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Spadaro A, Faude S, Perrone J, Thakrar AP, Lowenstein M, Delgado MK, Kilaru AS. Precipitated opioid withdrawal after buprenorphine administration in patients presenting to the emergency department: A case series. J Am Coll Emerg Physicians Open 2023; 4:e12880. [PMID: 36704210 PMCID: PMC9871399 DOI: 10.1002/emp2.12880] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Objectives Buprenorphine is a highly effective medication for the treatment of opioid use disorder, but it can cause precipitated withdrawal (PW) from opioids. Incidence, risk factors, and best approaches to management of PW are not well understood. Our objective was to describe adverse outcomes after buprenorphine administration among emergency department (ED) patients and assess whether they met the criteria for PW. Methods This study is a case series using retrospective chart review in a convenience sample of patients from 3 hospitals in an urban academic health system. This study included patients who were reported by clinicians as potential cases of PW. Relevant clinical data were abstracted from the electronic health record using a structured retrospective chart review instrument. Results A total of 13 cases were included and classified into the following 3 categories: (1) PW after buprenorphine administration consistent with guidelines (n = 5), (2) PW after deviating from guidelines (n = 4), and (3) protracted opioid withdrawal with no increase in Clinical Opiate Withdrawal Scale score (n = 4). A total of 11 patients had urine drug testing positive for fentanyl, and 11 patients received additional doses of buprenorphine for symptom management. Of the patients, 5 had self-directed hospital discharges, and 6 were ultimately discharged with prescriptions for buprenorphine. Conclusions Cases of adverse outcomes after buprenorphine administration in the ED and hospital meet criteria for PW, although some cases may have represented protracted opioid withdrawal. Further investigation into the incidence, risk factors, management of PW as well as patient perspectives is needed to expand and sustain the use of buprenorphine in EDs and hospitals.
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Affiliation(s)
- Anthony Spadaro
- Center for Addiction Medicine and PolicyPerelman School of Medicine, University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Center for Emergency Care Policy and ResearchDepartment of Emergency Medicine, Perelman School of Medicine, University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Sophia Faude
- Center for Addiction Medicine and PolicyPerelman School of Medicine, University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Center for Emergency Care Policy and ResearchDepartment of Emergency Medicine, Perelman School of Medicine, University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Department of Emergency MedicineGrossman School of Medicine, New York University Langone Health, New York, New York, USA
| | - Jeanmarie Perrone
- Center for Addiction Medicine and PolicyPerelman School of Medicine, University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Center for Emergency Care Policy and ResearchDepartment of Emergency Medicine, Perelman School of Medicine, University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Ashish P. Thakrar
- Center for Addiction Medicine and PolicyPerelman School of Medicine, University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- National Clinician Scholars ProgramUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Margaret Lowenstein
- Center for Addiction Medicine and PolicyPerelman School of Medicine, University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Division of General Internal MedicineDepartment of Medicine, Perelman School of Medicine, University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - M. Kit Delgado
- Center for Addiction Medicine and PolicyPerelman School of Medicine, University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Center for Emergency Care Policy and ResearchDepartment of Emergency Medicine, Perelman School of Medicine, University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Austin S. Kilaru
- Center for Addiction Medicine and PolicyPerelman School of Medicine, University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Center for Emergency Care Policy and ResearchDepartment of Emergency Medicine, Perelman School of Medicine, University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
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Hassman H, Strafford S, Shinde SN, Heath A, Boyett B, Dobbins RL. Open-label, rapid initiation pilot study for extended-release buprenorphine subcutaneous injection. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2023; 49:43-52. [PMID: 36001871 DOI: 10.1080/00952990.2022.2106574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
Background: For patients with opioid use disorder, buprenorphine extended-release injection (BUP-XR) achieves sustained therapeutic plasma concentrations, controls craving and withdrawal symptoms, and improves patient outcomes. Given retention challenges during transmucosal buprenorphine (BUP-TM) induction, assessing methods to quickly achieve sustained buprenorphine concentrations is important.Objectives: This open-label, single-group, single-center pilot study (NCT03993392) evaluated safety and tolerability of initiating BUP-XR following a single BUP-TM 4 mg dose.Methods: Eligible participants abstained from short and long-acting opioids for 6 and 24 hours, respectively. If the Clinical Opiate Withdrawal Scale (COWS) was ≥8, BUP-TM 4 mg was administered. Participants not exhibiting hypersensitivity, precipitated opioid withdrawal (POW), or sedation symptoms within 1 hour received BUP-XR 300 mg (assessed as inpatients for 48 hours and outpatients to Day 29). Endpoints were COWS score increase ≥6, independent adjudication of POW, and opioid use.Results: Twenty-six participants (14 male) received BUP-TM, 24 received BUP-XR, and 20 completed the study. After injection, COWS scores decreased from pre-BUP-TM baseline of 14.6 ± 4.1 to 6.9 ± 4.1 at 6 hours and 4.2 ± 3.2 at 24 hours. Most participants (62.5%) experienced maximum COWS scores pre-BUP-XR; 2 experienced a COWS score increase ≥6, occurring at 1 and 2 hours post-BUP-XR. By adjudication, 2/24 participants experienced POW. Irritability, anxiety, nausea, and pain were the most frequent adverse events (AEs) with no serious AEs.Conclusions: Results support increased flexibility for initiating BUP-XR. Initiating BUP-XR 300 mg following a single BUP-TM 4 mg dose was well tolerated. Although some participants initially experienced withdrawal symptoms after injection, significant symptomatic improvement was observed in all participants within 24 hours.
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Whiteside LK, D'Onofrio G, Fiellin DA, Edelman EJ, Richardson L, O'Connor P, Rothman RE, Cowan E, Lyons MS, Fockele CE, Saheed M, Freiermuth C, Punches BE, Guo C, Martel S, Owens PH, Coupet E, Hawk KF. Models for Implementing Emergency Department-Initiated Buprenorphine With Referral for Ongoing Medication Treatment at Emergency Department Discharge in Diverse Academic Centers. Ann Emerg Med 2022; 80:410-419. [PMID: 35752520 PMCID: PMC9588652 DOI: 10.1016/j.annemergmed.2022.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 04/26/2022] [Accepted: 05/04/2022] [Indexed: 12/24/2022]
Abstract
There has been a substantial rise in the number of publications and training opportunities on the care and treatment of emergency department (ED) patients with opioid use disorder over the past several years. The American College of Emergency Physicians recently published recommendations for providing buprenorphine to patients with opioid use disorder, but barriers to implementing this clinical practice remain. We describe the models for implementing ED-initiated buprenorphine at 4 diverse urban, academic medical centers across the country as part of a federally funded effort termed "Project ED Health." These 4 sites successfully implemented unique ED-initiated buprenorphine programs as part of a comparison of implementation facilitation to traditional educational dissemination on the uptake of ED-initiated buprenorphine. Each site describes the elements central to the ED process, including screening, treatment initiation, referral, and follow-up, while harnessing organizational characteristics, including ED culture. Finally, we discuss common facilitators to program success, including information technology and electronic medical record integration, hospital-level support, strong connections with outpatient partners, and quality improvement processes.
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Affiliation(s)
- Lauren K Whiteside
- Department of Emergency Medicine, University of Washington School of Medicine, Seattle, WA.
| | - Gail D'Onofrio
- Department of Emergency Medicine, Program in Addiction Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT; Program in Addiction Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - David A Fiellin
- Department of Emergency Medicine, Program in Addiction Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT; Program in Addiction Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT; Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT
| | - E Jennifer Edelman
- Program in Addiction Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT; Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT
| | - Lynne Richardson
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Patrick O'Connor
- Program in Addiction Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Richard E Rothman
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ethan Cowan
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Michael S Lyons
- Department of Emergency Medicine, Center for Addiction Research, University of Cincinnati College of Medicine, Cincinnati, OH; Center for Addiction Research, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Callan E Fockele
- Department of Emergency Medicine, University of Washington School of Medicine, Seattle, WA
| | - Mustapha Saheed
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Caroline Freiermuth
- Department of Emergency Medicine, Center for Addiction Research, University of Cincinnati College of Medicine, Cincinnati, OH; Center for Addiction Research, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Brittany E Punches
- Department of Emergency Medicine, Center for Addiction Research, University of Cincinnati College of Medicine, Cincinnati, OH; Center for Addiction Research, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Clara Guo
- Department of Emergency Medicine, Program in Addiction Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Shara Martel
- Department of Emergency Medicine, Program in Addiction Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Patricia H Owens
- Department of Emergency Medicine, Program in Addiction Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Edouard Coupet
- Department of Emergency Medicine, Program in Addiction Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Kathryn F Hawk
- Department of Emergency Medicine, Program in Addiction Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT; Program in Addiction Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
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Calcaterra SL, Bottner R, Martin M, Englander H, Weinstein ZM, Weimer MB, Lambert E, Ronan MV, Huerta S, Zaman T, Ullal M, Peterkin AF, Torres-Lockhart K, Buresh M, O’Brien MT, Snyder H, Herzig SJ. Management of opioid use disorder, opioid withdrawal, and opioid overdose prevention in hospitalized adults: A systematic review of existing guidelines. J Hosp Med 2022; 17:679-692. [PMID: 35880821 PMCID: PMC9474657 DOI: 10.1002/jhm.12908] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 05/11/2022] [Accepted: 05/22/2022] [Indexed: 12/20/2022]
Abstract
BACKGROUND Hospitalizations related to the consequences of opioid use are rising. National guidelines directing in-hospital opioid use disorder (OUD) management do not exist. OUD treatment guidelines intended for other treatment settings could inform in-hospital OUD management. OBJECTIVE Evaluate the quality and content of existing guidelines for OUD treatment and management. DATA SOURCES OVID MEDLINE, PubMed, Ovid PsychINFO, EBSCOhost CINHAL, ERCI Guidelines Trust, websites of relevant societies and advocacy organizations, and selected international search engines. STUDY SELECTION Guidelines published between January 2010 to June 2020 addressing OUD treatment, opioid withdrawal management, opioid overdose prevention, and care transitions among adults. DATA EXTRACTION We assessed quality using the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument. DATA SYNTHESIS Nineteen guidelines met the selection criteria. Most recommendations were based on observational studies or expert consensus. Guidelines recommended the use of nonstigmatizing language among patients with OUD; to assess patients with unhealthy opioid use for OUD using the Diagnostic Statistical Manual of Diseases-5th Edition criteria; use of methadone or buprenorphine to treat OUD and opioid withdrawal; use of multimodal, nonopioid therapy, and when needed, short-acting opioid analgesics in addition to buprenorphine or methadone, for acute pain management; ensuring linkage to ongoing methadone or buprenorphine treatment; referring patients to psychosocial treatment; and ensuring access to naloxone for opioid overdose reversal. CONCLUSIONS Included guidelines were informed by studies with various levels of rigor and quality. Future research should systematically study buprenorphine and methadone initiation and titration among people using fentanyl and people with pain, especially during hospitalization.
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Affiliation(s)
- Susan L. Calcaterra
- Department of Medicine, Division of General Internal Medicine and Division of Hospital Medicine, University of Colorado, Aurora, CO, USA
| | - Richard Bottner
- Department of Internal Medicine, Dell Medical School at The University of Texas at Austin, Austin, TX, USA
| | - Marlene Martin
- Department of Medicine, Division of Hospital Medicine, University of California San Francisco and San Francisco General Hospital, San Francisco, CA, USA
| | - Honora Englander
- Section of Addiction Medicine and Division of Hospital Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Zoe M. Weinstein
- Boston University School of Medicine, Boston Medical Center, Section of General Internal Medicine, Clinical Addiction Research and Education (CARE) Unit, Boston, MA, USA
| | | | - Eugene Lambert
- Harvard Medical School, Boston, MA and Massachusetts General Hospital, Medicine, Charlestown, MA, USA
| | - Matthew V. Ronan
- Harvard Medical School, Boston, MA and Massachusetts General Hospital, Medicine, Charlestown, MA, USA
- Department of Medicine, VA Boston Healthcare System, West Roxbury, MA, USA
| | - Sergio Huerta
- Department of Internal Medicine, Division of Hospital Medicine, University of New Mexico School of Medicine, NM, USA
| | - Tauheed Zaman
- San Francisco VA Medical Center, San Francisco, CA, USA
- Department of Psychiatry and Behavioral Sciences, University of California San Francisco, San Francisco, CA, USA
| | - Monish Ullal
- Department of Internal Medicine at Highland Hospital, Alameda Health System, Oakland, CA, USA
| | - Alyssa F. Peterkin
- Boston University School of Medicine, Boston Medical Center, Section of General Internal Medicine, Clinical Addiction Research and Education (CARE) Unit, Boston, MA, USA
| | | | - Megan Buresh
- Division of Addiction Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA
| | - Meghan T. O’Brien
- Department of Medicine, Division of Hospital Medicine, University of California San Francisco and San Francisco General Hospital, San Francisco, CA, USA
| | - Hannah Snyder
- Family Community Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Shoshana J. Herzig
- Harvard Medical School, Boston, MA and Massachusetts General Hospital, Medicine, Charlestown, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
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Calcaterra SL, Martin M, Bottner R, Englander H, Weinstein Z, Weimer MB, Lambert E, Herzig SJ. Management of opioid use disorder and associated conditions among hospitalized adults: A Consensus Statement from the Society of Hospital Medicine. J Hosp Med 2022; 17:744-756. [PMID: 35880813 PMCID: PMC9474708 DOI: 10.1002/jhm.12893] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 05/25/2022] [Accepted: 05/29/2022] [Indexed: 01/14/2023]
Abstract
Hospital-based clinicians frequently care for patients with opioid withdrawal or opioid use disorder (OUD) and are well-positioned to identify and initiate treatment for these patients. With rising numbers of hospitalizations related to opioid use and opioid-related overdose, the Society of Hospital Medicine convened a working group to develop a Consensus Statement on the management of OUD and associated conditions among hospitalized adults. The guidance statement is intended for clinicians practicing medicine in the inpatient setting (e.g., hospitalists, primary care physicians, family physicians, advanced practice nurses, and physician assistants) and is intended to apply to hospitalized adults at risk for, or diagnosed with, OUD. To develop the Consensus Statement, the working group conducted a systematic review of relevant guidelines and composed a draft statement based on extracted recommendations. Next, the working group obtained feedback on the draft statement from external experts in addiction medicine, SHM members, professional societies, harm reduction organizations and advocacy groups, and peer reviewers. The iterative development process resulted in a final Consensus Statement consisting of 18 recommendations covering the following topics: (1) identification and treatment of OUD and opioid withdrawal, (2) perioperative and acute pain management in patients with OUD, and (3) methods to optimize care transitions at hospital discharge for patients with OUD. Most recommendations in the Consensus Statement were derived from guidelines based on observational studies and expert consensus. Due to the lack of rigorous evidence supporting key aspects of OUD-related care, the working group identified important issues necessitating future research and exploration.
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Affiliation(s)
- Susan L. Calcaterra
- Department of Medicine, Division of General Internal Medicine and Division of Hospital Medicine, University of Colorado, Aurora, CO, USA
| | - Marlene Martin
- Department of Medicine, Division of Hospital Medicine, University of California San Francisco and San Francisco General Hospital, San Francisco, CA, USA
| | - Richard Bottner
- Department of Internal Medicine, Dell Medical School at The University of Texas at Austin, Austin, TX, USA
| | - Honora Englander
- Department of Medicine, Section of Addiction Medicine and Division of Hospital Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Zoe Weinstein
- Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA
| | | | - Eugene Lambert
- Harvard Medical School and Massachusetts General Hospital, Department of Medicine, Division of General Internal Medicine, Boston, MA, USA
| | - Shoshana J. Herzig
- Harvard Medical School and Massachusetts General Hospital, Department of Medicine, Division of General Internal Medicine, Boston, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
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Jain L, Morrisroe K, Modesto-Lowe V. To use or not to use buprenorphine for illegally manufactured fentanyl. Fam Pract 2022; 40:428-430. [PMID: 36048969 DOI: 10.1093/fampra/cmac098] [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: 11/15/2022] Open
Affiliation(s)
- Lakshit Jain
- General Psychiatry Department, Connecticut Valley Hospital, Middletown, CT, United States.,Department of Psychiatry, University of Connecticut, Farmington, CT, United States
| | - Kathleen Morrisroe
- Department of Psychiatry, University of Connecticut, Farmington, CT, United States
| | - Vania Modesto-Lowe
- Department of Psychiatry, University of Connecticut, Farmington, CT, United States
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Abstract
The incidence of opioid use disorder (OUD) and overdose deaths is rising yearly within the United States. Many cases are associated with illicitly manufactured fentanyl use. In addition to offering patients medications for OUD (methadone, buprenorphine, and naltrexone), the approach to this epidemic should involve increasing provider awareness and education about substance use disorders, expanding urine toxicology screens to test for fentanyl, and using low-threshold treatment approaches.
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Kavanagh K, Tallian K, Sepulveda JA, Rojas S, Martin S, Sikand H. Do buprenorphine doses and ratios matter in medication assisted treatment adherence? Ment Health Clin 2022; 12:241-246. [PMID: 36071736 PMCID: PMC9405633 DOI: 10.9740/mhc.2022.08.241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Accepted: 06/15/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction Buprenorphine (BUP), generally prescribed as buprenorphine/naloxone, is a key component of medication-assisted treatment (MAT) to manage opioid use disorder. Studies suggest higher doses of BUP increase treatment adherence. Routine urine drug screens (UDS) assist in monitoring MAT adherence via measurement of excreted BUP and its metabolite, norbuprenorphine (NBP). The clinical significance between BUP/NBP concentrations and their ratios for assessing adherence and substance use is not well-described. Methods We conducted a single-center, retrospective chart review of 195 clients age ≥18 years enrolled in a local MAT program from August 2017 to February 2021. Demographics, BUP doses, prescription history, and UDS results were collected. Participants were divided based on MAT adherence (<80% vs ≥80%) and median total daily dose (TDD) of BUP (≥16 mg vs <16 mg) in addition to pre- and post-COVID-19 cohorts. Results Median BUP/NBP urinary concentrations were significantly correlated with MAT adherence (P < .0001 for each) and a reduced percentage of positive UDS for opioids (P = .0004 and P < .0001, respectively) but not their ratios. Median TDD of BUP ≥16 mg (n = 126) vs <16 mg (n = 68) was not correlated with MAT adherence (P = .107) or incidence of nonprescription use (P = .117). A significantly higher incidence of UDS positive for opiates (P = .049) and alcohol (P = .035) was observed post-COVID-19. Discussion Clients appearing adherent to MAT who had higher concentrations of urinary BUP/NBP demonstrated a reduced incidence of opioid-positive UDS independent of the BUP dose prescribed. An increase in opioid- and alcohol-positive UDSs were observed during the COVID-19 pandemic.
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Affiliation(s)
- Kevin Kavanagh
- 1 Clinical Psychiatric Pharmacist, Health and human Services Agency Pharmacy, San Diego County Psychiatry Hospital, San Diego, California
| | | | - Joe A. Sepulveda
- 3 Chief of Psychiatry and Medical Director, Substance Use Disorder Services, Family Health Centers of San Diego, San Diego, California
| | - Sarah Rojas
- 4 Family Medicine Specialist, Family Health Centers of San Diego, San Diego, California
| | - Shedrick Martin
- 5 Clinical Pharmacist Specialist, Department of Pharmacy, Santa Rosa Memorial Hospital, Santa Rosa, California
| | - Harminder Sikand
- 6 Director of Clinical Services and Residency Programs, Department of Pharmacy, Scripps Mercy Hospital, San Diego, California
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A Neuropharmacological Model to Explain Buprenorphine Induction Challenges. Ann Emerg Med 2022; 80:509-524. [DOI: 10.1016/j.annemergmed.2022.05.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 05/25/2022] [Accepted: 05/27/2022] [Indexed: 11/17/2022]
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Kelly TD, Hawk KF, Samuels EA, Strayer RJ, Hoppe JA. Improving Uptake of Emergency Department-initiated Buprenorphine: Barriers and Solutions. West J Emerg Med 2022; 23:461-467. [PMID: 35980414 PMCID: PMC9391022 DOI: 10.5811/westjem.2022.2.52978] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Accepted: 02/14/2022] [Indexed: 11/13/2022] Open
Abstract
Emergency departments (ED) are increasingly providing buprenorphine to persons with opioid use disorder. Buprenorphine programs in the ED have strong support from public health leaders and emergency medicine specialty societies and have proven to be clinically effective, cost effective, and feasible. Even so, few ED buprenorphine programs currently exist. Given this imbalance between evidence-based practice and current practice, proven behavior change approaches can be used to guide local efforts to expand ED buprenorphine capacity. In this paper, we use the theory of planned behavior to identify and address the 1) clinician factors, 2) institutional factors, and 3) external factors surrounding ED buprenorphine implementation. By doing so, we seek to provide actionable and pragmatic recommendations to increase ED buprenorphine availability across different practice settings.
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Affiliation(s)
- Timothy D. Kelly
- Indiana University Emergency Medicine Residency, Indianapolis, Indiana
| | - Kathryn F. Hawk
- Yale School of Medicine, Department of Emergency Medicine, New Haven, Connecticut
| | - Elizabeth A. Samuels
- Alpert Medical School of Brown University, Department of Emergency Medicine, Providence, Rhode Island
| | - Reuben J. Strayer
- Maimonides Medical Center, Department of Emergency Medicine, Brooklyn, New York
| | - Jason A. Hoppe
- University of Colorado School of Medicine, Department of Emergency Medicine, Aurora, Colorado
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Sue KL, Cohen S, Tilley J, Yocheved A. A Plea From People Who Use Drugs to Clinicians: New Ways to Initiate Buprenorphine Are Urgently Needed in the Fentanyl Era. J Addict Med 2022; 16:389-391. [PMID: 35020693 DOI: 10.1097/adm.0000000000000952] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
With the worst opioid overdose death crisis in the United States history, urgent new approaches to assist people who use drugs onto medication for opioid use disorder are necessary. In this commentary, addiction medicine clinicians and drug user union representatives align to argue that conventional ways of buprenorphine initiation that require periods of withdrawal must be augmented with additional novel approaches to initiation. In the fentanyl era, members of the New England Users Union and Portland Users Union report encountering precipitated withdrawal, being unable to stop using full agonist opioids for a required period of time, and difficulty initiating this medication that could offer them some stability and life-saving treatment. People who use drugs should be involved at all levels with ongoing research, clinical and policy efforts to improve buprenorphine initiation as their lives and their suffering are at stake.
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Affiliation(s)
- Kimberly L Sue
- From the Program in Addiction Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT (KS, SC); National Harm Reduction Coalition New York, New York (KS); New England Users Union, Northampton,MA (JT); Portland Users Union, Portland, OR (AY)
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Mitchell P, Samsel S, Curtin KM, Price A, Turner D, Tramp R, Hudnall M, Parton J, Lewis D. Geographic disparities in access to Medication for Opioid Use Disorder across US census tracts based on treatment utilization behavior. Soc Sci Med 2022; 302:114992. [PMID: 35512612 DOI: 10.1016/j.socscimed.2022.114992] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 03/07/2022] [Accepted: 04/22/2022] [Indexed: 10/18/2022]
Abstract
Drug overdose is the leading cause of accidental death in the U.S. with deaths from opioid overdose occurring at a higher rate in rural areas. The gaps in the provision of healthcare services have been exacerbated by the opioid crisis leaving vulnerable populations without access to preventative care and education, harm reduction, both chronic and acute treatment of the symptoms of opioid use disorder (OUD), and long-term psychological support for those with OUD and their families. There has been a call in the literature -and a federal mandate-for increased access to opioid treatment facilities, but to date this access has not been operationalized using best practices in geography. Medication for Opioid Use Disorder (MOUD) with FDA-approved methadone or buprenorphine has been shown to increase treatment retention, reduce opioid use and associated health and societal harms, and reduce opioid related overdose, and as such is considered the most effective treatment for OUD. The objective of this study is to examine U.S. adults' spatial access to MOUD - specifically locations of certified Opioid Treatment Programs (OTPs) and DATA-waived Buprenorphine providers. A gravity-based variant of the enhanced two-step floating catchment area model is employed, where friction of distance is based on previously published willingness to travel distances for patients visiting OTPs, to assess how opioid agonist treatment accessibility varies across the nation. Findings suggest that there are extensive 'treatment deserts' where there is little to no physical access to MOUD, especially in rural areas. The significance of this work lies in the incorporation of treatment utilization behavior in the access metric, and the continued confirmation of gaps in access to OUD services despite federal efforts to improve accessibility.
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Affiliation(s)
- Penelope Mitchell
- Department of Geography, Laboratory for Location Science, University of Alabama, Tuscaloosa, AL, USA.
| | - Steven Samsel
- Institute of Data & Analytics, University of Alabama, Tuscaloosa, AL, USA
| | - Kevin M Curtin
- Department of Geography, Laboratory for Location Science, University of Alabama, Tuscaloosa, AL, USA
| | - Ashleigh Price
- Department of Geography, Laboratory for Location Science, University of Alabama, Tuscaloosa, AL, USA
| | - Daniel Turner
- Department of Geography, Laboratory for Location Science, University of Alabama, Tuscaloosa, AL, USA
| | - Ryan Tramp
- Institute of Data & Analytics, University of Alabama, Tuscaloosa, AL, USA
| | - Matthew Hudnall
- Department of Information Systems, Operations Management, and Statistics, University of Alabama, Tuscaloosa, AL, USA
| | - Jason Parton
- Department of Information Systems, Operations Management, and Statistics, University of Alabama, Tuscaloosa, AL, USA
| | - Dwight Lewis
- Department of Management, University of Alabama, Tuscaloosa, AL, USA
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Yu MJ, Hawk K. Resident attitudes, experiences, and preferences on initiating buprenorphine in the emergency department: A national survey. AEM EDUCATION AND TRAINING 2022; 6:e10779. [PMID: 35784380 PMCID: PMC9242423 DOI: 10.1002/aet2.10779] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 05/20/2022] [Accepted: 05/24/2022] [Indexed: 06/15/2023]
Abstract
Objectives The objective was to describe emergency medicine (EM) resident attitudes, preferences, and experiences around the knowledge and skills around the evidence-based treatment of opioid use disorder (OUD) in the emergency department (ED). Methods We created an online survey that was distributed by the Emergency Medicine Residents' Association research committee listserv to approximately 6600 resident physicians at all levels of EM residency training. Data were collected between June 2020 and October 2020. This 12-question voluntary, anonymous survey included questions exploring EM resident preferences and experiences around the education and exposure to the evidence-based management of patients with OUD in the ED setting. Descriptive statistics were used. Results A total of 288 of 6600 invited EM residents (response rate 4.4%) from 127 different EM residency programs across 38 states in the United States, District of Columbia, and Puerto Rico completed the survey. Most respondents (165/288; 57.3%) reported that it was "very important" for emergency physicians to have training to initiate buprenorphine treatment for patients with OUD. Just under half (140/288; 48.6%) reported they have or will receive X-waiver training during residency and 46.9% (135/288) reported experience prescribing buprenorphine in the ED. The estimated proportions of EM faculty at responding residents' primary teaching hospital with an X-waiver was "most or all" (48/285; 16.8%), "about half" (23/285; 8.1%), "a handful" (79/285; 27.7%), "one or two" (33/285; 11.6%), "none" (19/285; 6.7%), or "not sure" (83/285; 29.1%). Conclusion Survey results suggest that resident emergency physicians perceive the evidence-based management of OUD to be relevant to EM residency training and are interested in receiving training on initiating medications for OUD treatment in the ED. Opportunities to improve resident education and clinical use of buprenorphine during ED residency training were identified.
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Affiliation(s)
- Megan J. Yu
- Department of Emergency MedicineYale School of MedicineNew HavenConnecticutUSA
| | - Kathryn Hawk
- Department of Emergency MedicineYale School of MedicineNew HavenConnecticutUSA
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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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Spreen LA, Dittmar EN, Quirk KC, Smith MA. Buprenorphine initiation strategies for opioid use disorder and pain management: A systematic review. Pharmacotherapy 2022; 42:411-427. [PMID: 35302671 PMCID: PMC9310825 DOI: 10.1002/phar.2676] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 03/04/2022] [Accepted: 03/05/2022] [Indexed: 12/17/2022]
Abstract
Buprenorphine possesses many unique attributes that make it a practical agent for adults and adolescents with opioid use disorder (OUD) and/or acute or chronic pain. Sublingual buprenorphine has been the standard of care for treating OUD, but its use in pain management is not as clearly defined. Current practice guidelines recommend a period of mild‐to‐moderate withdrawal from opioids before transitioning to buprenorphine due to its ability to displace full agonists from the μ‐opioid receptor. However, this strategy can lead to negative physical and psychological outcomes for patients. Novel initiation strategies suggest that concomitant administration of small doses of buprenorphine with opioids can avoid the unwanted withdrawal associated with buprenorphine initiation. We aim to systematically review the buprenorphine initiation strategies that have emerged in the last decade. Embase, PubMed, and Cochrane Databases were searched for relevant literature. Studies were included if they were published in the English language and described the transition to buprenorphine from opioids. Data were collected from each study and synthesized using descriptive statistics. This review included 7 observational studies, 1 feasibility study, and 39 case reports/series which included 924 patients. The strategies utilized between the literature included traditional initiation (47.9%), microdosing with various buprenorphine formulations (16%), and miscellaneous methods (36.1%). Traditional initiation and microdosing initiation were compared in the data synthesis and analysis; miscellaneous methods were omitted given the high variability between methods. Overall, 95.6% of patients in the traditional initiation group and 96% of patients in the microdosing group successfully rotated to sublingual buprenorphine. Initiation regimens can vary widely depending on patient‐specific factors and buprenorphine formulation. A variety of buprenorphine transition strategies are published in the literature, many of which were effective for patients with OUD, pain, or both.
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Affiliation(s)
- Lauren A Spreen
- Department of Pharmacy Services, University of Michigan Health, Ann Arbor, Michigan, USA.,University of Michigan College of Pharmacy, Ann Arbor, Michigan, USA
| | - Emma N Dittmar
- University of Michigan College of Pharmacy, Ann Arbor, Michigan, USA
| | - Kyle C Quirk
- Department of Palliative Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Michael A Smith
- Department of Pharmacy Services, University of Michigan Health, Ann Arbor, Michigan, USA.,University of Michigan College of Pharmacy, Ann Arbor, Michigan, USA
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Affiliation(s)
- Nathaniel P Morris
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco
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67
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Kaplowitz E, Macmadu A, Green TC, Berk J, Rich JD, Brinkley-Rubinstein L. "It's probably going to save my life;" attitudes towards treatment among people incarcerated in the era of fentanyl. Drug Alcohol Depend 2022; 232:109325. [PMID: 35114617 PMCID: PMC9042078 DOI: 10.1016/j.drugalcdep.2022.109325] [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: 08/03/2021] [Revised: 01/17/2022] [Accepted: 01/18/2022] [Indexed: 11/03/2022]
Abstract
INTRODUCTION In recent years, there has been a dramatic increase in overdose deaths involving illicitly manufactured fentanyl. The risk of death due to fentanyl exposure is far higher for people without adequate tolerance, such as those being released from incarceration. However, little is known about knowledge and perceptions of fentanyl among people who are incarcerated. METHODS We conducted 40 semi-structured qualitative interviews with people who were incarcerated at the Rhode Island Department of Corrections (RIDOC). We explored the impressions of, preferences for and experiences with fentanyl among these people. Analysis employed a general, inductive approach using NVivo 12. RESULTS We found that a majority of the participants were familiar with fentanyl, sought to avoid it and utilized harm reduction techniques when using drugs and taking treatment with medication for opioid use disorder (MOUD) to reduce their risk of overdose. DISCUSSION Our findings suggest that broad access to MOUD, especially for incarcerated people, is increasingly necessary in the era of fentanyl, both to aid people seeking recovery due to the increased overdose risk of drug use and to reduce overdose morbidity for people who use drugs.
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Affiliation(s)
- Eliana Kaplowitz
- The Center for Health + Justice Transformation, The Miriam Hospital, Providence, RI, USA; Center of Biomedical Research Excellence on Opioids and Overdose, The Rhode Island Hospital, Providence, RI, USA; Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA.
| | - Alexandria Macmadu
- The Center for Health + Justice Transformation, The Miriam Hospital, Providence, RI, USA,Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - Traci C. Green
- Center of Biomedical Research Excellence on Opioids and Overdose, The Rhode Island Hospital, Providence, RI, USA,Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA,The Heller School of Social Policy and Management, Brandeis University, Waltham, MA, USA,Brown University School of Medicine, Providence, RI, USA
| | - Justin Berk
- Brown University School of Medicine, Providence, RI, USA,Rhode Island Department of Correction, Providence, RI, USA
| | - Josiah D. Rich
- The Center for Health + Justice Transformation, The Miriam Hospital, Providence, RI, USA,Center of Biomedical Research Excellence on Opioids and Overdose, The Rhode Island Hospital, Providence, RI, USA,Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA,Brown University School of Medicine, Providence, RI, USA
| | - Lauren Brinkley-Rubinstein
- The Center for Health + Justice Transformation, The Miriam Hospital, Providence, RI, USA,Department of Social Medicine, University of North Carolina at Chapel Hill, USA
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Smiley-McDonald HM, Attaway PR, Richardson NJ, Davidson PJ, Kral AH. Perspectives from law enforcement officers who respond to overdose calls for service and administer naloxone. HEALTH & JUSTICE 2022; 10:9. [PMID: 35212812 PMCID: PMC8874742 DOI: 10.1186/s40352-022-00172-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 02/02/2022] [Indexed: 05/27/2023]
Abstract
BACKGROUND Many law enforcement agencies across the United States equip their officers with the life-saving drug naloxone to reverse the effects of an opioid overdose. Although officers can be effectively trained to administer naloxone, and hundreds of law enforcement agencies carry naloxone to reverse overdoses, little is known about what happens on scene during an overdose call for service from an officer's perspective, including what officers perceive their duties and responsibilities to be as the incident evolves. METHODS The qualitative study examined officers' experiences with overdose response, their perceived roles, and what happens on scene before, during, and after an overdose incident. In-person interviews were conducted with 17 officers in four diverse law enforcement agencies in the United States between January and May 2020. RESULTS Following an overdose, the officers described that overdose victims are required to go to a hospital or they are taken to jail. Officers also described their duties on scene during and after naloxone administration, including searching the belongings of the person who overdosed and seizing any drug paraphernalia. CONCLUSION These findings point to a pressing need for rethinking standard operating procedures for law enforcement in these situations so that the intentions of Good Samaritan Laws are upheld and people get the assistance they need without being deterred from asking for future help.
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Affiliation(s)
- Hope M Smiley-McDonald
- Division for Applied Justice Research, RTI International, Research Triangle Park, North Carolina, USA.
| | - Peyton R Attaway
- Division for Applied Justice Research, RTI International, Research Triangle Park, North Carolina, USA
| | - Nicholas J Richardson
- Division for Applied Justice Research, RTI International, Research Triangle Park, North Carolina, USA
| | - Peter J Davidson
- Department of Medicine, Division Global Public Health, University of California, San Diego, La Jolla, California, USA
| | - Alex H Kral
- Community Health Research Division, RTI International, Berkeley, California, USA
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Mukau L, Wormley K, Tomaszewski C, Ahmad B, Vohra R, Herring A. Buprenorphine for High-dose Tramadol Dependence: A Case Report of Successful Outpatient Treatment. Clin Pract Cases Emerg Med 2022; 6:71-74. [PMID: 35226854 PMCID: PMC8885221 DOI: 10.5811/cpcem.2021.12.54602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 12/27/2021] [Indexed: 12/02/2022] Open
Abstract
Introduction During the coronavirus disease 2019 pandemic caused by the severe acute
respiratory syndrome coronavirus 2, deaths from opiate drug overdoses
reached their highest recorded annual levels in 2020. Medication-assisted
treatment for opiate use disorder has demonstrated efficacy in reducing
opiate overdoses and all-cause mortality and improving multiple other
patient-centered outcomes. Treatment of tramadol dependence in particular
poses unique challenges due to its combined action as opioid agonist and
serotonin-norepinephrine reuptake inhibitor. Tramadol puts patients with
dependence at risk for atypical withdrawal syndromes when attempting to
reduce use. Little evidence is available to guide treatment of tramadol
dependence. Case Report We present a case of high-dose tramadol addiction that began with misuse of
medically prescribed tramadol for treatment of musculoskeletal back pain.
The patient’s use reached oral consumption of 5000–6000
milligrams of illicit tramadol daily. She complained of common complications
of tramadol use disorder including memory impairment, excessive sedation,
and tramadol-induced seizures. The patient was referred to the emergency
department in a withdrawal crisis seeking treatment where she was
successfully managed with buprenorphine and phenobarbital and then linked to
ongoing outpatient treatment. Conclusion Our report adds to the limited guidance currently available on the acute
management of tramadol withdrawal and treatment of tramadol use disorder.
Our case suggests the initiation of high-dose buprenorphine may be an
effective and feasible option for emergency clinicians.
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Affiliation(s)
- Leslie Mukau
- University of California, San Diego, Department of Emergency Medicine, San Diego, California; El Centro Regional Medical Center, Department of Emergency Medicine, El Centro, California
| | - Kadia Wormley
- Highland Hospital – Alameda Health System, Department of Emergency Medicine, Oakland, California
| | - Christian Tomaszewski
- University of California, San Diego, Department of Emergency Medicine, San Diego, California; El Centro Regional Medical Center, Department of Emergency Medicine, El Centro, California
| | - Bushra Ahmad
- Imperial County Behavioral Health Services, Division of Substance Use Disorder Treatment Program, El Centro, California
| | - Rais Vohra
- University of California, San Francisco-Fresno, Department of Emergency Medicine, Fresno, California
| | - Andrew Herring
- Highland Hospital – Alameda Health System, Department of Emergency Medicine, Oakland, California; University of California, San Francisco, Department of Emergency Medicine, San Francisco, California
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Peterkin A, Laks J, Weinstein ZM. Current Best Practices for Acute and Chronic Management of Patients with Opioid Use Disorder. Med Clin North Am 2022; 106:61-80. [PMID: 34823735 DOI: 10.1016/j.mcna.2021.08.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This comprehensive review on opioids summarizes the scope of the current opioid epidemic, the diagnosis and treatment of opioid use disorder, and the medical and psychiatric complications of opioid use.
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Affiliation(s)
- Alyssa Peterkin
- Grayken Center for Addiction Medicine, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston Medical Center, 801 Massachusetts Avenue, Room 2070, Boston, MA 02118, USA.
| | - Jordana Laks
- Grayken Center for Addiction Medicine, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston Medical Center, 801 Massachusetts Avenue, Room 2103B, Boston, MA 02118, USA
| | - Zoe M Weinstein
- Grayken Center for Addiction Medicine, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston Medical Center, 801 Massachusetts Avenue, Room 2039, Boston, MA 02118, USA
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Guo CZ, D'Onofrio G, Fiellin DA, Edelman EJ, Hawk K, Herring A, McCormack R, Perrone J, Cowan E. Emergency department-initiated buprenorphine protocols: A national evaluation. J Am Coll Emerg Physicians Open 2021; 2:e12606. [PMID: 34877567 PMCID: PMC8630357 DOI: 10.1002/emp2.12606] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Revised: 10/28/2021] [Accepted: 11/02/2021] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVE Emergency department-initiated buprenorphine (BUP) for opioid use disorder is an evidence-based practice, but limited data exist on BUP initiation practices in real-world settings. We sought to characterize protocols for BUP initiation among a geographically diverse sample of emergency departments (EDs). METHODS In December 2020, we reviewed prestudy clinical BUP initiation protocols from all EDs participating in CTN0099 Emergency Department-INitiated bupreNOrphine VAlidaTION (ED-INNOVATION). We abstracted information on processes for identification of treatment-eligible patients, BUP administration, and discharge care. RESULTS All participating ED-INNOVATION sites across 22 states submitted protocols; 31 protocols were analyzed. Identification of treatment-eligible patients: Most EDs 22 (71%) relied on clinician judgment to determine appropriateness of BUP treatment with only 7 (23%) requiring decision support tools or diagnosis checklists. Before BUP initiation, 27 (87%) protocols required a documented Clinical Opiate Withdrawal Scale (COWS) score; 4 (13%) required a clinical diagnosis of withdrawal with optional COWS score. Twenty-seven (87%) recommended a minimum COWS score of 8 for ED-initiated BUP. BUP administration: Initial BUP dose ranged from 2-16 mg (mode = 4). For continued withdrawal symptoms, 27 (87%) protocols recommended an interval of 30-60 minutes between first and second BUP dose. Total BUP dose in the ED ranged from 8 to 32 mg. Discharge care: Twenty-eight (90%) protocols recommended a BUP prescription (mode 16 mg daily) at discharge. Naloxone prescription and/or provision was suggested in 23 (74%) protocols. CONCLUSIONS In this geographically diverse sample of EDs, protocols for ED-initiated BUP differed between sites. Future work should evaluate the association between this variation and patient outcomes.
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Affiliation(s)
- Clara Z. Guo
- Yale University School of MedicineNew HavenConnecticutUSA
| | - Gail D'Onofrio
- Department of Emergency MedicineYale University School of MedicineNew HavenConnecticutUSA
| | - David A. Fiellin
- Department of Internal MedicineYale University School of MedicineNew HavenConnecticutUSA
| | - E. Jennifer Edelman
- Department of Internal MedicineYale University School of MedicineNew HavenConnecticutUSA
| | - Kathryn Hawk
- Department of Emergency MedicineYale University School of MedicineNew HavenConnecticutUSA
| | - Andrew Herring
- Department of Emergency MedicineHighland Hospital – Alameda Health SystemUniversity of CaliforniaSan FranciscoCaliforniaUSA
| | - Ryan McCormack
- Department of Emergency MedicineNew York University School of MedicineNew YorkNew YorkUSA
| | - Jeanmarie Perrone
- Department of Emergency MedicinePerelman School of Medicine at the University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Ethan Cowan
- Department of Emergency MedicineIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
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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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