Postoperative buprenorphine continuation in stabilized buprenorphine patients: A population cohort study

BACKGROUND AND AIMS

Sudden discontinuation of buprenorphine in the treatment of opioid use disorder can increase the risk of subsequent relapse and overdose. Little is known about buprenorphine use in the perioperative period. The aim of this study was to determine the rate of buprenorphine continuation after hospital discharge following surgery and factors associated with continuation.

DESIGN

A population-based retrospective cohort study was conducted using administrative data from Ontario, Canada, between 2012 and 2018. The cohort included individuals on continuous buprenorphine prior to surgery. Logistic regression modeling was used to estimate the association of buprenorphine continuation with demographic, opioid agonist treatment, surgical and health service use factors.

SETTING

Administrative databases from Institute for Clinical Evaluative Sciences (ICES) were used, which capture the Ontario, Canada, population. The data sets describe physician billing, monitoring of controlled substances and hospital discharges.

PARTICIPANTS

Adults (≥ 18 years, n = 2176) had received a buprenorphine/naloxone product continuously for at least 60 days for the treatment of opioid use disorder and subsequently underwent a surgical procedure.

MEASUREMENTS

Continuation (versus discontinuation) of buprenorphine prescriptions in the 14 days after surgical discharge was recommended. Exposures included demographic, comorbidity, opioid agonist treatment, surgical and health service use characteristics.

FINDINGS

About 176 (8.1%) of the 2176 patients discontinued buprenorphine after surgery. Inpatient surgery (versus ambulatory) was associated with reduced odds of continuation, with an unadjusted odds ratio (OR) of 0.17 [95% confidence interval (CI) = 0.12-0.25] and an adjusted OR of 0.16 (95% CI = 0.11-0.23) after accounting for age, sex, rural residence, neighborhood income quintile, Charlson comorbidity index, psychiatric hospitalizations in the past 5 years and recent dispensed supply of buprenorphine (number needed to harm of 6.6).

CONCLUSIONS

In Ontario, Canada, from 2012 to 2018, most patients receiving continuous preoperative buprenorphine therapy continued buprenorphine use after surgery. Inpatient surgery was a strong predictor of discontinuation compared with ambulatory procedures.

Outpatient Microdose Induction with Transdermal Buprenorphine: A Case Series

Transdermal buprenorphine is FDA approved for chronic severe pain but has an increasing amount of data supporting its use to transition patients from full opioid agonists to sublingual buprenorphine via a microdose strategy. The literature has primarily focused on patients with a pain diagnosis or who have been prescribed opioids in inpatient units. This case series reviews the use of transdermal buprenorphine to transition patients from methadone and illicit opioids to sublingual buprenorphine. The authors identified seven patients from an outpatient opiate treatment program who received the transdermal buprenorphine protocol. All patients were prescribed methadone and used illicit heroin prior to and during the transition. Five patients (71.4%) successfully completed the transition to sublingual buprenorphine, with all five patients reporting no or mild withdrawal symptoms. These findings suggest that transdermal buprenorphine is a potentially safe and effective microdose induction method for patients who use illicit substances in an outpatient setting.

Low-dose Buprenorphine Initiation in Hospitalized Adults With Opioid Use Disorder: A Retrospective Cohort Analysis

OBJECTIVES

Patients with opioid use disorder (OUD) can initiate buprenorphine without requiring a withdrawal period through a low-dose (sometimes referred to as "micro-induction") approach. Although there is growing interest in low-dose buprenorphine initiation, current evidence is limited to case reports and small case series.

METHODS

We performed a retrospective cohort study of patients with OUD seen by a hospital-based addiction medicine consult service who underwent low-dose buprenorphine initiation starting during hospital admission. We then integrated our practice-based experiences with results from the existing literature to create practice considerations.

RESULTS

Sixty-eight individuals underwent 72 low-dose buprenorphine initiations between July 2019 and July 2020. Reasons for low-dose versus standard buprenorphine initiation included co-occurring pain (91.7%), patient anxiety around the possibility of withdrawal (69.4%), history of precipitated withdrawal (9.7%), opioid withdrawal intolerance (6.9%), and other reason/not specified (18.1%). Of the 72 low-dose buprenorphine initiations, 50 (69.4%) were completed in the hospital, 9 (12.5%) transitioned to complete as an outpatient, and 13 (18.1%) were terminated early. We apply our experiences and findings from literature to recommendations for varied clinical scenarios, including acute illness, co-occurring pain, opioid withdrawal intolerance, transition from high dose methadone to buprenorphine, history of precipitated withdrawal, and rapid hospital discharge. We share a standard low-dose initiation protocol with potential modifications based on above scenarios.

CONCLUSIONS

Low-dose buprenorphine initiation offers a well-tolerated and versatile approach for hospitalized patients with OUD. We share lessons from our experiences and the literature, and provide practical considerations for providers.

Transdermal buprenorphine for in-hospital transition from full agonist opioids to sublingual buprenorphine: a retrospective observational cohort study

INTRODUCTION

Patients with opioid use disorder may have difficulty transitioning from full-agonist opioids to sublingual buprenorphine due to the risk of precipitated opioid withdrawal. Novel strategies have been developed to facilitate this transition, including the use of micro-dosing with transdermal buprenorphine. We began using a transdermal buprenorphine transition strategy at our hospital in 2019.

METHODS

We performed a retrospective observational cohort study of patients treated with transdermal buprenorphine to facilitate transition from full-agonist opioids (prescribed or recreational) while hospitalized between January 2019 and December 2020. Patients were excluded if transdermal buprenorphine was given for pain, if they did not receive at least one dose of sublingual buprenorphine while hospitalized, or if their clinical course precluded analysis of their tolerance of the transition protocol. Data on the doses and timing of medications, symptoms during transition, and hospital outcomes were abstracted from the electronic medical record.

RESULTS

We identified 41 cases that satisfied inclusion and exclusion criteria. Thirty-five cases involved a transition from medically indicated opioids; of these, 8 cases involved a transition from methadone. Six cases involved a transition from illicit opioids used prior to hospital presentation. For patient transitioning from medically indicated opioids, the median milligram morphine equivalent (MME) on the day prior to transdermal buprenorphine application was 63.8 (range 0-900, IQR 153.8) and the median MME on the day of transdermal buprenorphine application was 34.5 (range 0-600, IQR 65.3). The median initial dose of sublingual buprenorphine administered was 8 mg (range 2-8mg, IQR 6mg), the median total first-day dose was 16mg (range 2-24mg, IQR 16mg), and the median total daily dose on the last day of follow-up was 16mg (range 2-24mg, IQR 16mg). In 38 cases, patients completed the transition to sublingual buprenorphine and were still taking buprenorphine at the time they left the hospital. The transition protocol was fairly well-tolerated, with 59% of cases tolerating it well and 32% tolerating it fairly.

DISCUSSION

Our findings suggest that the use of transdermal buprenorphine to facilitate transition to sublingual buprenorphine is generally well-tolerated, and may be helpful in hospitalized patients. We identified several areas for improvement in future practice by reviewing the clinical courses of patients who tolerated transition poorly. Limitations of the study include its retrospective chart review design, the lack of a standardized transition protocol during the study period, and the lack of standardized data in the medical record regarding patients' tolerance of the transition protocol. Future research should include prospective studies using a standardized protocol and structured, pre-planned assessments of opioid withdrawal during the transition period.

CONCLUSION

The use of transdermal buprenorphine to facilitate induction of sublingual buprenorphine therapy in hospitalized patients with OUD was generally well-tolerated in this single-center retrospective observational study. Further prospective research is needed to demonstrate efficacy and optimize treatment protocols.

Initiating buprenorphine to treat opioid use disorder without prerequisite withdrawal: a systematic review

BACKGROUND

Opioid withdrawal symptoms prior to buprenorphine initiation may be intolerable and as a result, alternative strategies have emerged. We aim to systematically review the efficacy and safety of buprenorphine initiation that aims to omit prerequisite withdrawal.

METHODS

We conducted a systematic literature search of MEDLINE and CENTRAL from 1996 through April 10, 2020, augmented with searches in Google Scholar and www.clinicaltrials.gov . A study was included if it was in patients with substance use disorder or chronic pain that were taking a full mu opioid agonist and transitioning to buprenorphine without preceding withdrawal, and reported withdrawal during initiation as an outcome. Two investigators independently screened citations and articles for inclusion, collected data using a standardized data collection tool, and assessed study risk of bias.

RESULTS

We included 15 case reports/series, reporting 24 unique cases, in our qualitative synthesis. No controlled studies were identified. Microdosing and bridging with a buprenorphine patch were the most common strategies reported. Transition to buprenorphine with complete cessation of opioid agonists was achieved in 87.5% (n = 21) of cases. Withdrawal during initiation occurred in 58.3% (n = 14) of cases, two of which were at least moderate in severity.

CONCLUSION

Buprenorphine initiation strategies that omit prerequisite withdrawal have emerged. Low quality evidence from case reports suggests withdrawal during initiation is common but most often mild in severity. There is an unmet need for controlled studies to inform their efficacy and safety compared with traditional strategies, including outcomes during initiation and in the long-term.