him balance out the effects of stimulants. He had also been offered SL BUP/NX, but the fear of withdrawal symptoms during the induction period had discouraged him from taking it. On the day of admission, he reported that he last used cocaine the same morning and last used fentanyl the day prior. His urine drug screen tested positive for fentanyl, methadone, opiates, and cocaine.

On the day of admission, he received 8–16 mg oral (PO) hydromorphone every 1 h (q1h) as needed for the management of pain and opioid withdrawal. He expressed that his goal was abstinence from unregulated opioids, noting that lately he was using opioids primarily to prevent withdrawal symptoms. Furthermore, he was interested in the BUP-XR depot because he found daily medication administration challenging.

He subsequently completed a BUP-TD induction over 48 h while continuing to receive hydromorphone as needed (Table 1). On the first day of induction, six 20 µg/h TD buprenorphine patches were applied to the patient’s back. After 24 h, six additional patches were applied. All patches were removed 48 h post induction, and he received 4 mg SL BUP/NX. He then received 300 mg SC BUP-XR four hours later. No precipitated withdrawal occurred during the induction period, as the clinical opiate withdrawal scale (COWS) score at baseline was 6 and subsequently decreased [16]. He received 4 mg SL BUP/NX PRN for withdrawal management, which was discontinued upon discharge. He was provided with an appointment with an outpatient addiction psychiatrist to receive his next BUP-XR injection. He remained on BUP-XR for several months prior to relapse. In his follow-up appointments preceding relapse, there were no reports of withdrawal symptoms or overdoses.

A 34-year-old woman, receiving social support for disability, and living with her mother in a private residence, was admitted to the same tertiary care hospital for asthma exacerbation and pneumonia. Her medical history included asthma, brachial plexopathy, and a right-hand fracture in 2018. Psychiatric history was significant for major depressive disorder (treated with sertraline), and self-reported ADHD. Her substance use history included opioid and stimulant use disorders, beginning four years prior. On admission, she endorsed smoking approximately 1 gram of unregulated fentanyl. She denied intravenous drug use or history of overdose. Past opioid agonist treatment (OAT) included BUP-XR depot injections (Sublocade®), which she was no longer taking. More recently, she was started on 500 mg daily of slow-release oral morphine (SROM, Kadian®), but had ongoing fentanyl due to cravings and withdrawal symptoms. She reported that her last fentanyl use was on the day of admission. Her urine drug screen was positive for fentanyl and opiates, and negative for cocaine, benzodiazepines, cannabis, and amphetamines.

On the day of admission, she was treated with azithromycin and ceftriaxone by the internal medicine team for pneumonia. She received 500 mg of SROM once daily, as well as the following medications for withdrawal management: 10-20 mg of oral morphine every 4 h as needed, 8-32 mg of oral hydromorphone every 3 h as needed, and 4-16 mg of subcutaneous hydromorphone every 3 h as needed. She reported a goal of abstinence from unregulated opioids, and subsequently underwent a BUP-TD induction over 48 h onto SC BUP-XR (Table 2). On the first day of induction, six 20 µg/h BUP-TD patches were applied on the patient’s back. After 24 h, six more patches were applied. After 48 h, all twelve patches were removed, and the patient received 4 mg SL BUP/NX. After 50.5 h, she received a 300 mg SC injection of BUP-XR. No precipitated withdrawal occurred during the induction period, as indicated by her low scores on the Clinical Opiate Withdrawal Scale (COWS), ranging from 1 to 5, i.e., only mild objective withdrawal symptoms. The patient noted that she tolerated the induction well and denied any side effects. A follow-up appointment was scheduled with her general practitioner for her next BUP-XR injection. She remained on BUP-XR for several months before relapse. In her follow-up appointments prior to relapse, there were no reports of withdrawal symptoms or overdose.