Whereas the initiation of buprenorphine for the therapy of opioid use disorder (OUD) within the emergency division (ED) is efficient in decreasing mortality and morbidity, there are limitations in each the timing and dose of buprenorphine after ED discharge.
Investigators, led by Andrew A. Herring, MD, Division of Emergency Medication, Highland Hospital — Alameda Well being System, examined the security and tolerability of an ED high-dose (>12 mg) buprenorphine induction for sufferers with OUD.
The workforce discovered the induction of high-dose buprenorphine was a protected and well-tolerated therapy in sufferers with untreated OUD, and didn’t end in elevated incidence of precipitated withdrawal or different adversarial occasion.
Investigators carried out a retrospective digital well being file (EHR) overview of sufferers aged ≥18 years handled with SL-buprenorphine at a big, city, security web ED in Oakland, California between January – December 2018.
Demographic info, together with self-reported race and ethnicity, was included within the evaluation to explain the demographic profile of sufferers receiving buprenorphine therapy within the ED.
The high-dose ED buprenorphine induction included a dose choice as much as 32 mg SL to elevated magnitude and length of opioid withdrawal suppression.
Additional, the collection of sufferers for high-dose buprenorphine induction (≥12 mg SL-buprenorphine) was decided primarily based on a affected person’s historical past, very important indicators, bodily examination findings, and analysis of complicating elements.
The workforce additionally used scoring programs such because the Medical Opioid Withdrawal Scale (COWS; gentle, 5-12; average, 13-24; extreme, >25).
Sufferers deemed clinically applicable for buprenorphine induction obtained an preliminary dose of 4 – 8 mg SL primarily based on stage of withdrawal, with reassessment in 30 – 45 minutes following.
Investigators famous doses ≤12 mg could possibly be administered to attain minimal to gentle withdrawal, with a COWS rating of <8.
As well as, sufferers with out medical issues, however boundaries to entry to buprenorphine after discharge have been provided the high-dose induction pathway.
The workforce famous the dosing could possibly be finished in increments of 4-8 mg, or the complete 24 mg without delay, relying on the affected person’s stage of withdrawal.
Major outcomes included the incidence of precipitated withdrawal and another critical adversarial occasion attributable to buprenorphine administration (sedation, decreased respiratory charge, hypoxia, naloxone rescue administration in ED or 24 hours after discharge).
Knowledge evaluation was carried out from April 2020 – March 2021.
A complete of 391 ED sufferers have been recognized as handled with SL-buprenorphine between January – December 2018 over a complete of 579 ED visits.
Demographic info included a median age of 36 years, 68.3% (n = 267) males, 43.5% (n = 170) Black and 14.6% (n = 57) have been Hispanic.
Additional, 22.5% of sufferers have been homeless (n = 88), with 41.2% (n = 161) of sufferers having a comorbid non-substance use-related psychiatric dysfunction. Over half (53.5%) of sufferers had by no means been handled with buprenorphine.
Investigators discovered there have been 366 (63.2%) high-dose inductions utilizing greater than 12 mg of SL-buprenorphine, together with 138 doses ≥28 mg.
The imply size of keep within the ED was 2.4 hours (1.6 – 3.75) and most sufferers have been assigned as low severity.
As well as, the workforce famous 5 circumstances of precipitated withdrawal, with 4 circumstances occurring after the standard dosing of 8 mg unrelated to high-dose buprenorphine.
They famous 3 life-threatening adversarial occasions requiring pressing intervention, however they have been decided to be unrelated to buprenorphine induction.
A complete of 45 contributors had return visits inside 24 hours of discharge, however investigators noticed no circumstances of precipitated withdrawal, opioid overdose, sedation, respiratory despair, or different adversarial occasion attributed to buprenorphine therapy.
Investigators concluded the high-dose buprenorphine therapy pathway was decided to be a protected and efficient technique of induction on the single, city ED.
“Our findings recommend that the high-dose induction pathway is protected, addresses withdrawal signs quickly, removes boundaries to short-term treatment entry, and extends the length of motion of buprenorphine, all of which supply substantial profit to the person and doubtlessly enhance follow-up,” investigators wrote.
The examine, “High-Dose Buprenorphine Induction in the Emergency Department for Treatment of Opioid Use Disorder,” was printed on-line in JAMA Community Open.