Buprenorphine Microdosing Cross Tapers: A Time for Change.

Buprenorphine is a partial opioid agonist that is Food and Drug Administration (FDA) approved to treat chronic pain and opioid use disorder (OUD). The national prescribing guidelines in the United States (US) recommend that patients transitioning from full opioid agonists to buprenorphine first undergo 12 or more hours of active opioid withdrawal, in order to avoid buprenorphine-precipitated opioid withdrawal. This opioid-free period imposes a significant barrier for many patients. Evidence is accumulating that using microdoses of buprenorphine to cross taper from full-agonist opioids to buprenorphine is a safe and effective way to avoid opioid withdrawal and uncontrolled pain. This microdose cross-tapering strategy is already being used across the US. The US prescribing guidelines and buprenorphine training would benefit from acknowledging this new approach. Additionally, to facilitate this strategy, the FDA should approve transdermal buprenorphine formulations for OUD and manufacturers could produce lower dose formulations of sublingual buprenorphine. The time has come for us to embrace buprenorphine microdosing cross tapers as a new standard of care.

Gabapentin dependence and withdrawal requiring an 18-month taper in a patient with alcohol use disorder: a case report.

Gabapentin has been widely used to manage post-herpetic neuralgia, peripheral neuropathy, seizure disorders, alcohol use disorder (AUD), alcohol withdrawal, and insomnia. Although usually well tolerated, gabapentin has been reported to cause severe physiologic dependence and withdrawal. Tapering gabapentin in this context poses a significant clinical challenge, with little published information to date on meeting this challenge. This case highlights the need for patient-centered slow tapers in patients with severe gabapentin dependence and withdrawal. We present a 32-year-old female effectively treated for AUD with 1,200 mg daily dose of gabapentin, who developed gabapentin dependence and severe withdrawal. Recognizing her intolerance to gabapentin withdrawal after a brief accidental pause of medication, a taper plan was initiated using the framework of the BRAVO Protocol. On average, she reduced daily gabapentin dose by 100 mg per month until she reached 300 mg. The taper then slowed to 20-30 mg dose decrements per month. For the last 100 mg, she tapered down at 5 mg decrements every one to two weeks to 60 mg, at which point she discontinued gabapentin. The entire taper process took eighteen months. The BRAVO protocol outlines a safe and compassionate strategy. Originally developed for opioids and adapted to benzodiazepines, the use of the Bravo Protocol provides a framework for a gabapentin taper. For patients in whom gabapentin treatment leads to severe dependence and withdrawal, the BRAVO Protocol provides a practical, patient-centered framework for tapering.

Case Report: Buprenorphine-A Treatment for Psychological Pain and Suicidal Ideation?

BACKGROUND AND OBJECTIVES: Buprenorphine is commonly used to manage opioid use disorder; however, the literature describes its potential role in treating treatment-resistant depression. METHODS: We present a patient with bipolar disorder and opioid use disorder, who presented status post-suicide attempt. RESULTS: After initiating buprenorphine-naloxone, the patient reported rapid improvement in depressive symptoms, pain, and suicidal ideation. DISCUSSION AND CONCLUSIONS: This case demonstrates buprenorphine's antisuicidal and mood-stabilizing capabilities, potentially via antagonizing κ-opioid receptors as well as reinstating the balance between reward and antireward circuitry. SCIENTIFIC SIGNIFICANCE: This case highlights buprenorphine-naloxone as a treatment for both treatment-resistant depression and opioid use disorder, as well as buprenorphine's rapid antidepressant, analgesic, and antisuicidal effects. (Am J Addict 2021;30:80-82).

Gastaut-Geschwind Syndrome, Faciobrachial Dystonic Seizure, and Autoimmune Limbic Encephalitis.

Here we report a case of a 55-year-old male who had presented with recent falls and behavioral changes, including a heightened religious preoccupation, hypergraphia, and paranoid ideations. He was initially treated for psychosis but soon exhibited absence-like seizures, which were consistent with faciobrachial dystonic seizures. Workup for underlying infectious, immunodeficiency, and autoimmune causes revealed antibodies towards the leucine-rich glioma inactivated subunit of the voltage-gated potassium complex. The patient was treated with steroids and intravenous immune globulin with symptomatic relief. In retrospect, the patient met criteria for Gastaut-Geschwind (GG) syndrome, with notable features of hypergraphia and hyperreligiosity. This case illustrates how the GG syndromal pattern contributes to the suspicion of autoimmune limbic encephalitis and may expedite diagnosis and prevent the accumulation of disability.

DNA branch nuclease activity of vaccinia A22 resolvase.

DNA replication, recombination, and repair can result in formation of diverse branched DNA structures. Many large DNA viruses are known to encode DNA branch nucleases, but several of the expected activities have not previously been found among poxvirus enzymes. Vaccinia encodes an enzyme, A22 resolvase, which is known to be active on four-stranded DNA junctions (Holliday junctions) or Holliday junction-like structures containing three of the four strands. Here we report that A22 resolvase in fact has a much wider substrate specificity than previously appreciated. A22 resolvase cleaves Y-junctions, single-stranded DNA flaps, transitions from double strands to unpaired single strands ("splayed duplexes"), and DNA bulges in vitro. We also report site-directed mutagenesis studies of candidate active site residues. The results identify the likely active site and support a model in which a single active site is responsible for cleavage on Holliday junctions and splayed duplexes. Lastly, we describe possible roles for the A22 resolvase DNA-branch nuclease activity in DNA replication and repair.