Emergency department‐initiated buprenorphine protocols: A national evaluation

Guo, Clara Z.; D’Onofrio, Gail; Fiellin, David A.; Edelman, E. Jennifer; Hawk, Kathryn; Herring, Andrew A.; McCormack, Ryan; Perrone, Jeanmarie; Cowan, Ethan

doi:10.1002/emp2.12606

Cited by 9 publications

(10 citation statements)

References 40 publications

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“…The patients who use fentanyl, in particular, are at risk for precipitated withdrawal, especially when they present with mild withdrawal symptoms [ 35 ]. At the time of our didactic, we used a COWs score of “8” to signal mild withdrawal in which buprenorphine could be used, which was consistent with other national protocols [ 36 ]. However, recent clinical experience during the rise of fentanyl suggests that a higher COWS score (“13”) is safer to prevent precipitated withdrawal.…”

Section: Discussionmentioning

confidence: 99%

A Brief Educational Intervention to Increase ED Initiation of Buprenorphine for Opioid Use Disorder (OUD)

et al. 2022

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Background Despite the evidence in support of the use of buprenorphine in the treatment of OUD and increasing ability of emergency medicine (EM) clinicians to prescribe it, emergency department (ED)-initiated buprenorphine is uncommon. Many EM clinicians lack training on how to manage acute opioid withdrawal or initiate treatment with buprenorphine. We developed a brief buprenorphine training program and assessed the impact of the training on subsequent buprenorphine initiation and knowledge retention. Methods We conducted a pilot randomized control trial enrolling EM clinicians to receive either a 30-min didactic intervention about buprenorphine (standard arm) or the didactic plus weekly messaging and a monetary inducement to administer and report buprenorphine use (enhanced arm). All participants were incentivized to complete baseline, immediate post-didactic, and 90-day knowledge and attitude assessment surveys. Our objective was to achieve first time ED buprenorphine prescribing events in clinicians who had not previously prescribed buprenorphine in the ED and to improve EM-clinician knowledge and perceptions about ED-initiated buprenorphine. We also assessed whether the incentives and reminder messaging in the enhanced arm led to more clinicians administering buprenorphine than those in the standard arm following the training; we measured changes in knowledge of and attitudes toward ED-initiated buprenorphine. Results Of 104 EM clinicians enrolled, 51 were randomized to the standard arm and 53 to the enhanced arm. Clinical knowledge about buprenorphine improved for all clinicians immediately after the didactic intervention (difference 19.4%, 95% CI 14.4% to 24.5%). In the 90 days following the intervention, one-third (33%) of all participants reported administering buprenorphine for the first time. Clinicians administered buprenorphine more frequently in the enhanced arm compared to the standard arm (40% vs. 26.3%, p = 0.319), but the difference was not statistically significant. The post-session knowledge improvement was not sustained at 90 days in the enhanced (difference 9.6%, 95% CI − 0.37% to 19.5%) or in the standard arm (difference 3.7%, 95% CI − 5.8% to 13.2%). All the participants reported an increased ability to recognize patients with opioid withdrawal at 90 days (enhanced arm difference .55, 95% CI .01–1.09, standard arm difference .85 95% CI .34–1.37). Conclusions A brief educational intervention targeting EM clinicians can be utilized to achieve first-time prescribing and improve knowledge around buprenorphine and opioid withdrawal. The use of weekly messaging and gain-framed incentivization conferred no additional benefit to the educational intervention alone. In order to further expand evidence-based ED treatment of OUD, focused initiatives that improve clinician competence with buprenorphine should be explored. Trial Registration Clin...

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Section: Discussionmentioning

confidence: 99%

A Brief Educational Intervention to Increase ED Initiation of Buprenorphine for Opioid Use Disorder (OUD)

et al. 2022

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“…Most traditional buprenorphine induction protocols start with 4 mg of buprenorphine (or 4/1 mg of buprenorphine/ naloxone if using Suboxone) once the COWS score is 8 or more. 22 An additional 4-mg dose is given after an hour if the patient tolerated the first one without experiencing precipitated withdrawal, for a total dose of 8 mg (or 8/2 mg of the combination product). Many patients will need a third, and some will need a fourth 4-mg dose between one and several hours later for recurring withdrawal symptoms.…”

Section: Buprenorphinementioning

confidence: 99%

Opioid Use Disorder, Adolescents, and the Importance of Treatment in the Emergency Department

Buresh,

Kaplan

2024

Pediatr Emer Care

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Deaths from opiate overdoses are climbing every year, especially from fentanyl. Adolescents are particularly vulnerable to the acute and chronic harms associated with drug use, addiction, and overdose. Providers in the acute care setting have a unique opportunity to address a population of adolescents with opioid use disorder who are at the highest risk of harm and who may be more receptive to help. It is critical that providers are familiar with the tools that are available to assist and have some facility with their application.

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“… 4 To avoid PW, guidelines recommend that buprenorphine should only be administered after patients experience moderate to severe withdrawal, typically 6 to 24 hours after the last opioid use. 5 …”

Section: Introductionmentioning

confidence: 99%

“…Although definitions vary, PW is characterized by a rapid worsening of opioid withdrawal symptoms shortly after buprenorphine administration 4 . To avoid PW, guidelines recommend that buprenorphine should only be administered after patients experience moderate to severe withdrawal, typically 6 to 24 hours after the last opioid use 5 …”

Section: Introductionmentioning

confidence: 99%

Precipitated opioid withdrawal after buprenorphine administration in patients presenting to the emergency department: A case series

et al. 2023

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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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Emergency department‐initiated buprenorphine protocols: A national evaluation

Cited by 9 publications

References 40 publications

A Brief Educational Intervention to Increase ED Initiation of Buprenorphine for Opioid Use Disorder (OUD)

A Brief Educational Intervention to Increase ED Initiation of Buprenorphine for Opioid Use Disorder (OUD)

Opioid Use Disorder, Adolescents, and the Importance of Treatment in the Emergency Department

Precipitated opioid withdrawal after buprenorphine administration in patients presenting to the emergency department: A case series

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