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

Abstract

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.

Perspectives from law enforcement officers who respond to overdose calls for service and administer naloxone

“…We urge law enforcement departments to reconsider their policies to force overdose victims to the hospital when state or local policies or laws do not mandate this practice. Although there could be some benefits from transporting people who have just overdosed to emergency departments that have robust recovery support, medication-assisted treatment (e.g., buprenorphine induction), and other harm reduction programs (Chen et al,2020;Collins et al, 2021;Curran et al,2021;D'Onofrio et al, 2015;Herring et al,2021), most emergency rooms do not offer culturally competent services for people who have overdosed (Bergstein et al,2021;Biancarelli et al,2019;Chan Carusone et al,2019;Reddy et al,2021). However, the continued demonstrated public health efficacy of naloxone "take home programs" (McDonald et al,2017) point to how first responder "leave behind" naloxone programswhich involve providing kits on scene to the overdose victim, family, and/or friends of the person who overdosed-could greatly mitigate future overdoses and show early promise for connecting victims to treatment (Scharf et al,2021).…”

Buprenorphine for High-dose Tramadol Dependence: A Case Report of Successful Outpatient Treatment

“…Herring et al have recently shown that high-dose buprenorphine (high-dose induction dose defined as greater than 12 mg) is both efficacious and safe in treating patients with opioid use disorder in the ED. 14 Extended-release (ER) tramadol has been shown to be as effective as buprenorphine for treating opioid withdrawal in two randomized controlled trials. Doses up to 600 mg/day of tramadol ER were used successfully in one randomized controlled trial, but the drug was quickly tapered over one week during their residential treatment.…”

Emergency department‐initiated buprenorphine protocols: A national evaluation

“…These initiation doses differ from what is suggested by both SAMHSA and ASAM, which both recommend a lower initial BUP dose of 2–4 mg. 3 , 24 More recent ED literature has also shown that higher doses of BUP (>12 mg during an ED visit) in patients experiencing opioid withdrawal can be tolerated in select patients. 27 , 38 , 39 …”

“…Although 8 mg of BUP for withdrawal was the day 1 limit set by the Food and Drug Administration label for Suboxone (buprenorphine/naloxone), studies have ended day 1 of BUP on a higher total dose. 27 , 38 , 39 , 42 Although the ideal indications for and safety of higher day 1 doses of BUP in patients coming to the ED is under investigation, a higher maximum BUP dose may be beneficial not only for withdrawal relief but also for patients with barriers to follow‐up care such as prolonged wait time for postdischarge follow‐up or prior authorizations. 27 , 30 On the whole, variability in initial and maximum ED doses of BUP and the timing between doses in ED BUP initiation protocols underscore both the flexibility of BUP initiation across different EDs settings and a lack of consensus on best practices.…”

“…They are more often uninsured or underinsured, and many have coexisting mental health issues and unstable housing. 17 , 26 , 27 ED patients often have more acute illnesses compared to those in office‐based settings and may require more intense treatment and monitoring. In addition to these patient‐related differences, EDs are faced with mounting pressures caused by unprecedented crowding; thus, enhancing throughput has become a priority.…”