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Praeger VC, Frei MY, Pham D, Praeger AJ, Lubman DI, Arunogiri S. Rotation from methadone to buprenorphine using a micro-dosing regime in patients with opioid use disorder and serious mental illness: A case series. Drug Alcohol Rev 2024. [PMID: 38894653 DOI: 10.1111/dar.13885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 04/07/2024] [Accepted: 05/14/2024] [Indexed: 06/21/2024]
Abstract
INTRODUCTION Inducting buprenorphine from methadone has traditionally involved initial opioid withdrawal, with risk of mental state deterioration in patients with serious mental illness (SMI). Micro-dosing of buprenorphine, with small incremental doses, is a novel off-label approach to transitioning from methadone and does not require a period of methadone abstinence. Given the limited literature about buprenorphine microdosing, we aimed to evaluate the feasibility and safety of inducting buprenorphine in a series of patients on methadone with SMI. METHODS For this retrospective case series, we reviewed the records of 16 patients with SMI at a Melbourne addiction treatment centre, from January 2021 to July 2022, who transitioned via micro-dosing, from high-dose methadone (>30 mg) to buprenorphine and depot-buprenorphine. Psychiatric diagnoses, mental state, other substance withdrawal, transfer success, transition time, opioid withdrawal symptoms and overall patient experience were collected via objective and subjective reporting. RESULTS Methadone to buprenorphine transfer was completed by 88% of patients. Mental health measures remained stable with the exception of mildly increased anxiety. Median transfer time was 6.5 days for inpatients, 9 days for mixed setting and 10 days for outpatients. Most patients (93%) rated their experience 'manageable' reporting mild withdrawal symptoms. One patient met study criteria for precipitated withdrawal. DISCUSSION AND CONCLUSIONS This retrospective case series provides evidence that the use of a micro-dosing buprenorphine induction for methadone to buprenorphine transitions, including to depot-buprenorphine, has negligible risk, is tolerated by patients with SMI and is unlikely to precipitate an exacerbation of their mental illness.
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Affiliation(s)
| | - Matthew Y Frei
- Turning Point, Eastern Health, Melbourne, Victoria, Australia
| | - Dan Pham
- Turning Point, Eastern Health, Melbourne, Victoria, Australia
| | - Adrian J Praeger
- Department of Neurosurgery, Monash Hospital, Melbourne, Victoria, Australia
- Department of Surgery, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Dan I Lubman
- Turning Point, Eastern Health, Melbourne, Victoria, Australia
- Monash Addiction Research Centre, Eastern Health Clinical School, Faculty of Medicine, Nursing & Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Shalini Arunogiri
- Turning Point, Eastern Health, Melbourne, Victoria, Australia
- Monash Addiction Research Centre, Eastern Health Clinical School, Faculty of Medicine, Nursing & Health Sciences, Monash University, Melbourne, Victoria, Australia
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Azar P, Schneiderman H, Barron H, Wong JSH, Meyer M, Newman-Azar D, Narimani M, Ignaszewski MJ, Mathew N, Mullen R, Krausz RM, Maharaj AR. Rapid induction of transdermal buprenorphine to subcutaneous extended-release buprenorphine for the treatment of opioid use disorder. Addict Sci Clin Pract 2024; 19:50. [PMID: 38886826 PMCID: PMC11184727 DOI: 10.1186/s13722-024-00479-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 05/28/2024] [Indexed: 06/20/2024] Open
Abstract
BACKGROUND Buprenorphine is an effective and safe treatment for opioid use disorder, but the requirement for moderate opioid withdrawal symptoms to emerge prior to initiation is a significant treatment barrier. CASE PRESENTATION We report on two cases of hospitalized patients with severe, active opioid use disorder, in which we initiated treatment with transdermal buprenorphine over 48 h, followed by the administration of a single dose of sublingual buprenorphine/naloxone and then extended-release subcutaneous buprenorphine. The patients did not experience precipitated withdrawal and only had mild withdrawal symptoms. CONCLUSIONS This provides preliminary evidence for a rapid induction strategy that may improve tolerability, caregiver burden, and treatment retention as compared to previous induction strategies.
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Affiliation(s)
- Pouya Azar
- Integrated Psychiatry, Pain, and Addiction Service, Vancouver General Hospital, Flr 8-2775 Laurel St, V5Z 1M9, Vancouver, BC, Canada.
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.
| | | | - Henry Barron
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - James S H Wong
- Integrated Psychiatry, Pain, and Addiction Service, Vancouver General Hospital, Flr 8-2775 Laurel St, V5Z 1M9, Vancouver, BC, Canada
- Addictions and Concurrent Disorders Research Group, Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Maximilian Meyer
- Addictions and Concurrent Disorders Research Group, Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Clinic of Adult Psychiatry, University of Basel Psychiatric Clinics, University of Basel, Basel, Switzerland
| | - Dayyon Newman-Azar
- Integrated Psychiatry, Pain, and Addiction Service, Vancouver General Hospital, Flr 8-2775 Laurel St, V5Z 1M9, Vancouver, BC, Canada
| | - Matin Narimani
- Integrated Psychiatry, Pain, and Addiction Service, Vancouver General Hospital, Flr 8-2775 Laurel St, V5Z 1M9, Vancouver, BC, Canada
- School of Biomedical Engineering, Faculty of Medicine, Faculty of Engineering, University of British Columbia, Vancouver, BC, Canada
| | - Martha J Ignaszewski
- Integrated Psychiatry, Pain, and Addiction Service, Vancouver General Hospital, Flr 8-2775 Laurel St, V5Z 1M9, Vancouver, BC, Canada
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Substance Use Response and Facilitation Service, BC Children's Hospital, Provincial Health Services Authority, British Columbia, Canada
| | - Nickie Mathew
- Integrated Psychiatry, Pain, and Addiction Service, Vancouver General Hospital, Flr 8-2775 Laurel St, V5Z 1M9, Vancouver, BC, Canada
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- BC Mental Health & Substance Use Services, Provincial Health Services Authority, British, Columbia, Canada
| | - Rodney Mullen
- Integrated Psychiatry, Pain, and Addiction Service, Vancouver General Hospital, Flr 8-2775 Laurel St, V5Z 1M9, Vancouver, BC, Canada
- The C4 Foundation, Coronado, CA, USA
| | - Reinhard M Krausz
- Addictions and Concurrent Disorders Research Group, Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Anil R Maharaj
- Pharmacokinetics Modeling and Simulation Laboratory, Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
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Shahlapour M, Singh S, Christine PJ, Laks J, Evans J, Farrell NM, Khan GK, Taylor JL, Rozansky H. Novel Uses of Methadone Under the "72-Hour Rule" to Facilitate Transitions of Care and Low-Dose Buprenorphine Induction in an Outpatient Bridge Clinic. J Addict Med 2024; 18:345-347. [PMID: 38329815 DOI: 10.1097/adm.0000000000001281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2024]
Abstract
BACKGROUND Federal regulations restrict methadone for opioid use disorder (OUD) treatment to licensed opioid treatment programs (OTPs). However, providers in other settings can administer methadone for opioid withdrawal under the "72-hour rule" while linking to further care. Prior work has demonstrated that methadone initiation in a low-barrier bridge clinic is associated with high OTP linkage and 1-month retention rates. We describe 2 other novel applications of the 72-hour rule in which methadone withdrawal management facilitated linkage to inpatient hospitalization and outpatient buprenorphine induction. CASE PRESENTATIONS Patient 1 was a 46-year-old woman with OUD complicated by serious injection-related infections. Severe opioid withdrawal limited her ability to tolerate emergency department wait times and receive inpatient care. We administered methadone for opioid withdrawal in an outpatient bridge clinic immediately before emergency department referral; this enabled hospital admission for intravenous antibiotics and anticoagulation. Patient 2 was a 36-year-old man with OUD desiring buprenorphine treatment. He had been unable to complete traditional buprenorphine induction without experiencing precipitated withdrawal. Thus, we recommended a low-dose buprenorphine induction overlapping with a full opioid agonist. Given the patient's preference to stop using fentanyl immediately, he received 72 hours of methadone for withdrawal treatment during the induction phase and successfully transitioned to buprenorphine without significant concomitant fentanyl use. CONCLUSION In addition to facilitating OTP linkage, on-demand 72-hour methadone administration for opioid withdrawal can reduce barriers to acute medical care and buprenorphine treatment.
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Affiliation(s)
- Minaliza Shahlapour
- From the Department of Adult Medicine, East Boston Neighborhood Health Center, Boston, MA (MS); Internal Medicine Residency Program, Boston Medical Center, Boston, MA (SS); Division of General Internal Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO (PJC); Section of General Internal Medicine, Boston University Chobanian and Avedisian School of Medicine & Boston Medical Center, Boston, MA (JL, GKK, JLT, HR); Grayken Center for Addiction, Boston Medical Center, Boston, MA (JL, GKK, JLT, HR); The Dimock Center, Boston, MA (JE); Department of Pharmacy, Boston Medical Center, Boston, MA (NMF); and Department of Emergency Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, MA (NMF)
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Jones BLH, Geier M, Neuhaus J, Coffin PO, Snyder HR, Soran CS, Knight KR, Suen LW. Withdrawal during outpatient low dose buprenorphine initiation in people who use fentanyl: a retrospective cohort study. Harm Reduct J 2024; 21:80. [PMID: 38594721 PMCID: PMC11005253 DOI: 10.1186/s12954-024-00998-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 04/02/2024] [Indexed: 04/11/2024] Open
Abstract
BACKGROUND Buprenorphine is an effective treatment for opioid use disorder (OUD); however, buprenorphine initiation can be complicated by withdrawal symptoms including precipitated withdrawal. There has been increasing interest in using low dose initiation (LDI) strategies to reduce this withdrawal risk. As there are limited data on withdrawal symptoms during LDI, we characterize withdrawal symptoms in people with daily fentanyl use who underwent initiation using these strategies as outpatients. METHODS We conducted a retrospective chart review of patients with OUD using daily fentanyl who were prescribed 7-day or 4-day LDI at 2 substance use disorder treatment clinics in San Francisco. Two addiction medicine experts assessed extracted chart documentation for withdrawal severity and precipitated withdrawal, defined as acute worsening of withdrawal symptoms immediately after taking buprenorphine. A third expert adjudicated disagreements. Data were analyzed using descriptive statistics. RESULTS There were 175 initiations in 126 patients. The mean age was 37 (SD 10 years). 71% were men, 26% women, and 2% non-binary. 21% identified as Black, 16% Latine, and 52% white. 60% were unstably housed and 75% had Medicaid insurance. Substance co-use included 74% who used amphetamines, 29% cocaine, 22% benzodiazepines, and 19% alcohol. Follow up was available for 118 (67%) initiations. There was deviation from protocol instructions in 22% of these initiations with follow up. 31% had any withdrawal, including 21% with mild symptoms, 8% moderate and 2% severe. Precipitated withdrawal occurred in 10 cases, or 8% of initiations with follow up. Of these, 7 had deviation from protocol instructions; thus, there were 3 cases with follow up (3%) in which precipitated withdrawal occurred without protocol deviation. CONCLUSIONS Withdrawal was relatively common in our cohort but was mostly mild, and precipitated withdrawal was rare. Deviation from instructions, structural barriers, and varying fentanyl use characteristics may contribute to withdrawal. Clinicians should counsel patients who use fentanyl that mild withdrawal symptoms are likely during LDI, and there is still a low risk for precipitated withdrawal. Future studies should compare withdrawal across initiation types, seek ways to support patients in initiating buprenorphine, and qualitatively elicit patients' withdrawal experiences.
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Affiliation(s)
- Benjamin L H Jones
- Medical Student Center, UCSF School of Medicine, 533 Parnassus Avenue, S-245, San Francisco, CA, 94143, USA.
| | - Michelle Geier
- San Francisco Department of Public Health, 101 Grove Street, San Francisco, CA, 94102, USA
| | - John Neuhaus
- Department of Epidemiology and Biostatistics, University of California San Francisco, 550 16th Street, 2nd Floor, San Francisco, CA, 94158, USA
| | - Phillip O Coffin
- San Francisco Department of Public Health, 101 Grove Street, San Francisco, CA, 94102, USA
- Department of Medicine, University of California San Francisco, 505 Parnassus Avenue, San Francisco, CA, 94143, USA
| | - Hannah R Snyder
- Department of Family and Community Medicine, University of California San Francisco, 995 Potrero Avenue, San Francisco, CA, 94110, USA
| | - Christine S Soran
- Division of General Internal Medicine, San Francisco General Hospital, 1001 Potrero Avenue, San Francisco, CA, 94110, USA
- Division of Substance Abuse and Addiction Medicine, San Francisco General Hospital, University of California San Francisco, 1001 Potrero Avenue, San Francisco, CA, 94110, USA
| | - Kelly R Knight
- Department of Humanities and Social Sciences, University of California San Francisco, 490 Illinois Street, 7th Floor, San Francisco, CA, 94143, USA
| | - Leslie W Suen
- Department of Medicine, University of California San Francisco, 505 Parnassus Avenue, San Francisco, CA, 94143, USA
- Division of General Internal Medicine, San Francisco General Hospital, 1001 Potrero Avenue, San Francisco, CA, 94110, USA
- Division of Substance Abuse and Addiction Medicine, San Francisco General Hospital, University of California San Francisco, 1001 Potrero Avenue, San Francisco, CA, 94110, USA
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Hickey TR, Manepalli AK, Hitt JM. Buprenorphine Facilitates Rapid Weaning From Very-High-Dose Intrathecal Hydromorphone. Cureus 2024; 16:e59134. [PMID: 38803786 PMCID: PMC11129534 DOI: 10.7759/cureus.59134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2024] [Indexed: 05/29/2024] Open
Abstract
Pain management in patients on chronic opioid therapy is a common clinical challenge. The phenomena of opioid-induced hyperalgesia and tolerance are important contributors to that challenge. There are multiple strategies described to wean opioid doses and/or transition patients off opioids altogether. However, there is very little data to guide transitions off chronic intrathecal opioids. Here, we report on two patients with intractable post-laminectomy pain syndrome, resulting in severe functional limitation in the setting of opioid escalation culminating in the intrathecal delivery of hydromorphone to daily doses as high as 20 mg/day. We describe their rapid successful weaning off opioids using low-dose buprenorphine, which resulted in a dramatic improvement in pain and function.
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Affiliation(s)
- Thomas R Hickey
- Anesthesiology, Yale University School of Medicine, VA Connecticut Healthcare System, West Haven, USA
| | - Ashok K Manepalli
- Anesthesiology, Northeast Anesthesia and Pain Specialists, Concord, USA
| | - James M Hitt
- Anesthesiology, VA Western New York Healthcare System, Buffalo, USA
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Krichbaum M, Fernandez D, Singh-Franco D. Barriers and Best Practices on the Management of Opioid Use Disorder. J Pain Palliat Care Pharmacother 2024; 38:56-73. [PMID: 38100521 DOI: 10.1080/15360288.2023.2290565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 11/26/2023] [Indexed: 12/17/2023]
Abstract
Opioids refer to chemicals that agonize opioid receptors in the body resulting in analgesia and sometimes, euphoria. Opiates include morphine and codeine; semi-synthetic opioids include heroin, hydrocodone, oxycodone, and buprenorphine; and fully synthetic opioids include tramadol, fentanyl and methadone. In 2021, an estimated 5.6 million individuals met criteria for opioid use disorder. This article provides an overview of the pharmacology of heroin and non-prescription fentanyl (NPF) and its synthetic analogues, and summarizes the literature related to the management of opioid use disorder, overdose, and withdrawal. This is followed by a description of barriers to treatment and best practices for management with a discussion on recent updates and their potential impact on this patient population. This is followed by a description of barriers to treatment and best practices for management with a discussion on recent updates and their potential impact on this patient population.
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Affiliation(s)
- Michelle Krichbaum
- Clinical Manager-Pain Management and Palliative Care, Baptist Health South Florida, Miami, FL, USA
| | | | - Devada Singh-Franco
- Associate Professor, Pharmacy Practice, Nova Southeastern University, Health Professions Division, Barry and Judy Silverman College of Pharmacy, Fort Lauderdale, FL, USA
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Hughes T, Nasser N, Mitra A. Overview of best practices for buprenorphine initiation in the emergency department. Int J Emerg Med 2024; 17:23. [PMID: 38373992 PMCID: PMC10877824 DOI: 10.1186/s12245-024-00593-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 01/26/2024] [Indexed: 02/21/2024] Open
Abstract
In recent decades, opioid overdoses have increased dramatically in the United States and peer countries. Given this, emergency medicine physicians have become adept in reversing and managing complications of acute overdose. However, many remain unfamiliar with initiating medication for opioid use disorder such as buprenorphine, a high-affinity partial opioid agonist. Emergency department-based buprenorphine initiation is supported by a significant body of literature demonstrating a marked reduction in mortality in addition to increased engagement in care. Buprenorphine initiation is also safe, given both the pharmacologic properties of buprenorphine that reduce the risk of diversion or recreational use, and previously published literature demonstrating low rates of respiratory depression, sedation, and precipitated withdrawal. Further, barriers to emergency department-based initiation have been reduced in recent years, with publicly available dosing and up-titration schedules, numerous publications overviewing best practices for managing precipitated withdrawal, and removal of USA policies previously restricting patient access and provider prescribing, with the removal of the X-waiver via the Medication Access and Training Expansion Act. Despite reductions in barriers, buprenorphine initiation in the emergency room remains underutilized. Poor uptake has been attributed to numerous individual and systemic barriers, including inadequate education, provider stigma, and insufficient access to outpatient follow-up care. The following practice innovation aims to summarize previously published evidence-based best practices and provide an accessible, user-friendly initiation guide to increase emergency physician comfortability with buprenorphine initiation going forward.
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Affiliation(s)
- Terence Hughes
- The Mount Sinai Hospital, 1 Gustav Levy Place, New York, NY, 10029-6574, USA
| | - Nicholas Nasser
- The Mount Sinai Hospital, 1 Gustav Levy Place, New York, NY, 10029-6574, USA.
| | - Avir Mitra
- Mount Sinai Beth Israel, 281 1st Ave, New York, NY, 10003, USA
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Arnouk S, Wunderlich JR, Sidelnik SA. Evaluation of Low-dose Buprenorphine Initiation With Buprenorphine Buccal Films in Hospitalized Patients: A Retrospective Cohort Study. J Addict Med 2024; 18:42-47. [PMID: 37847570 DOI: 10.1097/adm.0000000000001236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Abstract
OBJECTIVE Low-dose buprenorphine initiation (LDBI) strategies to transition patients from full opioid agonists to buprenorphine have previously been described using sublingual films, intravenous solution, transdermal patches, and, more recently, buccal films. The objective of this study was to describe the effectiveness of LDBI using novel titration schedules with buccal films. METHODS This is a retrospective cohort study of hospitalized patients with opioid use disorder (OUD) or physiologic dependence to opioids who underwent LDBI with buprenorphine buccal films at NYU Langone Health. Two LDBI protocols were evaluated, including a short titration schedule over 4 days and a long schedule over 7 days. The primary outcomes of interest included LDBI completion rates and incidence of opioid withdrawal. RESULTS Forty-two patients underwent 46 LDBIs at NYU Langone Health between October 2020 and April 2022. The cohort comprised patients with OUD (57%), chronic pain with OUD (33%), and chronic pain without OUD (10%). Indications for LDBI most commonly included co-occurring pain precluding discontinuation of full opioid agonists (72%), prior history of precipitated withdrawal (30%), and methadone use (23%). The overall completion rate of LDBI was 78%. Withdrawal was encountered in 33% of patients; however, only 2 patients required LDBI discontinuation as a result. On multivariate analysis, a diagnosis of OUD was independently associated with withdrawal during LDBI. CONCLUSIONS Buprenorphine buccal films can successfully be used off-label to facilitate LDBI in the hospital setting. We present 4- and 7-day titration protocols, which were well-tolerated, and provide practical considerations for use.
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Affiliation(s)
- Serena Arnouk
- From the Department of Pharmacy, NYU Langone Health, New York, NY (SA); Department of Psychiatry, University of Iowa Hospitals & Clinics, Iowa City, IA (JRW); Department of Psychiatry, NYU Langone Health, New York, NY (SAS)
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Vu PD, Bansal V, Chitneni A, Robinson CL, Viswanath O, Urits I, Kaye AD, Nguyen A, Govindaraj R, Chen GH, Hasoon J. Buprenorphine for Chronic Pain Management: a Narrative Review. Curr Pain Headache Rep 2023; 27:811-820. [PMID: 37897592 DOI: 10.1007/s11916-023-01185-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2023] [Indexed: 10/30/2023]
Abstract
PURPOSE OF REVIEW The aim of this review is to educate healthcare professionals regarding buprenorphine for the use of opioid use disorder (OUD) as well as for chronic pain management. This review provides physicians and practitioners with updated information regarding the distinct characteristics and intricacies of prescribing buprenorphine. RECENT FINDINGS Buprenorphine is approved by the US Food and Drug Administration (FDA) for acute pain, chronic pain, opioid use disorder (OUD), and opioid dependence. When compared to most other opioids, buprenorphine offers superior patient tolerability, an excellent half-life, and minimal respiratory depression. Buprenorphine does have notable side effects as well as pharmacokinetic properties that require special attention, especially if patients require future surgical interventions. Many physicians are not trained to initiate or manage patients on buprenorphine. However, buprenorphine offers a potentially safer alternative for medication management for patients who require chronic opioid therapy for pain or have OUD. This review provides updated information on buprenorphine for both chronic pain and OUD.
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Affiliation(s)
- Peter D Vu
- Department of Physical Medicine and Rehabilitation, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX, USA
| | - Vishal Bansal
- Department of Physical Medicine and Rehabilitation, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX, USA
| | - Ahish Chitneni
- Department of Rehabilitation and Regenerative Medicine, New York-Presbyterian Hospital - Columbia and Cornell, New York, NY, USA
| | - Christopher L Robinson
- Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Omar Viswanath
- Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, LA, USA
| | - Ivan Urits
- Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, LA, USA
| | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, LA, USA
| | - Anvinh Nguyen
- Department of Anesthesiology, Baylor College of Medicine, Houston, TX, USA
| | - Ranganathan Govindaraj
- Department of Anesthesiology, Critical Care, and Pain Medicine, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX, USA
| | - Grant H Chen
- Department of Anesthesiology, Critical Care, and Pain Medicine, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX, USA
| | - Jamal Hasoon
- Department of Anesthesiology, Critical Care, and Pain Medicine, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX, USA.
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Miller JC, Brooks MA, Wurzel KE, Cox EJ, Wurzel JF. A Guide to Expanding the Use of Buprenorphine Beyond Standard Initiations for Opioid Use Disorder. Drugs R D 2023; 23:339-362. [PMID: 37938531 PMCID: PMC10676346 DOI: 10.1007/s40268-023-00443-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2023] [Indexed: 11/09/2023] Open
Abstract
Buprenorphine has become an important medication in the context of the ongoing opioid epidemic. However, complex pharmacologic properties and varying government regulations create barriers to its use. This narrative review is intended to facilitate buprenorphine use-including non-traditional initiation methods-by providers ranging from primary care providers to addiction specialists. This article briefly discusses the opioid epidemic and the diagnosis and treatment of opioid use disorder (OUD). We then describe the basic and complex pharmacologic properties of buprenorphine, linking these properties to their clinical implications. We guide readers through the process of initiating buprenorphine in patients using full agonist opioids. As there is no single recommended approach for buprenorphine initiation, we discuss the details, advantages, and disadvantages of the standard, low-dose, bridging-strategy, and naloxone-facilitated initiation techniques. We consider the pharmacology of, and evidence base for, buprenorphine in the treatment of pain, in both OUD and non-OUD patients. Throughout, we address the use of buprenorphine in children and adolescent patients, and we finish with considerations related to the settings of pregnancy and breastfeeding.
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Affiliation(s)
- James C Miller
- Psychiatry Residency Spokane, Providence Sacred Heart Medical Center and Children's Hospital, 101 W Eighth Ave, Spokane, WA, 99204, USA
| | - Michael A Brooks
- Psychiatry Residency Spokane, Providence Sacred Heart Medical Center and Children's Hospital, 101 W Eighth Ave, Spokane, WA, 99204, USA
| | - Kelly E Wurzel
- Psychiatry Residency Spokane, Providence Sacred Heart Medical Center and Children's Hospital, 101 W Eighth Ave, Spokane, WA, 99204, USA
| | - Emily J Cox
- Providence Research Network, Renton, WA, USA
| | - John F Wurzel
- Psychiatry Residency Spokane, Providence Sacred Heart Medical Center and Children's Hospital, 101 W Eighth Ave, Spokane, WA, 99204, USA.
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Hardy M, Grable S, Otley R, Pershing M. Survey of Buprenorphine Low-dose Regimens Used by Healthcare Institutions. J Addict Med 2023; 17:521-527. [PMID: 37788604 DOI: 10.1097/adm.0000000000001163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
BACKGROUND Buprenorphine microdosing ("low-dosing") allows for initiation of buprenorphine without requiring patients to endure withdrawal. Case studies suggest its favorable utility as an alternative to conventional buprenorphine induction. However, published regimens vary in duration, dosage forms used, and timing of full opioid agonist discontinuation. METHODS This cross-sectional survey study sought to determine how buprenorphine low-dosing is approached by medical institutions across the United States. The primary end point was characterization of inpatient buprenorphine low-dosing regimens. Situations and types of patients in which low-dosing is used and obstacles to institutional protocol development were also collected. An online survey was disseminated through professional pharmacy organizations and personal contacts. Responses were collected over 4 weeks. RESULTS Twenty-three unique protocols were collected from 25 institutions. Most protocols used buccal (8 protocols) or transdermal (8 protocols) buprenorphine as first doses before transitioning to sublingual buprenorphine. The most common starting doses were buprenorphine 20 μg/h transdermal, 150 μg buccal, and 0.5 mg sublingual. Patients unable to tolerate conventional buprenorphine induction or those who potentially used fentanyl nonmedically were most likely to be prescribed low-dosing. The most common obstacle to developing an internal low-dosing protocol was lack of existing consensus guidelines. CONCLUSIONS Similar to published regimens, internal protocols are variable. Buccal first doses may be used more commonly in practice based on survey results, while transdermal first doses are more commonly reported in publications. More research is needed to determine whether differences in starting formulations impact safety and efficacy of buprenorphine low-dosing in the inpatient setting.
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Affiliation(s)
- Monika Hardy
- From the Community Hospital of the Monterey Peninsula, Monterey, CA (MH); OhioHealth Grant Medical Center Columbus, OH (SG); OhioHealth Marion General Hospital Marion, OH (RO); and OhioHealth Research Institute Columbus, OH (MP)
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Noel M, Abbs E, Suen L, Samuel L, Dobbins S, Geier M, Soran CS. The Howard Street Method: A Community Pharmacy-led Low Dose Overlap Buprenorphine Initiation Protocol for Individuals Using Fentanyl. J Addict Med 2023; 17:e255-e261. [PMID: 37579105 DOI: 10.1097/adm.0000000000001154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
OBJECTIVES Buprenorphine treatment significantly reduces morbidity and mortality for people with opioid use disorder. Fear of precipitated withdrawal remains a barrier to starting buprenorphine for patients who use synthetic opioids, particularly fentanyl. We aim to evaluate the development and implementation of a buprenorphine low dose overlap initiation (LDOI) protocol in an urban public health community pharmacy. METHODS We performed a retrospective chart review of patients with nonprescribed fentanyl use (N = 27) to examine clinical outcomes of a buprenorphine LDOI schedule, named the Howard Street Method, dispensed from a community pharmacy in San Francisco from January to December 2020. RESULTS Twenty-seven patients were prescribed the Howard Street Method. Twenty-six patients picked up the prescription and 14 completed the protocol. Of those who completed the protocol, 11 (79%) reported no symptoms of withdrawal and 3 (21%) reported mild symptoms. Four patients (29%) reported cessation of full opioid agonist use and 10 (71%) reported reduction in their use by the end of the protocol. At 30 days, 12 patients (86%) were retained in care and 10 (71%) continued buprenorphine. At 180 days, 6 patients (43%) were retained in care and 2 (14%) were still receiving buprenorphine treatment. CONCLUSIONS We found that a LDOI blister-pack protocol based at a community pharmacy was a viable intervention for starting buprenorphine treatment and a promising alternative method for buprenorphine initiation in an underresourced, safety-net population of people using fentanyl.
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Affiliation(s)
- Marnie Noel
- From the San Francisco Department of Public Health, San Francisco, CA (MN, EA, LS, SD, MG); John Muir Behavioral Health Center, Concord, CA (MN); National Clinician Scholars Program, Philip R. Lee Institute for Health Policy, University of California, San Francisco, San Francisco, CA (LS); San Francisco Veteran Affairs Medical Center, San Francisco, CA (LS); and Division of General Internal Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, CA (CSS)
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Thakrar AP, Faude S, Perrone J, Milone MC, Lowenstein M, Snider CK, Spadaro A, Delgado MK, Nelson LS, Kilaru AS. Association of Urine Fentanyl Concentration With Severity of Opioid Withdrawal Among Patients Presenting to the Emergency Department. J Addict Med 2023; 17:447-453. [PMID: 37579106 PMCID: PMC10440418 DOI: 10.1097/adm.0000000000001155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
Abstract
BACKGROUND AND AIMS Fentanyl is involved in most US drug overdose deaths and its use can complicate opioid withdrawal management. Clinical applications of quantitative urine fentanyl testing have not been demonstrated previously. The aim of this study was to determine whether urine fentanyl concentration is associated with severity of opioid withdrawal. DESIGN This is a retrospective cross-sectional study. SETTING This study was conducted in 3 emergency departments in an urban, academic health system from January 1, 2020, to December 31, 2021. PARTICIPANTS This study included patients with opioid use disorder, detectable urine fentanyl or norfentanyl, and Clinical Opiate Withdrawal Scale (COWS) recorded within 6 hours of urine drug testing. MEASUREMENTS The primary exposure was urine fentanyl concentration stratified as high (>400 ng/mL), medium (40-399 ng/mL), or low (<40 ng/mL). The primary outcome was opioid withdrawal severity measured with COWS within 6 hours before or after urine specimen collection. We used a generalized linear model with γ distribution and log-link function to estimate the adjusted association between COWS and the exposures. FINDINGS For the 1127 patients in our sample, the mean age (SD) was 40.0 (10.7), 384 (34.1%) identified as female, 332 (29.5%) reported their race/ethnicity as non-Hispanic Black, and 658 (58.4%) reported their race/ethnicity as non-Hispanic White. For patients with high urine fentanyl concentrations, the adjusted mean COWS (95% confidence interval) was 4.4 (3.9-4.8) compared with 5.5 (5.1-6.0) among those with medium and 7.7 (6.8-8.7) among those with low fentanyl concentrations. CONCLUSIONS Lower urine fentanyl concentration was associated with more severe opioid withdrawal, suggesting potential clinical applications for quantitative urine measurements in evolving approaches to fentanyl withdrawal management.
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Affiliation(s)
- Ashish P. Thakrar
- Center for Addiction Medicine and Policy, Perelman School of Medicine, University of Pennsylvania
- National Clinician Scholars Program, University of Pennsylvania
| | - Sophia Faude
- Center for Addiction Medicine and Policy, Perelman School of Medicine, University of Pennsylvania
- Department of Emergency Medicine, Grossman School of Medicine, New York University Langone Health
| | - Jeanmarie Perrone
- Center for Addiction Medicine and Policy, Perelman School of Medicine, University of Pennsylvania
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania
| | - Michael C. Milone
- Center for Addiction Medicine and Policy, Perelman School of Medicine, University of Pennsylvania
- Department of Pathology and Laboratory Medicine, University of Pennsylvania
| | - Margaret Lowenstein
- Center for Addiction Medicine and Policy, Perelman School of Medicine, University of Pennsylvania
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania
| | - Christopher K. Snider
- Penn Medicine Center for Health Care Innovation, University of Pennsylvania, Philadelphia
| | - Anthony Spadaro
- Center for Addiction Medicine and Policy, Perelman School of Medicine, University of Pennsylvania
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania
| | - M. Kit Delgado
- Center for Addiction Medicine and Policy, Perelman School of Medicine, University of Pennsylvania
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania
| | - Lewis S. Nelson
- Center for Addiction Medicine and Policy, Perelman School of Medicine, University of Pennsylvania
- Department of Emergency Medicine, Rutgers New Jersey Medical School
| | - Austin S. Kilaru
- Center for Addiction Medicine and Policy, Perelman School of Medicine, University of Pennsylvania
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania
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Seval N, Nunez J, Roth PMD, Meredith S, Strong M, Frank CA, Litwin AH, Levin FR, Brady KT, Nunes EV, Springer SA. Inpatient Low-dose Transitions From Full Agonist Opioids Including Methadone Onto Long-acting Depot Buprenorphine: Case Series From a Multicenter Clinical Trial. J Addict Med 2023; 17:e232-e239. [PMID: 37579095 PMCID: PMC10368784 DOI: 10.1097/adm.0000000000001136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVES Persons with opioid use disorder (OUD) suffer disproportionately from morbidity and mortality related to serious addiction-related infections requiring hospitalization. Long-acting buprenorphine (LAB) is an underused medication for OUD that may facilitate linkage to care and treatment retention when administered before hospital discharge. Transition onto buprenorphine in the inpatient setting is often complicated by pain, active infection management, potential surgical interventions, and risk of opioid withdrawal in transition from full agonists to a partial agonist. METHODS The COMMIT Trial is a randomized controlled trial evaluating LAB administered by infectious disease physicians and hospitalists compared with treatment as usual for persons with OUD hospitalized with infections. We report a case series of participants on full agonist opioids including methadone who were transitioned to sublingual buprenorphine using low-dose ( microdosing ) strategies followed by LAB injection. RESULTS Seven participants with current opioid use disorder and life-threatening infections, all with significant concurrent pain and many requiring surgical intervention, underwent low-dose transitions starting at buccal buprenorphine doses ranging from 225 μg to 300 μg 3 times a day on the first day. All were well tolerated with average time to LAB injection of 7.5 days (range, 5-10 days). CONCLUSIONS Inpatient low-dose buprenorphine transition from full agonist opioids including methadone onto LAB is feasible even in those with complex hospitalizations for concurrent infections and/or surgery. This strategy facilitates dosing of LAB before hospital discharge when risk of opioid relapse and overdose are significant.
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Affiliation(s)
- Nikhil Seval
- Yale School of Medicine, Department of Internal Medicine, Section of Infectious Disease. Yale AIDS Program. New Haven, CT
| | - Johnathan Nunez
- Penn State Hershey College of Medicine and Milton S. Hershey Medical Center, Division of Infectious Diseases and Epidemiology, Department of Medicine. Hershey, PA
| | - Prerana MD Roth
- Prisma Health, Department of Internal Medicine, Addiction Medicine Center, Greenville, SC
| | - Schade Meredith
- Penn State Hershey College of Medicine and Milton S. Hershey Medical Center, Division of Infectious Diseases and Epidemiology, Department of Medicine. Hershey, PA
| | - Michelle Strong
- Prisma Health, Department of Internal Medicine, Addiction Medicine Center, Greenville, SC
| | - Cynthia A. Frank
- Yale School of Medicine, Department of Internal Medicine, Section of Infectious Disease. Yale AIDS Program. New Haven, CT
| | - Alain H. Litwin
- Prisma Health, Department of Internal Medicine, Addiction Medicine Center, Greenville, SC
- University of South Carolina School of Medicine – Greenville, Greenville, SC
| | - Frances R. Levin
- Columbia University Irving Medical Center, Department of Psychiatry and New York State Psychiatric Institute
| | - Kathleen T. Brady
- Medical University of South Carolina, Clinical Neuroscience Division, Department of Psychiatry and Behavioral Sciences. Charleston, SC
| | - Edward V. Nunes
- University of South Carolina School of Medicine – Greenville, Greenville, SC
| | - Sandra A. Springer
- Yale School of Medicine, Department of Internal Medicine, Section of Infectious Disease. Yale AIDS Program. New Haven, CT
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Ho JJ, Jones KF, Merlin JS, Sager Z, Childers J. Buprenorphine Initiation: Low-Dose Methods #457. J Palliat Med 2023; 26:867-869. [PMID: 37276524 DOI: 10.1089/jpm.2023.0047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023] Open
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Murray JP, Pucci G, Weyer G, Ari M, Dickson S, Kerins A. Low dose IV buprenorphine inductions for patients with opioid use disorder and concurrent pain: a retrospective case series. Addict Sci Clin Pract 2023; 18:38. [PMID: 37264449 DOI: 10.1186/s13722-023-00392-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Accepted: 05/19/2023] [Indexed: 06/03/2023] Open
Abstract
BACKGROUND Hospitalizations are a vital opportunity for the initiation of life-saving opioid agonist therapy (OAT) for patients with opioid use disorder. A novel approach to OAT initiation is the use of IV buprenorphine for low dose induction, which allows patients to immediately start buprenorphine at any point in a hospitalization without stopping full agonist opioids or experiencing significant withdrawal. METHODS This is a retrospective case series of 33 patients with opioid use disorder concurrently treated with full agonist opioids for pain who voluntarily underwent low dose induction at a tertiary academic medical center. Low dose induction is the process of initiating very low doses of buprenorphine at fixed intervals with gradual dose increases in patients who recently received or are simultaneously treated with full opioid agonists. Our study reports one primary outcome: successful completion of the low dose induction (i.e. transitioned from low dose IV buprenorphine to sublingual buprenorphine-naloxone) and three secondary outcomes: discharge from the hospital with buprenorphine-naloxone prescription, self-reported pain scores, and nursing-assessed clinical opiate withdrawal scale (COWS) scores over a 6-day period, using descriptive statistics. COWS and pain scores were obtained from day 0 (prior to starting the low dose induction) to day 5 to assess the effect on withdrawal symptoms and pain control. RESULTS Thirty patients completed the low dose induction (30/33, 90.9%). Thirty patients (30/33, 90.9%) were discharged with a buprenorphine prescription. Pain and COWS scores remained stable over the course of the study period. Mean COWS scores for all patients were 2.6 (SD 2.8) on day 0 and 1.6 (SD 2.6) on day 5. Mean pain scores for all patients were 4.4 (SD 2.1) on day 0 and 3.5 on day 5 (SD 2.1). CONCLUSIONS This study found that an IV buprenorphine low dose induction protocol was well-tolerated by a group of 33 hospitalized patients with opioid use disorder with co-occurring pain requiring full agonist opioid therapy. COWS and pain scores improved for the majority of patients. This is the first case series to report mean daily COWS and pain scores over an extended period throughout a low dose induction process.
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Affiliation(s)
- John P Murray
- Department of Medicine, University of Chicago, 5841 S Maryland Ave, Chicago, IL, 60637, USA.
| | - Geoffrey Pucci
- Department of Pharmacology, University of Chicago, 5841 S Maryland Ave, Chicago, IL, 60637, USA
| | - George Weyer
- Department of Medicine, University of Chicago, 5841 S Maryland Ave, Chicago, IL, 60637, USA
| | - Mim Ari
- Department of Medicine, University of Chicago, 5841 S Maryland Ave, Chicago, IL, 60637, USA
| | - Sarah Dickson
- Department of Medicine, University of Chicago, 5841 S Maryland Ave, Chicago, IL, 60637, USA
| | - Angela Kerins
- Department of Pharmacology, University of Chicago, 5841 S Maryland Ave, Chicago, IL, 60637, USA
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Lepore G, Morley-McLaughlin T, Davidson N, Han C, Masese C, Reynolds G, Saltz V, Robinson SA. Buprenorphine reduces somatic withdrawal in a mouse model of early-life morphine exposure. Drug Alcohol Depend 2023; 248:109938. [PMID: 37267743 DOI: 10.1016/j.drugalcdep.2023.109938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 05/10/2023] [Accepted: 05/11/2023] [Indexed: 06/04/2023]
Abstract
The rising prevalence of early-life opioid exposure has become a pressing public health issue in the U.S. Neonates exposed to opioids in utero are at risk of experiencing a constellation of postpartum withdrawal symptoms commonly referred to as neonatal opioid withdrawal syndrome (NOWS). Buprenorphine (BPN), a partial agonist at the mu-opioid receptor (MOR) and antagonist at the kappa-opioid receptor (KOR), is currently approved to treat opioid use disorder in adult populations. Recent research suggests that BPN may also be effective in reducing withdrawal symptoms in neonates who were exposed to opioids in utero. We sought to determine whether BPN attenuates somatic withdrawal in a mouse model of NOWS. Our findings indicate that the administration of morphine (10mg/kg, s.c.) from postnatal day (PND) 1-14 results in increased somatic symptoms upon naloxone-precipitated (1mg/kg, s.c.) withdrawal. Co-administration of BPN (0.3mg/kg, s.c.) from PND 12-14 attenuated symptoms in morphine-treated mice. On PND 15, 24h following naloxone-precipitated withdrawal, a subset of mice was examined for thermal sensitivity in the hot plate test. BPN treatment significantly increased response latency in morphine-exposed mice. Lastly, neonatal morphine exposure elevated mRNA expression of KOR, and reduced mRNA expression of corticotropin-releasing hormone (CRH) in the periaqueductal gray when measured on PND 14. Altogether, this data provides support for the therapeutic effects of acute low-dose buprenorphine treatment in a mouse model of neonatal opioid exposure and withdrawal.
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Affiliation(s)
- Gina Lepore
- Department of Systems Pharmacology and Translational Therapeutics. Perelman School of Medicine, University of PennsylvaniaPhiladelphiaPA19104, United States
| | | | - Natalie Davidson
- Department of Psychology, Williams CollegeWilliamsMA01267, United States
| | - Caitlin Han
- Department of Psychology, Williams CollegeWilliamsMA01267, United States
| | - Cynthia Masese
- Department of Psychology, Williams CollegeWilliamsMA01267, United States
| | - Grace Reynolds
- Department of Psychology, Williams CollegeWilliamsMA01267, United States
| | - Victoria Saltz
- Department of Psychology, Williams CollegeWilliamsMA01267, United States
| | - Shivon A Robinson
- Department of Psychology, Williams CollegeWilliamsMA01267, United States.
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18
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Faude S, Delgado MK, Perrone J, McFadden R, Xiong RA, O'Donnell N, Wood C, Solomon G, Lowenstein M. Variability in opioid use disorder clinical presentations and treatment in the emergency department: A mixed-methods study. Am J Emerg Med 2023; 66:53-60. [PMID: 36706482 PMCID: PMC10038883 DOI: 10.1016/j.ajem.2023.01.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 01/03/2023] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND There is strong evidence for emergency department (ED)-initiated treatment of opioid use disorder (OUD). However, implementation is variable, and ED management of OUD may differ by clinical presentation. Our aim was to use mixed methods to explore variation in ED-based OUD care by patient clinical presentation and understand barriers and facilitators to ED implementation of OUD treatment across scenarios. METHODS We analyzed treatment outcomes in OUD-related visits within three urban, academic EDs from 12/2018 to 7/2020 following the implementation of interventions to increase ED-initiated OUD treatment. We assessed differences in treatment with medications for OUD (MOUDs) by clinical presentation (overdose, withdrawal, others). These data were integrated with results from 5 focus groups conducted with 28 ED physicians and nurses January to April 2020 to provide a richer understanding of clinician perspectives on caring for ED patients with OUD. RESULTS Of the 1339 total opioid-related visits, there were 265 (20%) visits for overdose, 123 (9%) for withdrawal, and 951 (71%) for other OUD-related conditions. 23% of patients received MOUDs during their visit or at discharge. Treatment with MOUDs was least common in overdose presentations (6%) and most common in withdrawal presentations (69%, p < 0.001). Buprenorphine was prescribed at discharge in 15% of visits, including 42% of withdrawal visits, 14% of other OUD-related visits, and 5% of overdose visits (p < 0.001). In focus groups, clinicians highlighted variation in ED presentations among patients with OUD. Clinicians also highlighted key aspects necessary for successful treatment initiation including perceived patient receptivity, provider confidence, and patient clinical readiness. CONCLUSIONS ED-based treatment of OUD differed by clinical presentation. Clinician focus groups identified several areas where targeted guidance or novel approaches may improve current practices. These results highlight the need for tailored clinical guidance and can inform health system and policy interventions seeking to increase ED-initiated treatment for OUD.
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Affiliation(s)
- Sophia Faude
- Department of Emergency Medicine, Grossman School of Medicine, New York University Langone Health, New York, NY, United States of America
| | - M Kit Delgado
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States of America.
| | - Jeanmarie Perrone
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States of America.
| | - Rachel McFadden
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States of America.
| | - Ruiying Aria Xiong
- Division of General Internal Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States of America.
| | - Nicole O'Donnell
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States of America. Nicole.O'
| | - Christian Wood
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States of America.
| | - Gabrielle Solomon
- School of Arts and Sciences, University of Pennsylvania, Philadelphia, PA, United States of America.
| | - Margaret Lowenstein
- Division of General Internal Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States of America.
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Sanjanwala AR, Lim G, Krans EE. Opioids and Opioid Use Disorder in Pregnancy. Obstet Gynecol Clin North Am 2023; 50:229-240. [PMID: 36822706 DOI: 10.1016/j.ogc.2022.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
Overdose is a leading cause of pregnancy-associated morbidity and mortality in the United States. As such, all obstetric providers have a responsibility to provide evidence-based care for patients with opioid use disorder to mitigate adverse outcomes associated with substance use during pregnancy.
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Affiliation(s)
- Aalok R Sanjanwala
- Department of Obstetrics, Gynecology & Reproductive Sciences, Division of Maternal-Fetal Medicine, University of Pittsburgh School of Medicine, 300 Halket Street Pittsburgh, PA 15213, USA
| | - Grace Lim
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, 300 Halket Street, Pittsburgh, PA 15213, USA; Department of Obstetrics, Gynecology & Reproductive Sciences, University of Pittsburgh School of Medicine, 300 Halket Street, Pittsburgh, PA 15213, USA
| | - Elizabeth E Krans
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Pittsburgh School of Medicine, Magee-Womens Research Institute, 300 Halket Street, Pittsburgh, PA 15213, USA.
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48-hour Induction of Transdermal Buprenorphine to Sublingual Buprenorphine/Naloxone: The IPPAS Method. J Addict Med 2023; 17:233-236. [PMID: 36149002 DOI: 10.1097/adm.0000000000001072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Buprenorphine is an effective medication for the treatment of opioid use disorder. However, the traditional method of buprenorphine induction requires a period of abstinence and the development of at least moderate withdrawal, which can be barriers in starting treatment. We present the case of a hospitalized patient with opioid use disorder using unregulated fentanyl, who underwent a transdermal buprenorphine induction over 48 hours to initiate sublingual buprenorphine/naloxone on the third day. The patient experienced minimal levels of withdrawal and did not experience precipitated withdrawal. The ease of use of this novel induction method over previously published induction protocols can greatly improve the accessibility of buprenorphine for patients and healthcare staff.
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Wang J, Claman A, Singh S, Sidelnik SA, Arshed A. Best Practices in Substance Use Disorders to Achieve Treatment Equity in Consultation-Liaison Psychiatry. Psychiatr Ann 2023. [DOI: 10.3928/00485713-20230103-04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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22
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Neale KJ, Weimer MB, Davis MP, Jones KF, Kullgren JG, Kale SS, Childers J, Broglio K, Merlin JS, Peck S, Francis SY, Bango J, Jones CA, Sager Z, Ho JJ. Top Ten Tips Palliative Care Clinicians Should Know About Buprenorphine. J Palliat Med 2023; 26:120-130. [PMID: 36067137 DOI: 10.1089/jpm.2022.0399] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Pain management in palliative care (PC) is becoming more complex as patients survive longer with life-limiting illnesses and population-wide trends involving opioid misuse become more common in serious illness. Buprenorphine, a generally safe partial mu-opioid receptor agonist, has been shown to be effective for both pain management and opioid use disorder. It is critical that PC clinicians become comfortable with indications for its use, strategies for initiation while understanding risks and benefits. This article, written by a team of PC and addiction-trained specialists, including physicians, nurse practitioners, social workers, and a pharmacist, offers 10 tips to demystify buprenorphine use in serious illness.
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Affiliation(s)
- Kyle J Neale
- The Lois U and Harry R Horvitz Palliative Medicine Program, Department of Palliative Medicine and Supportive Care, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Melissa B Weimer
- Program in Addiction Medicine, Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Mellar P Davis
- Department of Palliative Care, Geisinger Medical Center, Danville, Pennsylvania, USA
| | | | - Justin G Kullgren
- Palliative Medicine Clinical Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Sachin S Kale
- Division of Palliative Medicine, Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Julie Childers
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Kathleen Broglio
- Section of Palliative Medicine, Geisel School of Medicine at Dartmouth, Collaboratory for Implementation Sciences at Dartmouth, Lebanon, New Hampshire, USA
| | - Jessica S Merlin
- Section of Palliative Care and Medical Ethics and Palliative Research Center, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Sarah Peck
- Division of Palliative Medicine, Emory University Healthcare Midtown, Atlanta, Georgia, USA
| | - Sheria Y Francis
- Collaborative Care Management, University of Pittsburgh Medical Center Presbyterian Shadyside, Pittsburgh, Pennsylvania, USA
| | | | - Christopher A Jones
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Zachary Sager
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - J Janet Ho
- Division of Palliative Medicine, University of California San Francisco, San Francisco, California, USA
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23
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Karavolis ZA, Roy PJ. Adapting low-dose buprenorphine induction to meet patient needs: A pilot study. DRUG AND ALCOHOL DEPENDENCE REPORTS 2022; 5:100104. [PMID: 36844162 PMCID: PMC9948859 DOI: 10.1016/j.dadr.2022.100104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 09/25/2022] [Accepted: 09/30/2022] [Indexed: 11/07/2022]
Abstract
Introduction Low-dose buprenorphine induction (LDBI) has been proposed to initiate buprenorphine in patients who are taking full opioid agonists in order to limit the risk of precipitated withdrawal. The objective of this study was to understand how real-world patient-specific adjustments in LDBI protocols impacted success rates in buprenorphine conversion. Methods This case series identified patients seen by the Addiction Medicine Consult Service at UPMC Presbyterian Hospital who were started on LDBI with transdermal buprenorphine followed by sublingual buprenorphine-naloxone between April 20, 2021, and July 20, 2021. The primary outcome was successful induction of sublingual buprenorphine. Characteristics of interest included total morphine milligram equivalents (MME) in the 24 hours prior to induction, MME during each day of induction, total time of induction, and final daily maintenance buprenorphine dose. Results Of the 21 patients included for analysis, 19 (91%) successfully completed LDBI and converted to a maintenance buprenorphine dose. Median (IQR) opioid analgesia utilization in the 24 hours prior to induction was 113 MME (63-166 MME) in the converted group and 83 MME (75-92 MME) in the group that did not convert. Conclusions Transdermal buprenorphine patch followed by sublingual buprenorphine-naloxone resulted in a high success rate for LDBI. Patient-specific adjustments may be considered in order to effect a high success rate of conversion.
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Affiliation(s)
- Zoe A. Karavolis
- UPMC, Pittsburgh, PA, United States,University of Pittsburgh, School of Pharmacy, Pittsburgh, PA, United States,Corresponding author at: 200 Lothrop St, Pittsburgh, PA 15213, United States.
| | - Payel J. Roy
- UPMC, Pittsburgh, PA, United States,University of Pittsburgh, School of Medicine, Pittsburgh, PA, United States
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Suen LW, Lee TG, Silva M, Walton P, Coffin PO, Geier M, Soran CS. Rapid Overlap Initiation Protocol Using Low Dose Buprenorphine for Opioid Use Disorder Treatment in an Outpatient Setting: A Case Series. J Addict Med 2022; 16:534-540. [PMID: 35149614 PMCID: PMC11006272 DOI: 10.1097/adm.0000000000000961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Fear and risk of precipitated withdrawal are barriers for initiating buprenorphine in individuals with opioid use disorder, particularly among those using fentanyl. A buprenorphine rapid overlap initiation (ROI) protocol (also knownas "rapidmicro-dosing") utilizing small, escalating doses of buprenorphine can overcome this barrier, reaching therapeutic doses in 3 to 4 days. We sought to demonstrate the feasibility of implementing a buprenorphine ROI protocol for buprenorphine initiation in the outpatient setting. METHODS We conducted a retrospective chart review of patients prescribed an outpatient ROI protocol at the Office-based Buprenorphine Induction Clinic from October to December 2020. The ROI protocol utilizes divided doses of sublingual buprenorphine tablets and blister packaging for easier dosing. Patients were not required to stop other opioid use and were advised to follow up on day 4 of initiation. RESULTS Twelve patients were included, of whom eleven (92%) were using fentanyl at intake. Eleven patients picked up their prescription. Seven patients returned for follow-up (58%), and all 7 completed the ROI protocol. One patient reported any withdrawal symptoms, which were mild. At 30 days, 7 patients (58%) were retained in care, and 5 (42%) were still receiving buprenorphine treatment, 4 (33%) of whom had been abstinent from nonprescribed opioid use for ≥2 weeks. CONCLUSIONS The ROI protocol was successful in initiating buprenorphine treatment for patients in our outpatient clinic, many of whom were using fentanyl. The ROI protocol may offer a safe alternative to traditional buprenorphine initiation and warrants further study.
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Affiliation(s)
- Leslie W Suen
- From the National Clinician Scholars Program, Philip R. Lee Institute for Health Policy, University of California, San Francisco, CA (LWS); San Francisco Veterans Affairs Medical Center, San Francisco, CA (LWS); San Francisco Department of Public Health, San Francisco, CA (TGL, PC, MG); Division of Substance Abuse and Addiction Medicine, San Francisco General Hospital, University of California, San Francisco, CA (MS, PW, CSS); Division of General Internal Medicine, San Francisco General Hospital, University of California, San Francisco, CA (CSS)
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Carswell N, Angermaier G, Castaneda C, Delgado F. Management of opioid withdrawal and initiation of medications for opioid use disorder in the hospital setting. Hosp Pract (1995) 2022; 50:251-258. [PMID: 35837678 DOI: 10.1080/21548331.2022.2102776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Opioid use disorder (OUD) has become increasingly prevalent among hospitalized patients in the United States and globally. As its prevalence increases, this provides a valuable opportunity for clinicians in the hospital setting to engage and initiate management and treatment of OUD. This article aims to provide hospitalists and other clinicians working in the hospital with a narrative review of the management of opioid withdrawal and the initiation of medications for opioid use disorder (MOUD) in the hospital and provide an update on a novel low dose approach to buprenorphine induction (also commonly referred to as the "microinduction" method). Management can initially include treating withdrawal symptoms with opioids as well as with a combination of non-opioid medications such as alpha 2 agonists, benzodiazepines, and/or antiemetics as needed. Besides simply managing withdrawal symptoms, clinicians can further improve the care of patients with OUD through initiating maintenance treatment with MOUD, ideally with opioids used in the initial management of withdrawal. Opioid detoxification is an inferior method of primary treatment and is associated with relapse and poor outcomes. In contrast, treatment with MOUD using methadone or buprenorphine is associated with superior treatment outcomes and reduced relapse compared to detoxification alone. Treatment with MOUD using methadone or buprenorphine can be successfully used in the hospital setting. A novel low dose approach to buprenorphine induction may be useful in minimizing precipitated withdrawals in patients who have recently used or received opioids, which makes this an attractive option in the hospital where patients are frequently on opioids for acutely painful conditions. The hospital setting also provides a valuable opportunity for clinicians to address harm reduction in patients with OUD. Finally, clinicians can improve the long-term outcomes of patients with OUD by ensuring a smooth discharge with adequate and timely follow-up.
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Affiliation(s)
- Nico Carswell
- Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
| | - Giselle Angermaier
- Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
| | - Christopher Castaneda
- Department of Psychiatry, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
| | - Fabrizzio Delgado
- Department of Psychiatry, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
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Buprenorphine precipitated opioid withdrawal: Prevention and management in the ED setting. Am J Emerg Med 2022; 58:22-26. [DOI: 10.1016/j.ajem.2022.05.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 05/05/2022] [Accepted: 05/07/2022] [Indexed: 01/19/2023] Open
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Kaliamurthy S, Jegede O, Hermes G. Community based buprenorphine micro-induction in the context of methadone maintenance treatment and fentanyl - Case report. J Addict Dis 2022; 41:175-180. [PMID: 35377273 DOI: 10.1080/10550887.2022.2051985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION The micro-induction method of initiating buprenorphine is becoming a popular method for initiating buprenorphine in patients with Opioid Use Disorder, who are on full opioid agonists, either prescribed or non-prescribed, in order to avoid precipitated withdrawal. Given the rising concerns around illicit fentanyl use, this method of initiating buprenorphine has become another tool for clinicians to help patients with Opioid Use Disorder, even when multiple full opioid agonists are involved. While the process for initiating buprenorphine through this process is well studied, the characteristics of patients who are able to tolerate this initiation method in an outpatient setting is not. CASE(S) We present the cases of two patients with Opioid Use Disorder in a community-based methadone maintenance program in whom micro-induction methods were used to initiate buprenorphine without lowering the methadone dose. Both patients successfully transitioned to buprenorphine without precipitated withdrawal. One of the patients was also using fentanyl at the time of induction and was able to abstain from fentanyl use following the induction process. CONCLUSION Initiating Buprenorphine using micro-induction strategies in a community based outpatient clinic in patients who are already on full opioid agonists is feasible, in these particular cases, the methadone dose or concurrent fentanyl use did not affect the outcome. We present the characteristics of the patient and the community clinic hoping that this helps more clinicians in replicating this induction strategy.
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Affiliation(s)
- Sivabalaji Kaliamurthy
- Department of Psychiatry, Yale University School of Medicine; APT Foundation, New Haven, CT, USA
| | - Oluwole Jegede
- Department of Psychiatry, Yale University School of Medicine; APT Foundation, New Haven, CT, USA
| | - Gretchen Hermes
- Department of Psychiatry, Yale University School of Medicine; APT Foundation, New Haven, CT, USA.,Yale Stress Center, New Haven, CT, USA
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Baumgartner K, Salmo E, Liss D, Devgun J, Mullins M, Galati B, Kelly J, Schwarz E. Transdermal buprenorphine for in-hospital transition from full agonist opioids to sublingual buprenorphine: a retrospective observational cohort study. Clin Toxicol (Phila) 2022; 60:688-693. [PMID: 35048759 DOI: 10.1080/15563650.2022.2028802] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Patients with opioid use disorder may have difficulty transitioning from full-agonist opioids to sublingual buprenorphine due to the risk of precipitated opioid withdrawal. Novel strategies have been developed to facilitate this transition, including the use of micro-dosing with transdermal buprenorphine. We began using a transdermal buprenorphine transition strategy at our hospital in 2019. METHODS We performed a retrospective observational cohort study of patients treated with transdermal buprenorphine to facilitate transition from full-agonist opioids (prescribed or recreational) while hospitalized between January 2019 and December 2020. Patients were excluded if transdermal buprenorphine was given for pain, if they did not receive at least one dose of sublingual buprenorphine while hospitalized, or if their clinical course precluded analysis of their tolerance of the transition protocol. Data on the doses and timing of medications, symptoms during transition, and hospital outcomes were abstracted from the electronic medical record. RESULTS We identified 41 cases that satisfied inclusion and exclusion criteria. Thirty-five cases involved a transition from medically indicated opioids; of these, 8 cases involved a transition from methadone. Six cases involved a transition from illicit opioids used prior to hospital presentation. For patient transitioning from medically indicated opioids, the median milligram morphine equivalent (MME) on the day prior to transdermal buprenorphine application was 63.8 (range 0-900, IQR 153.8) and the median MME on the day of transdermal buprenorphine application was 34.5 (range 0-600, IQR 65.3). The median initial dose of sublingual buprenorphine administered was 8 mg (range 2-8mg, IQR 6mg), the median total first-day dose was 16mg (range 2-24mg, IQR 16mg), and the median total daily dose on the last day of follow-up was 16mg (range 2-24mg, IQR 16mg). In 38 cases, patients completed the transition to sublingual buprenorphine and were still taking buprenorphine at the time they left the hospital. The transition protocol was fairly well-tolerated, with 59% of cases tolerating it well and 32% tolerating it fairly. DISCUSSION Our findings suggest that the use of transdermal buprenorphine to facilitate transition to sublingual buprenorphine is generally well-tolerated, and may be helpful in hospitalized patients. We identified several areas for improvement in future practice by reviewing the clinical courses of patients who tolerated transition poorly. Limitations of the study include its retrospective chart review design, the lack of a standardized transition protocol during the study period, and the lack of standardized data in the medical record regarding patients' tolerance of the transition protocol. Future research should include prospective studies using a standardized protocol and structured, pre-planned assessments of opioid withdrawal during the transition period. CONCLUSION The use of transdermal buprenorphine to facilitate induction of sublingual buprenorphine therapy in hospitalized patients with OUD was generally well-tolerated in this single-center retrospective observational study. Further prospective research is needed to demonstrate efficacy and optimize treatment protocols.
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Affiliation(s)
- Kevin Baumgartner
- Department of Emergency Medicine, Division of Medical Toxicology, Washington University School of Medicine, St. Louis, MO, USA
| | - Ellen Salmo
- Department of Emergency Medicine, Division of Medical Toxicology, Washington University School of Medicine, St. Louis, MO, USA
| | - David Liss
- Department of Emergency Medicine, Division of Medical Toxicology, Washington University School of Medicine, St. Louis, MO, USA
| | - Jason Devgun
- Department of Emergency Medicine, Division of Medical Toxicology, Washington University School of Medicine, St. Louis, MO, USA
| | - Michael Mullins
- Department of Emergency Medicine, Division of Medical Toxicology, Washington University School of Medicine, St. Louis, MO, USA
| | - Bridget Galati
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
| | - Jeannie Kelly
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Evan Schwarz
- Department of Emergency Medicine, Division of Medical Toxicology, Washington University School of Medicine, St. Louis, MO, USA
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Quirk K, Stevenson M. Buprenorphine Microdosing for the Pain and Palliative Care Clinician. J Palliat Med 2022; 25:145-154. [PMID: 34978915 DOI: 10.1089/jpm.2021.0378] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Buprenorphine (BUP) can be a safe and effective alternative to traditional opioids for many patients with chronic pain. For patients on higher doses of opioids, rotation to BUP is complicated by the requirement of an opioid-free interval or withdrawal during the transition. Microdosing inductions, in which BUP is gradually titrated, while full agonist opioids are continued, are a viable alternative to traditional inductions. The objective of this article is to review the current literature on BUP microdosing induction, with a focus on patients using opioids for pain. A literature review of the PubMed database was performed in the United States on articles published from inception to May 2021. A total of 34 publications were included. The most commonly utilized microdosing strategy involved administering divided doses of sublingual (SL) products marketed for opioid use disorder treatment, with 25 (73.5%) articles reporting use of partial SL tablets or films (ranging from 1/8 to 1/2 of a 2 mg product) at some point during the induction. Transdermal patches, low-dose SL BUP available in Europe, intravenous BUP, and buccal BUP have also been used. Beyond the products used, the speed of the microinduction, setting, final BUP dosing, and management of concomitant full agonists vary widely in the literature. Microdosing regimens should be individualized based on local guidelines and patient-specific factors. Further studies comparing the safety and efficacy of different protocols are warranted.
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Affiliation(s)
- Kyle Quirk
- Department of Palliative Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Maximillian Stevenson
- Department of Palliative Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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Abstract
Low dose buprenorphine initiation, is an alternative method of initiating buprenorphine in which the starting dose is very low and gradually increased to therapeutic levels over a period of days. This method takes advantage of slow displacement of the full opioid agonist from mu-opioid receptors, avoiding the need for a person with opioid use disorder to experience opioid withdrawal symptoms before initiating buprenorphine, while also minimizing the risk of precipitated opioid withdrawal. With this initiation method, full opioid agonists can be continued as buprenorphine is initiated, expanding the population to which buprenorphine can be offered. To date, the literature on low dose initiation is primarily case-based but rapidly growing. While evidence emerges, guidance for the use of low dose initiation is clearly desired and urgently needed in the context of an increasingly risky and contaminated opioid drug supply, particularly with high potency synthetic opioids, driving overdose deaths. Despite limited evidence, several principles to guide low dose initiation have been identified including: (1) choosing the appropriate clinical situation, (2) initiating at a low buprenorphine dose, (3) titrating the buprenorphine dose gradually, (4) continuing the full opioid agonist even if it is nonmedical, (5) communicating clearly with frequent monitoring, (6) pausing or delaying buprenorphine dose changes if opioid withdrawal symptoms occur, and (7) prioritizing care coordination. We review a practical approach to low dose initiation in hospital-based and outpatient settings guided by the current evidence.
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Synergistic Effect of Ketamine and Buprenorphine Observed in the Treatment of Buprenorphine Precipitated Opioid Withdrawal in a Patient With Fentanyl Use. J Addict Med 2021; 16:483-487. [PMID: 34789683 DOI: 10.1097/adm.0000000000000929] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Optimal treatment of buprenorphine precipitated opioid withdrawal (BPOW) is unclear. Full agonist treatment of BPOW is limited by buprenorphine's high-affinity blockade at mu-opioid receptors (μORs). Buprenorphine's partial agonism (low intrinsic efficacy) at μORs can limit the effectiveness of even massive doses once BPOW has begun. Adjunct medications, such as clonidine, are rarely effective in severe BPOW. Ketamine is an N-methyl-D-aspartate receptor antagonist with a potentially ideal pharmacologic profile for treatment of BPOW. Ketamine reduces opioid withdrawal symptoms independently of direct μOR binding, synergistically potentiates the effectiveness of buprenorphine μOR signaling, reverses (resensitizes) fentanyl induced μOR receptor desensitization, and inhibits descending pathways of hyperalgesia and central sensitization. Ketamine's rapid antidepressant effects potentially address depressive symptoms and subjective distress that often accompanies BPOW. Ketamine is inexpensive, safe, and available in emergency departments. To date, neither ketamine as treatment for BPOW nor to support uncomplicated buprenorphine induction has been described. CASE DESCRIPTION We report a case of an illicit fentanyl-using OUD patient who experienced severe BPOW during an outpatient low-dose cross taper buprenorphine induction (ie, "microdose"). The BPOW was successfully treated in the emergency department with a combination of ketamine (0.6 mg/kg intravenous over 1 hour) combined with high-dose buprenorphine (16 mg sublingual single dose); 3 days later he was administered a month-long dose of extended-release subcutaneous buprenorphine which was repeated monthly (300 mg). At 90 days the patient remained in treatment and reported continuous abstinence from fentanyl use. CONCLUSIONS This single case observation raises important questions about the potential therapeutic role of ketamine as a treatment for BPOW. BPOW is an important clinical problem for which there is currently only limited guidance and no universally accepted approach. Prospective study comparing the effectiveness of differing pharmacologic approaches to treat BPOW is urgently needed.
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De Aquino JP, Parida S, Avila-Quintero VJ, Flores J, Compton P, Hickey T, Gómez O, Sofuoglu M. Opioid-induced analgesia among persons with opioid use disorder receiving methadone or buprenorphine: A systematic review of experimental pain studies. Drug Alcohol Depend 2021; 228:109097. [PMID: 34601272 PMCID: PMC8595687 DOI: 10.1016/j.drugalcdep.2021.109097] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 09/10/2021] [Accepted: 09/17/2021] [Indexed: 01/25/2023]
Abstract
BACKGROUND Treating acute pain among persons with opioid use disorder (OUD) on opioid agonist therapy (OAT) is complex, and the therapeutic benefits of opioids remain unclear when weighted against their abuse potential and respiratory depressant effects. METHODS We conducted a systematic review of experimental pain studies examining opioid-induced analgesia among persons with OUD on OAT. We searched multiple databases from inception to July 30, 2021. Study quality was assessed by previously established validity measures. RESULTS Nine studies were identified, with a total of 225 participants, of whom 63% were male, and 37% were female. Six studies included methadone-maintained persons with OUD; four studies included buprenorphine-maintained persons with OUD; and three studies included healthy persons as comparison groups. Either additional doses of OAT or other opioids - morphine, oxycodone, hydromorphone, or remifentanil - were administered. In seven studies, persons with OUD on OAT did not experience analgesia, despite receiving opioid doses up to 20 times greater than those clinically used to treat severe pain among the opioid naïve. Conversely, in two studies, high-potency opioids did produce analgesia, albeit with greater abuse potential. Notably, persons with OUD on OAT remained vulnerable to respiratory depression. CONCLUSIONS Although persons with OUD on OAT can derive analgesic effects from opioids, high-potency compounds may be required to achieve clinically significant pain relief. Further, persons with OUD on OAT may remain vulnerable to opioid-induced abuse potential and respiratory depression. Together, these finding have clinical, methodological, and mechanistic implications for the treatment of acute pain in the context of OAT.
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Affiliation(s)
- Joao P De Aquino
- VA Connecticut Healthcare System, 950 Campbell Avenue, Building 36/116A4, West Haven, CT 06516, USA; Yale University School of Medicine, Department of Psychiatry, 300 George Street, New Haven, CT 06511, USA.
| | - Suprit Parida
- VA Connecticut Healthcare System, 950 Campbell Avenue, Building 36/116A4, West Haven, CT 06516, USA; Yale University School of Medicine, Department of Psychiatry, 300 George Street, New Haven, CT 06511, USA
| | - Victor J Avila-Quintero
- Yale University School of Medicine, Department of Psychiatry, 300 George Street, New Haven, CT 06511, USA
| | - Jose Flores
- Yale University School of Medicine, Department of Psychiatry, 300 George Street, New Haven, CT 06511, USA
| | - Peggy Compton
- Department of Family and Community Health, University of Pennsylvania, 418 Curie Boulevard, Room 402, Philadelphia, PA 19104, USA
| | - Thomas Hickey
- VA Connecticut Healthcare System, 950 Campbell Avenue, Building 36/116A4, West Haven, CT 06516, USA; Yale University School of Medicine, Department of Anesthesiology, 333 Cedar Street, New Haven, CT 06520, USA
| | - Oscar Gómez
- Department of Physiological Sciences, Faculty of Medicine, Pontificia Universidad Javeriana, 7th Street, 46-62, Bogota, Colombia
| | - Mehmet Sofuoglu
- VA Connecticut Healthcare System, 950 Campbell Avenue, Building 36/116A4, West Haven, CT 06516, USA; Yale University School of Medicine, Department of Psychiatry, 300 George Street, New Haven, CT 06511, USA
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Accurso AJ. Blister-Packing of 2 mg Buprenorphine Monoproduct as a Patient-Centered Method of Microdosing for Buprenorphine Induction. Clin Drug Investig 2021; 41:663-664. [PMID: 34125417 DOI: 10.1007/s40261-021-01048-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/26/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Anthony J Accurso
- Sunset Terrace Family Health Center at NYU Brooklyn, 514 49th Street, Brooklyn, NY, 11220, USA.
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