Approach to buprenorphine use for opioid withdrawal treatment in the emergency setting

Abstract

Opioid use disorder (OUD) is increasing in prevalence throughout the world, with approximately three million individuals in the United States affected. Buprenorphine is a medication designed, researched, and effectively used to assist in OUD recovery. Objective: This narrative review discusses an approach to initiating buprenorphine in the emergency department (ED) for opioid-abuse recovery. Discussion: Buprenorphine is a partial mu-opioid receptor agonist with high affinity and low intrinsic activity. Buprenorphine's long half-life, high potency, and 'ceiling effect' for both euphoric sensation and adverse effects make it an optimal treatment alternative for patients presenting to the ED with opioid withdrawal. While most commonly provided as a sublingual film or tablet, buprenorphine can also be delivered via transbuccal, transdermal, subdermal (implant), subcutaneous, and parenteral routes. Prior to ED administration, caution is recommended to avoid precipitation of buprenorphine-induced opioid withdrawal. Following the evaluation of common opioid withdrawal symptoms, a step-by-step approach to buprenorphine can by utilized to reach a sustained withdrawal relief. A multimodal medication-assisted treatment (MAT) plan involving pharmacologic treatment, as well as counseling and behavioral therapy, is essential to maintaining opioid remission. Patients may be safely discharged with safe-use counseling, close outpatient follow-up, and return precautions for continued management of their OUD. Establishing a buprenorphine program in the ED involves a multifactorial approach to establish a pro-buprenorphine culture. Conclusions: Buprenorphine is an evidence-based, safe, effective treatment option for OUD in an ED-setting. Though successfully utilized by many ED-based treatment programs, the stigma of 'replacing one opioid with another' remains a barrier. Evidence-based discussions on the safety and benefits of buprenorphine are essential to promoting a culture of acceptance and optimizing ED OUD treatment.

<p>Prescribing Buprenorphine for Opioid Use Disorders in the ED: A Review of Best Practices, Barriers, and Future Directions</p>

“…In studies, initial induction doses ranged from 2 mg to 4 mg and up to a maximum of 16 mg over the ED course. 19,20,22,23,27,[31][32][33] Timing of buprenorphine administration included waiting 24 hours after the last known use of extended-release opioids, 27,31,32,34 6-12 hours after the last known use of short-acting opioids, 27,32,34 and 48 hours following the use of methadone after that agent had been substantially tapered. 34 No studies compared different induction regimens or different practices for subsequent dosing, so the optimal induction regimen for improving outcomes remains unknown.…”

“…Research studies found these side effects to be relatively infrequent. Adverse effects of induction in the ED included precipitated withdrawal, 13,20,31,33,34 sedation, 31,34 QT prolongation (lengthening of a segment of the heart beat that can lead to arrhythmias), 31,32 and potential P450 medication interactions. 32 No studies reported adverse events during follow-up periods after the ED induction.…”

“…Follow-up arrangements varied by study, and there were no comparative studies looking at the different follow-up interventions separately from buprenorphine treatment. Some studies described X-waivered ED providers prescribing a 3-day supply of buprenorphine-naloxone to bridge patients to outpatient care 13,23,31,34 or medicationassisted therapy (MAT) clinics. [31][32][33] In some cases, the prescribing physician in the ED may also see the patient in clinic.…”

“…Some studies described X-waivered ED providers prescribing a 3-day supply of buprenorphine-naloxone to bridge patients to outpatient care 13,23,31,34 or medicationassisted therapy (MAT) clinics. [31][32][33] In some cases, the prescribing physician in the ED may also see the patient in clinic. 19 More intensive follow-up support includes coordination with psychological or case management services in the ED.…”

Understandings steps and challenges to take-home naloxone and buprenorphine/naloxone implementation in Québec emergency rooms: SuboxED project

“…D'Onofrio et al (2015) found that the ED initiation of B/n was cost-effective for patients with opioid use disorders (6). Following this landmark study, emergency physicians across the United States (Oakland, California; Camden, New Jersey; Syracuse, New York) and in Canada (Alberta and Ontario) have initiated programs that use the ED proactively to address the opioid epidemic by initiating treatment with B/n as part of opioid agonist therapy for opioid use disorders (8)(9)(10)(11). Other provinces in Canada, like Nova Scotia and British Columbia, have started a takehome naloxone programs from their EDs (12).…”