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Englander H, Thakrar AP, Bagley SM, Rolley T, Dong K, Hyshka E. Caring for Hospitalized Adults With Opioid Use Disorder in the Era of Fentanyl: A Review. JAMA Intern Med 2024:2818022. [PMID: 38683591 DOI: 10.1001/jamainternmed.2023.7282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/01/2024]
Abstract
Importance The rise of fentanyl and other high-potency synthetic opioids across US and Canada has been associated with increasing hospitalizations and unprecedented overdose deaths. Hospitalization is a critical touchpoint to engage patients and offer life-saving opioid use disorder (OUD) care when admitted for OUD or other medical conditions. Observations Clinical best practices include managing acute withdrawal and pain, initiating medication for OUD, integrating harm reduction principles and practices, addressing in-hospital substance use, and supporting hospital-to-community care transitions. Fentanyl complicates hospital OUD care. Fentanyl's high potency intensifies pain, withdrawal, and cravings and increases the risk for overdose and other harms. Fentanyl's unique pharmacology has rendered traditional techniques for managing opioid withdrawal and initiating buprenorphine and methadone inadequate for some patients, necessitating novel strategies. Further, co-use of opioids with stimulants drugs is common, and the opioid supply is unpredictable and can be contaminated with benzodiazepines, xylazine, and other substances. To address these challenges, clinicians are increasingly relying on emerging practices, such as low-dose buprenorphine initiation with opioid continuation, rapid methadone titration, and the use of alternative opioid agonists. Hospitals must also reconsider conventional approaches to in-hospital substance use and expand clinicians' understanding and embrace of harm reduction, which is a philosophy and set of practical strategies that supports people who use drugs to be safer and healthier without judgment, coercion, or discrimination. Hospital-to-community care transitions should ensure uninterrupted access to OUD care after discharge, which requires special consideration and coordination. Finally, improving hospital-based addiction care requires dedicated infrastructure and expertise. Preparing hospitals across the US and Canada to deliver OUD best practices requires investments in clinical champions, staff education, leadership commitment, community partnerships, quality metrics, and financing. Conclusions and Relevance The findings of this review indicate that fentanyl creates increased urgency and new challenges for hospital OUD care. Hospital clinicians and systems have a central role in addressing the current drug crisis.
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Affiliation(s)
- Honora Englander
- Section of Addiction Medicine in General Internal Medicine and the Division of Hospital Medicine, Department of Medicine, Oregon Health and Science University, Portland
| | - Ashish P Thakrar
- Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Sarah M Bagley
- Section of General Internal Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
| | | | - Kathryn Dong
- Department of Emergency Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Elaine Hyshka
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
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Weber AN, Trebach J, Brenner MA, Thomas MM, Bormann NL. Managing Opioid Withdrawal Symptoms During the Fentanyl Crisis: A Review. Subst Abuse Rehabil 2024; 15:59-71. [PMID: 38623317 PMCID: PMC11016949 DOI: 10.2147/sar.s433358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 04/05/2024] [Indexed: 04/17/2024] Open
Abstract
Illicitly manufactured fentanyl (IMF) is a significant contributor to the increasing rates of overdose-related deaths. Its high potency and lipophilicity can complicate opioid withdrawal syndromes (OWS) and the subsequent management of opioid use disorder (OUD). This scoping review aimed to collate the current OWS management of study populations seeking treatment for OWS and/or OUD directly from an unregulated opioid supply, such as IMF. Therefore, the focus was on therapeutic interventions published between January 2010 and November 2023, overlapping with the period of increasing IMF exposure. A health science librarian conducted a systematic search on November 13, 2023. A total of 426 studies were screened, and 173 studies were reviewed at the full-text level. Forty-nine studies met the inclusion criteria. Buprenorphine and naltrexone were included in most studies with the goal of transitioning to a long-acting injectable version. Various augmenting agents were tested (buspirone, memantine, suvorexant, gabapentin, and pregabalin); however, the liberal use of adjunctive medication and shortened timelines to initiation had the most consistently positive results. Outside of FDA-approved medications for OUD, lofexidine, gabapentin, and suvorexant have limited evidence for augmenting opioid agonist initiation. Trials often have low retention rates, particularly when opioid agonist washout is required. Neurostimulation strategies were promising; however, they were developed and studied early. Precipitated withdrawal is a concern; however, the rates were low and adequately mitigated or managed with low- or high-dose buprenorphine induction. Maintenance treatment continues to be superior to detoxification without continued management. Shorter induction protocols allow patients to initiate evidence-based treatment more quickly, reducing the use of illicit or non-prescribed substances.
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Affiliation(s)
| | - Joshua Trebach
- Department of Emergency Medicine, University of Iowa, Iowa City, IA, USA
| | - Marielle A Brenner
- Department of Emergency Medicine, University of Iowa, Iowa City, IA, USA
| | | | - Nicholas L Bormann
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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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] [What about the content of this article? (0)] [Affiliation(s)] [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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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 2024:01271255-990000000-00279. [PMID: 38329815 DOI: 10.1097/adm.0000000000001281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [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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Weimer MB, Herring AA, Kawasaki SS, Meyer M, Kleykamp BA, Ramsey KS. ASAM Clinical Considerations: Buprenorphine Treatment of Opioid Use Disorder for Individuals Using High-potency Synthetic Opioids. J Addict Med 2023; 17:632-639. [PMID: 37934520 DOI: 10.1097/adm.0000000000001202] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/30/2023]
Abstract
ABSTRACT Treatment of opioid use disorder (OUD) with buprenorphine has evolved considerably in the last decade as the scale of the OUD epidemic has increased along with the emergence of high-potency synthetic opioids (HPSOs) and stimulants in the drug supply. These changes have outpaced the development of prospective research, so a clinical consideration document based on expert consensus is needed to address pressing clinical questions. This clinical considerations document is based on a narrative literature review and expert consensus and will specifically address considerations for changes to the clinical practice of treatment of OUD with buprenorphine for individuals using HPSO. An expert panel developed 6 key questions addressing buprenorphine initiation, stabilization, and long-term treatment for individuals with OUD exposed to HPSO in various treatment settings. Broadly, the clinical considerations suggest that individualized strategies for buprenorphine initiation may be needed. The experience of opioid withdrawal negatively impacts the success of buprenorphine treatment, and attention to its management before and during buprenorphine initiation should be proactively addressed. Buprenorphine dose and dosing frequency should be individualized based on patients' treatment needs, the possibility of novel components in the drug supply should be considered during OUD treatment, and all forms of opioid agonist treatment should be offered and considered for patients. Together, these clinical considerations attempt to be responsive to the challenges and opportunities experienced by frontline clinicians using buprenorphine for the treatment of OUD in patients using HPSOs and highlight areas where prospective research is urgently needed.
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Affiliation(s)
- Melissa B Weimer
- From the Yale School of Medicine, Program in Addiction Medicine, New Haven, CT (MBW); Yale School of Public Health, New Haven, CT (MBW); Division of Addiction Medicine, Highland Hospital-Alameda Health System, Oakland, CA (AAH); Department of Psychiatry and Internal Medicine, Penn State Health, Hershey, PA (SSK); University of Vermont, Burlington, VT (MM); BAK and Associates, Baltimore, MD (BAK); NYS Office of Addiction Services and Supports (OASAS), Albany, NY (KSR)
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French R, McFadden R, Stewart R, Christian H, Compton P. "I Just Need Proper Treatment": Being Hospitalized for Endocarditis among Individuals Who Inject Drugs Being Hospitalized for Endocarditis. J Gen Intern Med 2023; 38:2470-2477. [PMID: 36941420 PMCID: PMC10465454 DOI: 10.1007/s11606-023-08133-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 03/01/2023] [Indexed: 03/23/2023]
Abstract
BACKGROUND Rates of hospitalization for injection drug use-associated infective endocarditis (IDU-IE) are increasing. Much is known about the poor outcomes of patients with IDU-IE; less is known about the patient experience during hospitalization. OBJECTIVE To explore the experience of being hospitalized for endocarditis among individuals who inject drugs, providing a foundation on which to develop strategies to improve care for these patients. DESIGN Qualitative interviews with hospitalized patients undergoing cardiothoracic surgery with a history of injection drug use between February 2021 and May 2022 at the Hospital of the University of Pennsylvania. PARTICIPANTS Cardiothoracic surgery patients with a documented history of injection drug use and the ability to speak English were recruited during their hospital stay. APPROACH Thematic analysis of interviews guided by phenomenology and harm reduction theory was used to identify recurrent themes. Interviews were digitally recorded and transcribed and analyzed using NVIVO software. KEY RESULTS Interviews from 13 participants resulted in four major themes around Hospital Experience: (1) Kindness as an Antidote to Dehumanizing Treatment; (2) Relationships with the Care Team; (3) Withdrawal and Pain Management; and (4) Anticipating and Experiencing the Transition out the Hospital. Participants recounted long histories of dehumanizing care during previous hospitalizations, noted the value of open, sincere, and non-judgmental communication with clinical teams, expressed overall satisfaction with the management of their symptoms during the current hospitalization, reported self-discharging during previous hospitalizations due to undertreated pain and withdrawal, and noted significant challenges around discharge planning and execution. CONCLUSIONS Participants noted structural (e.g., discharge planning) and interpersonal (e.g., stigma from care team) barriers to quality hospital care. They also noted that expressions of kindness from hospital staff were meaningful and comforting. Patients with IDU-IE face multi-dimensional challenges in the hospital. Their perspectives can meaningfully inform programs and initiatives to improve their outcomes and support recovery.
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Affiliation(s)
- Rachel French
- University of Pennsylvania School of Nursing, Philadelphia, PA, 19104, USA.
| | - Rachel McFadden
- Hospital of the University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Rebecca Stewart
- Center for Mental Health, University of Pennsylvania School of Medicine, Philadelphia, PA, 19104, USA
| | - Hanna Christian
- Center for Mental Health, University of Pennsylvania School of Medicine, Philadelphia, PA, 19104, USA
| | - Peggy Compton
- University of Pennsylvania School of Nursing, Philadelphia, PA, 19104, USA
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Sokolski E, Skogrand E, Goff A, Englander H. Rapid Low-dose Buprenorphine Initiation for Hospitalized Patients With Opioid Use Disorder. J Addict Med 2023; 17:e278-e280. [PMID: 37579112 DOI: 10.1097/adm.0000000000001133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Low-dose buprenorphine initiation allows patients to start buprenorphine for treatment of opioid use disorder (OUD) while continuing full-agonist opioids. This strategy is beneficial for hospitalized patients who may have acute pain and are not able to tolerate withdrawal. However, most protocols require 7-10 to complete, which may create barriers in patients with shorter or unpredictable lengths of stay. OBJECTIVE This cohort study examined the efficacy and feasibility of a rapid low-dose buprenorphine initiation protocol in the hospital setting. METHODS We performed a retrospective cohort study of hospitalized patients with OUD (diagnosed by DSM-5 criteria) seen by an addiction medicine consult service at a single academic medical center who started buprenorphine via a rapid low-dose initiation between November 2021 and May 2022. Patients were prospectively tracked using an electronic registry, and data were abstracted from the electronic health record. RESULTS Twenty-four patients underwent rapid low-dose initiation during the study period. All patients received full-agonist opioids before starting buprenorphine. Thirteen (54%) patients reported using fentanyl, with 5 patients reported endorsing use within 48 hours preceding buprenorphine initiation. Nineteen (79%) patients completed initiation with an average time to completion of 72 hours. Among patients who reported fentanyl use in the 48 hours before starting buprenorphine, 60% completed initiation and 40% elected to transition to methadone. No patients experienced precipitated withdrawal. CONCLUSIONS Rapid low-dose buprenorphine initiation provides a feasible and well-tolerated alternative to traditional and slower low-dose initiations for hospitalized patients.
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Affiliation(s)
- Eleasa Sokolski
- From the Section of Addiction Medicine, Division of General Internal Medicine and Geriatrics, Department of Medicine, Oregon Health and Science University, Portland, OR (E Sokolski, AG, HE); Department of Pharmacy Services, Oregon Health and Science University, Portland, OR (E Skogrand); and Division of Hospital Medicine, Department of Medicine, Section of Addiction Medicine, Oregon Health and Science University, Portland, OR (HE)
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Adams KK, Cohen SM, Guerra ME, Weimer MB. Low-dose Initiation of Buprenorphine in Hospitalized Patients Using Buccal Buprenorphine: A Case Series. J Addict Med 2023; 17:474-476. [PMID: 37579114 DOI: 10.1097/adm.0000000000001146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
OBJECTIVE To describe a low-dose buprenorphine initiation strategy with buccal buprenorphine. METHODS This is a case series of hospitalized patients with opioid use disorder (OUD) and/or chronic pain who underwent low-dose buprenorphine initiation with buccal buprenorphine to sublingual buprenorphine. Results are descriptively reported. RESULTS Forty-five patients underwent low-dose buprenorphine initiation from January 2020 to July 2021. Twenty-two (49%) patients had OUD only, 5 (11%) patients had chronic pain only, and 18 (40%) patients had both OUD and chronic pain. Thirty-six (80%) patients had documented history of heroin or non-prescribed fentanyl use before admission. Acute pain in 34 (76%) patients was the most commonly documented rationale for low-dose buprenorphine initiation. Methadone was the most common outpatient opioid utilized before admission (53%). The addiction medicine service consulted on 44 (98%) cases and median length of stay was approximately 2 weeks. Thirty-six (80%) patients completed the transition to sublingual buprenorphine with a median completion dose of 16 mg daily. Of the 24 patients (53%) with consistently documented Clinical Opiate Withdrawal Scale scores, no patients experienced severe opioid withdrawal. Fifteen (62.5%) experienced mild or moderate withdrawal and 9 (37.5%) experienced no withdrawal (Clinical Opiate Withdrawal Scale score <5) during the entire process. Continuity of postdischarge prescription refills ranged from 0 to 37 weeks and the median number of buprenorphine refills was 7 weeks. CONCLUSIONS Low-dose buprenorphine initiation with buccal buprenorphine to sublingual buprenorphine was well tolerated and can be safely and effectively utilized for patients whose clinical scenario precludes traditional buprenorphine initiation strategies.
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Affiliation(s)
- Kathleen K Adams
- From the Department of Pharmacy Practice, University of Connecticut School of Pharmacy (KKA); Program in Addiction Medicine, Section of General Internal Medicine, Yale School of Medicine (SMC, MBW); and Department of Pharmacy Services, Yale New Haven Hospital Pharmacy Services (MEG)
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Vogel M, Dürsteler KM, Dürsteler KM. Buprenorphine Induction: Just a Piece of the Puzzle. J Addict Med 2023; 17:494-495. [PMID: 37579122 DOI: 10.1097/adm.0000000000001144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Daniulaityte R, Nahhas RW, Silverstein S, Martins S, Carlson RG. Trajectories of non-prescribed buprenorphine and other opioid use: A multi-trajectory latent class growth analysis. J Subst Use Addict Treat 2023; 147:208973. [PMID: 36804351 PMCID: PMC10044504 DOI: 10.1016/j.josat.2023.208973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 09/26/2022] [Accepted: 01/31/2023] [Indexed: 02/11/2023]
Abstract
INTRODUCTION With the increasing use of non-prescribed buprenorphine (NPB), we need more data to identify the longitudinal patterns of NPB use. The goal of this natural history study is to characterize heterogeneity in trajectories of NPB, other opioid use, and participation in medication for opioid disorder (MOUD) treatment among a community-recruited sample of individuals with current opioid use disorder (OUD). METHODS The study recruited a community-based sample of 357 individuals with OUD who used NPB in the past 6 months in Ohio, United States, for baseline and follow-up assessments (every 6 months for 2 years) of drug use, treatment participation, and other health and psychosocial characteristics. The study used multiple imputation to handle missing data. We used a multi-trajectory latent class growth analysis (MT-LCGA) to find salient groupings of participants based on the trajectories of NPB, other opioid use, and treatment participation. RESULTS Over time, NPB use frequency declined from a mean of 14.6 % of days at baseline to 3.6 % of days at 24-month follow-up along with declines in heroin/fentanyl (56.4 % to 23.6 % of days) and non-prescribed pharmaceutical opioid (NPPO) use (11.6 % to 1.5 % of days). Participation in MOUD treatment increased from a mean of 17.0 % of days at baseline to 52.4 % of days at 24 months. MT-LCGA identified a 6-class model. All six classes showed declines in NPB use. Class 1 (28 %) was characterized by high and increasing MOUD treatment utilization. Class 2 (21 %) showed sustained high levels of heroin/fentanyl use and had the lowest levels of NPB use (2.2 % of days) at baseline. Class 3 (3 %) was characterized as the primary NPPO use group. Class 4 (5 %) transitioned from high levels of NPB use to increased MOUD treatment utilization. It had the highest levels of NPB use at baseline (average of 80.7 % of days) that decreased to an average of 12.9 % of days at 24 months. Class 5 (16 %) showed transition from high levels of heroin/fentanyl use to increased MOUD treatment utilization. Class 6 (27 %) showed decreased heroin/fentanyl use over time and low MOUD treatment utilization. Classes showed varying levels of improvement in psychosocial functioning, polydrug use, and overdose risks. CONCLUSION Overall, our findings suggest that NPB use was generally self-limiting with individuals reducing their use over time as some engage in greater utilization of MOUD treatment. A need exists for continuing improvements in MOUD treatment access and retention.
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Affiliation(s)
- Raminta Daniulaityte
- College of Health Solutions, Arizona State University, Phoenix, AZ, United States of America.
| | - Ramzi W Nahhas
- Department of Population and Public Health Sciences, Boonshoft School of Medicine, Wright State University, United States of America; Department of Psychiatry, Boonshoft School of Medicine, Wright State University, United States of America
| | - Sydney Silverstein
- Department of Population and Public Health Sciences, Boonshoft School of Medicine, Wright State University, United States of America
| | - Silvia Martins
- Department of Epidemiology Columbia University Mailman School of Public Health, United States of America
| | - Robert G Carlson
- Department of Population and Public Health Sciences, Boonshoft School of Medicine, Wright State University, United States of America
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Dunn KE. Iteration is not solving the opioid crisis, it's time for transformation. Am J Drug Alcohol Abuse 2023; 49:151-158. [PMID: 36920881 DOI: 10.1080/00952990.2023.2170807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
Opioid use disorder (OUD) produces exceedingly high rates of morbidity and mortality in the United States and throughout the world. Almost 90% of persons qualifying for treatment do not enter treatment and 72% of those who initiate treatment leave within 60 days. This Perspective posits that over the past decade our OUD treatment system has produced only small iterative gains in treatment access because, in part, it is founded in a series of top-down regulatory policies dating back more than 100 years. These policies prioritized restricting persons with OUD from having access to opioid agonists over empirical discovery of treatment best practice. It further suggests that for persons who are not already responding positively to our existing treatments, we may need to fundamentally transform care to enact true, meaningful change. Four potential considerations are outlined: expanding beyond long-acting opioids for treatment, embracing safe use as a viable therapeutic target, ending closed medication distribution systems, and partnering with our patients. The overarching aim of this discussion is to motivate broader thinking about new solutions for the patients for whom the existing strategies are not working and who may benefit from more transformative approaches. Though efforts to-date to expand existing treatment systems and find new ways to promote existing MOUDs have been important, these efforts have represented iterative changes. For us to meet our goal of substantially reducing opioid-related harms, it may be time to consider strategies that represent true transformation.
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Affiliation(s)
- Kelly E Dunn
- Department of Psychiatry and Behavioral Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Englander H, Gregg J, Levander XA. Envisioning Minimally Disruptive Opioid Use Disorder Care. J Gen Intern Med 2023; 38:799-803. [PMID: 36401107 PMCID: PMC9676870 DOI: 10.1007/s11606-022-07939-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 11/04/2022] [Indexed: 11/21/2022]
Abstract
Most people who need and want treatment for opioid addiction cannot access it. Among those who do get treatment, only a fraction receive evidence-based, life-saving medications for opioid use disorder (MOUD). MOUD access is not simply a matter of needing more clinicians or expanding existing treatment capacity. Instead, many facets of our health systems and policies create unwarranted, inflexible, and punitive practices that create life-threatening barriers to care. In the USA, opioid use disorder care is maximally disruptive. Minimally disruptive medicine (MDM) is a framework that focuses on achieving patient goals while imposing the smallest possible burden on patients' lives. Using MDM framing, we highlight how current medical practices and policies worsen the burden of treatment and illness, compound life demands, and strain resources. We then offer suggestions for programmatic and policy changes that would reduce disruption to the lives of those seeking care, improve health care quality and delivery, begin to address disparities and inequities, and save lives.
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Affiliation(s)
- Honora Englander
- Section of Addiction Medicine in Division of General Internal Medicine & Geriatrics, Department of Medicine, Oregon Health & Science University, Portland, OR, USA. .,Division of Hospital Medicine, Department of Medicine, Oregon Health & Science University, Portland, OR, USA.
| | | | - Ximena A Levander
- Section of Addiction Medicine in Division of General Internal Medicine & Geriatrics, Department of Medicine, Oregon Health & Science University, Portland, OR, USA
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Reed MK, Murali V, Sarpoulaki N, Zavodnick JH, Hom JK, Rising KL. Hospitalist perspectives on buprenorphine treatment for inpatients with opioid use disorder. Drug Alcohol Depend Rep 2022; 5:100106. [PMID: 36844165 PMCID: PMC9948932 DOI: 10.1016/j.dadr.2022.100106] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 09/30/2022] [Accepted: 09/30/2022] [Indexed: 11/05/2022]
Abstract
Background Patients with opioid use disorder (OUD) have high hospital admission rates. Hospitalists, clinicians that work in inpatient medical settings, may have a unique opportunity to intervene on behalf of these patients, yet their experience with and attitudes towards treating patients with OUD need further exploration. Methods We conducted qualitative analysis of 22 semi-structured interviews with hospitalists between January and April 2021 in Philadelphia, PA. Participants were hospitalists in one major metropolitan university hospital and one urban community hospital in a city with a high prevalence of OUD and overdose deaths. Participants were asked about their experiences, successes, and difficulties in treating hospitalized patients with OUD. Results Twenty-two hospitalists were interviewed. Participants were majority female (14, 64%) and White (16, 73%). We identified the following common themes: lack of training/experience with OUD, a lack of community OUD treatment infrastructure, a lack of inpatient OUD/withdrawal treatment resources, the "X-waiver" as a barrier to prescribing buprenorphine, the "ideal" patient to start on buprenorphine, and the hospital as an ideal intervention setting. Conclusions Hospitalization due to acute illness or complication of drug use represents a potential intervention point to initiate treatment for patients with OUD. While hospitalists exhibit willingness to prescribe medications, provide harm reduction education, and link patients to outpatient addiction treatment, they identify training and infrastructure barriers that must first be addressed.
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Affiliation(s)
- Megan K Reed
- Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, 1015 Walnut Street, Curtis Building, Suite 704, Philadelphia, PA 19107, United States,Center for Connected Care, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, United States,College of Population Health, Thomas Jefferson University, Philadelphia, PA, United States,Corresponding author at: Thomas Jefferson University, 1015 Walnut Street, Curtis Building, Suite 704, Philadelphia, PA 19107, United States.
| | - Vignesh Murali
- Center for Connected Care, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, United States
| | - Nazanin Sarpoulaki
- Center for Connected Care, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, United States
| | - Jillian H. Zavodnick
- Department of Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, United States
| | - Jeffrey K. Hom
- Division of Substance Use Prevention and Harm Reduction, Philadelphia Department of Public Health, PA, United States
| | - Kristin L Rising
- Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, 1015 Walnut Street, Curtis Building, Suite 704, Philadelphia, PA 19107, United States,Center for Connected Care, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, United States,College of Nursing, Thomas Jefferson University, Philadelphia, PA, USA
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Affiliation(s)
- Ashish P Thakrar
- National Clinician Scholars Program at the Corporal Michael J. Crescenz Veterans Affairs Medical Center, University of Pennsylvania, PA, USA.,Division of Addiction Medicine, Department of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
| | - Robert A Kleinman
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
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Schoenfeld EM, Westafer LM, Beck SA, Potee BG, Vysetty S, Simon C, Tozloski JM, Girardin AL, Soares WE. "Just give them a choice": Patients' perspectives on starting medications for opioid use disorder in the ED. Acad Emerg Med 2022; 29:928-943. [PMID: 35426962 PMCID: PMC9378535 DOI: 10.1111/acem.14507] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 04/11/2022] [Accepted: 04/12/2022] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Medications for opioid use disorder (MOUD) prescribed in the emergency department (ED) have the potential to save lives and help people start and maintain recovery. We sought to explore patient perspectives regarding the initiation of buprenorphine and methadone in the ED with the goal of improving interactions and fostering shared decision making (SDM) around these important treatment options. METHODS We conducted semistructured interviews with a purposeful sample of people with opioid use disorder (OUD) regarding ED visits and their experiences with MOUD. The interview guide was based on the Ottawa Decision Support Framework, a framework for examining decisional needs and tailoring decisional support, and the research team's experience with MOUD and SDM. Interviews were recorded, transcribed, and analyzed in an iterative process using both the Ottawa Framework and a social-ecological framework. Themes were identified and organized and implications for clinical care were noted and discussed. RESULTS Twenty-six participants were interviewed, seven in person in the ED and 19 via video conferencing software. The majority had tried both buprenorphine and methadone, and almost all had been in an ED for an issue related to opioid use. Participants reported social, pharmacological, and emotional factors that played into their decision making. Regarding buprenorphine, they noted advantages such as its efficacy and logistical ease and disadvantages such as the need to wait to start it (risk of precipitated withdrawal) and that one could not use other opioids while taking it. Additionally, participants felt that: (1) both buprenorphine and methadone should be offered; (2) because "one person's pro is another person's con," clinicians will need to understand the facets of the options; (3) clinicians will need to have these conversations without appearing judgmental; and (4) many patients may not be "ready" for MOUD, but it should still be offered. CONCLUSIONS Although participants were supportive of offering buprenorphine in the ED, many felt that methadone should also be offered. They felt that treatment should be tailored to an individual's needs and circumstances and clarified what factors might be important considerations for people with OUD.
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Affiliation(s)
- Elizabeth M. Schoenfeld
- Department of Emergency Medicine UMASS Chan Medical School–Baystate Springfield Massachusetts USA
- Department for Healthcare Delivery and Population Science UMASS Chan Medical School–Baystate Springfield Massachusetts USA
| | - Lauren M. Westafer
- Department of Emergency Medicine UMASS Chan Medical School–Baystate Springfield Massachusetts USA
- Department for Healthcare Delivery and Population Science UMASS Chan Medical School–Baystate Springfield Massachusetts USA
| | | | | | - Sravanthi Vysetty
- Lincoln Memorial University DeBusk College of Osteopathic Medicine Harrogate Tennessee USA
| | - Caty Simon
- Urban Survivors Union Greensboro North Carolina USA
- Whose Corner Is It Anyway Holyoke Massachusetts USA
| | - Jillian M. Tozloski
- Department of Emergency Medicine UMASS Chan Medical School–Baystate Springfield Massachusetts USA
| | - Abigail L. Girardin
- Department of Emergency Medicine UMASS Chan Medical School–Baystate Springfield Massachusetts USA
| | - William E. Soares
- Department of Emergency Medicine UMASS Chan Medical School–Baystate Springfield Massachusetts USA
- Department for Healthcare Delivery and Population Science UMASS Chan Medical School–Baystate Springfield Massachusetts USA
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