High‐dose buprenorphine for treatment of high potency opioid use disorder

Danilewitz, Marlon; McLean, Mark

doi:10.1111/dar.13017

Cited by 18 publications

(28 citation statements)

References 15 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…For most individuals with OUD, higher doses are required for effective agonist blockade and suppression of opioid withdrawal and craving. [15][16][17][18][19][20][21] An accelerated induction procedure that achieves therapeutic buprenorphine levels obtained in less than 3 to 4 hours, vs the typical 2 to 3 days, could potentially increase safety during the crucial gap between ED discharge and continuation of treatment in the outpatient setting. 4,17,22 Thus, we evaluated an ED high-dose (>12 mg) buprenorphine induction clinical pathway (Figure 1).…”

Section: Introductionmentioning

confidence: 99%

“…Existing treatment guidelines published by the Department of Health and Human Services, 12 , 13 , 14 which were developed for office-based practice, limit the maximum sublingual (SL) buprenorphine induction dose during the first 24 hours to 8 to 12 mg. For most individuals with OUD, higher doses are required for effective agonist blockade and suppression of opioid withdrawal and craving. 15 , 16 , 17 , 18 , 19 , 20 , 21 An accelerated induction procedure that achieves therapeutic buprenorphine levels obtained in less than 3 to 4 hours, vs the typical 2 to 3 days, could potentially increase safety during the crucial gap between ED discharge and continuation of treatment in the outpatient setting. 4 , 17 , 22 …”

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

High-Dose Buprenorphine Induction in the Emergency Department for Treatment of Opioid Use Disorder

et al. 2021

View full text Add to dashboard Cite

IMPORTANCE Emergency departments (EDs) sporadically use a high-dose buprenorphine induction strategy for the treatment of opioid use disorder (OUD) in response to the increasing potency of the illicit opioid drug supply and commonly encountered delays in access to followup care.OBJECTIVE To examine the safety and tolerability of high-dose (>12 mg) buprenorphine induction for patients with OUD presenting to an ED. DESIGN, SETTING, AND PARTICIPANTSIn this case series of ED encounters, data were manually abstracted from electronic health records for all ED patients with OUD treated with buprenorphine at a single, urban, safety-net hospital in Oakland, California, for the calendar year 2018. Data analysis was performed from April 2020 to March 2021.INTERVENTIONS ED physicians and advanced practice practitioners were trained on a high-dose sublingual buprenorphine induction protocol, which was then clinically implemented. MAIN OUTCOMES AND MEASURESVital signs; use of supplemental oxygen; the presence of precipitated withdrawal, sedation, and respiratory depression; adverse events; length of stay; and hospitalization during and 24 hours after the ED visit were reported according to total sublingual buprenorphine dose (range, 2 to >28 mg). RESULTSAmong a total of 391 unique patients (median [interquartile range] age, 36 [29-48] years), representing 579 encounters, 267 (68.3%) were male and 170 were (43.5%) Black. Homelessness (88 patients [22.5%]) and psychiatric disorders (161 patients [41.2%]) were common. A high dose of sublingual buprenorphine (>12 mg) was administered by 54 unique clinicians during 366 (63.2%)encounters, including 138 doses (23.8%) greater than or equal to 28 mg. No cases of respiratory depression or sedation were reported. All 5 (0.8%) cases of precipitated withdrawal had no association with dose; 4 cases occurred after doses of 8 mg of buprenorphine. Three serious adverse events unrelated to buprenorphine were identified. Nausea or vomiting was rare (2%-6% of cases).The median (interquartile range) length of stay was 2.4 (1.6-3.75) hours. CONCLUSIONS AND RELEVANCEThese findings suggest that high-dose buprenorphine induction, adopted by multiple clinicians in a single-site urban ED, was safe and well tolerated in patients with untreated OUD. Further prospective investigations conducted in multiple sites would enhance these findings.

show abstract

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

High-Dose Buprenorphine Induction in the Emergency Department for Treatment of Opioid Use Disorder

et al. 2021

View full text Add to dashboard Cite

show abstract

mentioning

confidence: 99%

“…Two case reports in this issue highlight the potential challenges high potency opioid use might pose for contemporary OAT paradigms, particularly in relation to dose requirements [9,10]. Danilewitz et al raise the question of whether buprenorphine doses higher than 32 mg may be required in some cases to adequately manage craving and withdrawal [9]. There is a paucity of evidence specifically focusing on buprenorphine dosing in fentanyl use disorder; preclinical studies suggest that methadone and buprenorphine may be less effective at blocking the effects of fentanyl compared with lower efficacy opioids such as heroin, but clinical studies are yet to demonstrate if this is the case [7].…”

mentioning

confidence: 99%

See 1 more Smart Citation

Opioid agonist treatment in the time of fentanyl: What can we learn from emerging evidence?

Arunogiri

Nielsen

2020

Drug and Alcohol Review

View full text Add to dashboard Cite

Buprenorphine Dose and Time to Discontinuation Among Patients With Opioid Use Disorder in the Era of Fentanyl

Chambers,

Hallowell,

Zullo

et al. 2023

JAMA Netw Open

View full text Add to dashboard Cite

ImportanceBuprenorphine treatment for opioid use disorder (OUD) has more than doubled since 2009. However, current US Food and Drug Administration buprenorphine dosing guidelines are based on studies among people using heroin, prior to the emergence of fentanyl in the illicit drug supply.ObjectiveTo estimate the association between buprenorphine dose and time to treatment discontinuation during a period of widespread fentanyl availability.Design, Setting, and ParticipantsThis retrospective cohort study used statewide Rhode Island Prescription Drug Monitoring Program data. Participants were Rhode Island residents initiating buprenorphine treatment for OUD between October 1, 2016, and September 30, 2020. Data analysis was performed from December 9, 2022, to August 10, 2023.ExposureDaily dose of buprenorphine (16 mg and 24 mg) defined starting on the day of initiation based on total quantity and days’ supply dispensed. Patients were censored on any dose change.Main Outcomes and MeasuresBuprenorphine treatment discontinuation in the 180 days following initiation, defined as a gap in treatment of more than 27 days based on prescription fill dates and days’ supply. Kaplan-Meier and Cox regression survival analyses were conducted to estimate the association between buprenorphine dose and time to treatment discontinuation, controlling for potential informative censoring and measured potential confounders.ResultsAmong 6499 patients initiating buprenorphine treatment for OUD, most were aged 25 to 44 years (57%; n = 3682), were male (61%; n = 3950), and had private (47%; n = 3025) or Medicaid (33%; n = 2153) insurance. More than half of patients were prescribed a daily dose of interest at initiation (16 mg: 50%; n = 3264; 24 mg: 10%; n = 668). In Kaplan-Meier analyses, 58% of patients discontinued buprenorphine treatment within 180 days (16 mg: 59% vs 24 mg: 53%; log-rank test P = .005). In Cox regression analyses, patients prescribed a dose of 16 mg had a greater risk of treatment discontinuation than those prescribed 24 mg (adjusted hazard ratio, 1.20; 95% CI, 1.06-1.37).Conclusions and RelevanceIn this cohort study of patients initiating buprenorphine treatment from 2016 to 2020, patients prescribed a 24 mg dose of buprenorphine remained in treatment longer than those prescribed 16 mg. The value of higher buprenorphine doses than currently recommended needs to be considered for improving retention in treatment.

show abstract

High‐dose buprenorphine for treatment of high potency opioid use disorder

Cited by 18 publications

References 15 publications

High-Dose Buprenorphine Induction in the Emergency Department for Treatment of Opioid Use Disorder

High-Dose Buprenorphine Induction in the Emergency Department for Treatment of Opioid Use Disorder

Opioid agonist treatment in the time of fentanyl: What can we learn from emerging evidence?

Buprenorphine Dose and Time to Discontinuation Among Patients With Opioid Use Disorder in the Era of Fentanyl

Contact Info

Product

Resources

About