Managing opioid withdrawal precipitated by buprenorphine with buprenorphine

Oakley, Bridget; Wilson, Hester; Hayes, Victoria; Lintzeris, Nicholas

doi:10.1111/dar.13228

Cited by 24 publications

(22 citation statements)

References 6 publications

(13 reference statements)

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“…3 , 24 ACEP recommends both additional BUP and ancillary medications for targeted symptoms but acknowledges the limited published data on the rapid effectiveness of additional BUP. 31 , 43 …”

Section: Discussionmentioning

confidence: 99%

Emergency department‐initiated buprenorphine protocols: A national evaluation

et al. 2021

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Objective Emergency department‐initiated buprenorphine (BUP) for opioid use disorder is an evidence‐based practice, but limited data exist on BUP initiation practices in real‐world settings. We sought to characterize protocols for BUP initiation among a geographically diverse sample of emergency departments (EDs). Methods In December 2020, we reviewed prestudy clinical BUP initiation protocols from all EDs participating in CTN0099 Emergency Department‐INitiated bupreNOrphine VAlidaTION (ED‐INNOVATION). We abstracted information on processes for identification of treatment‐eligible patients, BUP administration, and discharge care. Results All participating ED‐INNOVATION sites across 22 states submitted protocols; 31 protocols were analyzed. Identification of treatment‐eligible patients : Most EDs 22 (71%) relied on clinician judgment to determine appropriateness of BUP treatment with only 7 (23%) requiring decision support tools or diagnosis checklists. Before BUP initiation, 27 (87%) protocols required a documented Clinical Opiate Withdrawal Scale (COWS) score; 4 (13%) required a clinical diagnosis of withdrawal with optional COWS score. Twenty‐seven (87%) recommended a minimum COWS score of 8 for ED‐initiated BUP. BUP administration : Initial BUP dose ranged from 2–16 mg (mode = 4). For continued withdrawal symptoms, 27 (87%) protocols recommended an interval of 30–60 minutes between first and second BUP dose. Total BUP dose in the ED ranged from 8 to 32 mg. Discharge care : Twenty‐eight (90%) protocols recommended a BUP prescription (mode 16 mg daily) at discharge. Naloxone prescription and/or provision was suggested in 23 (74%) protocols. Conclusions In this geographically diverse sample of EDs, protocols for ED‐initiated BUP differed between sites. Future work should evaluate the association between this variation and patient outcomes.

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Section: Discussionmentioning

confidence: 99%

Emergency department‐initiated buprenorphine protocols: A national evaluation

et al. 2021

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“…High-dose (eg, 16 mg) buprenorphine alone may be sufficient to induce rapid withdrawal and “rescue” simultaneously in monitored inpatient settings. Somewhat paradoxically, buprenorphine “rescue” may also be therapeutically useful in cases of buprenorphine inductions that unintentionally precipitate withdrawal (ie, rescuing from buprenorphine with more buprenorphine) 20 . With more study, protocols that eliminate the gradual methadone taper may become the “standard” transition of the future.…”

Section: Discussionmentioning

confidence: 99%

Rapid Transition to Buprenorphine in a Patient With Methadone-Related QTc Interval Prolongation

Brogdon

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Cox

et al. 2021

Journal of Addiction Medicine

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BackgroundPatients with opioid use disorder (OUD) who are managed on methadone often require transition to buprenorphine therapy. Current recommendations require months to gradually taper off of methadone; however, in some cases, the need to transition is urgent. Only a few rapid methadone-to-buprenorphine transitions have been reported and there are no established protocols to guide clinicians in these cases.Case PresentationA 43-year-old man on 95 mg methadone for opioid use disorder experienced cardiac arrest attributable to ventricular fibrillation caused by QTc interval prolongation from methadone. In the hospital, a gradual taper of methadone was initiated but proved intolerable; the patient requested to restart his home dose of methadone and leave against medical advice. A rapid transition was initiated instead. Naltrexone (25 mg) was used to precipitate acute withdrawal followed 1 hour later by a “rescue” with buprenorphine/naloxone (16 mg/4 mg). The Clinical Opiate Withdrawal Score (COWS) peaked at 21 post-naltrexone and fell quickly to 15 within a half-hour of buprenorphine/naloxone administration. The patient was maintained on a total daily dose of 16 mg/4 mg buprenorphine/naloxone through the time of discharge.ConclusionsA patient requiring an urgent taper off of methadone due to adverse cardiac effects successfully transitioned to buprenorphine/naloxone within 2 hours by using naltrexone to precipitate withdrawal followed by a “rescue” with buprenorphine/naloxone. A relatively high dose of 16 mg/4 mg buprenorphine/naloxone successfully arrested withdrawal symptoms. With further refinement, this protocol may be an important technique for urgent methadone-to-buprenorphine transitions in the inpatient setting.

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“…Traditional initiation of therapy, in fact, requires the patient to be in withdrawal, for which clinicians may offer patients medications to self-manage. Precipitated withdrawal, which can occur during buprenorphine initiation, involves symptoms of severe opioid withdrawal that may require emergency medical care [ 69 ]. This condition has become more frequent in the context of fentanyl use, leading to novel approaches to initiating buprenorphine like overlap or low-dose initiation (see “Initiating Buprenorphine”) [ 70 ].…”

Section: Managing Opioid Use Disordermentioning

confidence: 99%

Primary care management of Long-Term opioid therapy

et al. 2022

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The United States underwent massive expansion in opioid prescribing from 1990–2010, followed by opioid stewardship initiatives and reduced prescribing. Opioids are no longer considered first-line therapy for most chronic pain conditions and clinicians should first seek alternatives in most circumstances. Patients who have been treated with opioids long-term should be managed differently, sometimes even continued on opioids due to physiologic changes wrought by long-term opioid therapy and documented risks of discontinuation. When providing long-term opioid therapy, clinicians should document opioid stewardship measures, including assessments, consents, medication reconciliation, and offering naloxone, along with the rationale to continue opioid therapy. Clinicians should screen regularly for opioid use disorder and arrange for or directly provide treatment. In particular, buprenorphine can be highly useful for co-morbid pain and opioid use disorder. Addressing other substance use disorders, as well as preventive health related to substance use, should be a priority in patients with opioid use disorder. Patient-centered practices, such as shared decision-making and attending to related facets of a patient’s life that influence health outcomes, should be implemented at all points of care. Key messages Although opioids are no longer considered first-line therapy for most chronic pain, management of patients already taking long-term opioid therapy must be individualised. Documentation of opioid stewardship measures can help to organise opioid prescribing and protect clinicians from regulatory scrutiny. Management of resultant opioid use disorder should include provision of medications, most often buprenorphine, and several additional screening and preventive measures.

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Managing opioid withdrawal precipitated by buprenorphine with buprenorphine

Cited by 24 publications

References 6 publications

Emergency department‐initiated buprenorphine protocols: A national evaluation

Emergency department‐initiated buprenorphine protocols: A national evaluation

Rapid Transition to Buprenorphine in a Patient With Methadone-Related QTc Interval Prolongation

Primary care management of Long-Term opioid therapy

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