A practical guide for buprenorphine initiation in the primary care setting.

Buprenorphine is a safe and effective treatment for opioid use disorder but remains underutilized because a major challenge of conventional buprenorphine initiation (termed induction) is that the patient must already be in opioid withdrawal. Previous legal barriers and clinician lack of familiarity with the unique pharmacology of buprenorphine have also limited its use. In this review, we outline changes regarding buprenorphine prescribing laws and physician perceptions of buprenorphine. We also review buprenorphine pharmacology and novel low-dose buprenorphine induction procedures that can be adopted in primary care settings to improve treatment acceptability, retention, and outcomes.

Discontinuing antidepressants: Pearls and pitfalls.

Stopping antidepressants can be challenging due to the high rate of discontinuation symptoms. Patients with antidepressant discontinuation syndrome (ADS) commonly experience insomnia, flu-like symptoms, mood disturbances, dizziness, and paresthesias, but a broad array of adverse effects is possible. Symptoms can last for days to months, and different symptoms have different durations. Patient education, identification of patients most at risk for developing symptoms, and a slow antidepressant taper or cross-taper are important steps in mitigating the risk of ADS and managing patient concerns about ADS. Tapers should be carried out over weeks to months. Discontinuation symptoms should be managed with restarting the prior dose of antidepressant and then tapering even more slowly, with additional symptomatic management as needed.