• Basia Hamata, Donald Griesdale, Jessica Hann, and Pouya Rezazadeh-Azar.
• BC Centre on Substance Use, Canada (BH, JH), Foundry Central Office, University of British Columbia, Vancouver General Hospital, Complex Pain and Addiction Services, Canada (PR-A), Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Canada (DG).
• J Addict Med. 2020 Dec 1; 14 (6): 514-517.

BackgroundBuprenorphine/naloxone has been shown to be an effective treatment of opioid use disorder. According to the Canadian National clinical practice guideline on the management of opioid use disorders, given the superior safety profile of buprenorphine/naloxone and its potential for flexible take-home dosing in comparison to other opioid agonist medication it is strongly recommended to initiate opioid agonist treatment with buprenorphine/naloxone as the preferred first-line treatment when possible. Due to its pharmacological properties induction can be challenging, requiring the cessation of all opioids for a certain amount of time to avoid the risk of precipitated withdrawal symptoms. For this reason, buprenorphine/naloxone is not initiated for the treatment of opioid use disorder in critically ill patients where continuous infusion of opioids are required for maintenance of sedation resulting in a missed opportunity for first line treatment of that patient's opioid use disorder.Case SummaryWe present a case of a 29-year-old female with opioid use disorder admitted for infective endocarditis and septic shock requiring intubation for hypoxic respiratory failure secondary to bilateral lung septic emboli with a high opioid debt requiring higher than typical doses of fentanyl and dexmedetomidine infusions to maintain sedation with clinical objective sign of inadequate treatment of her pain and opioid withdrawal. She was successfully started on buprenorphine/naloxone using a rapid micro-induction technique that did not cause precipitated withdrawal or require cessation of her fentanyl infusion.ConclusionThis case illustrates a new method for starting buprenorphine/naloxone in a critically ill intubated patient, where buprenorphine/naloxone was never a consideration in this specific patient population.Scientific SignificanceThis method can be used to minimize barriers to opioid agonist therapy in intubated patients.

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