High-Dose Buprenorphine Initiation in the Emergency Department Among Patients Using Fentanyl and Other Opioids.
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ABSTRACT:
SUBMITTER: Snyder H
PROVIDER: S-EPMC9984967 | biostudies-literature | 2023 Mar
REPOSITORIES: biostudies-literature
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High-Dose Buprenorphine Initiation in the Emergency Department Among Patients Using Fentanyl and Other Opioids.
Snyder Hannah H Chau Brendon B Kalmin Mariah M MM Speener Melissa M Campbell Arianna A Moulin Aimee A Herring Andrew A AA
JAMA network open 20230301 3
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Project description:ImportanceThe rise of high-potency opioids such as fentanyl makes buprenorphine initiation challenging due to the risks of precipitated withdrawal, prompting the exploration of strategies, such as low-dose initiation (LDI) of buprenorphine. However, no comparative studies on LDI outcomes exist.ObjectiveTo evaluate outpatient outcomes associated with 2 LDI protocols of buprenorphine among individuals with opioid use disorder (OUD) using fentanyl.Design, setting, and participantsThis cohort study analyzed data on adults with OUD who self-reported daily fentanyl use and underwent buprenorphine initiation using LDI. Data were extracted from the electronic health records of 2 substance use disorder treatment clinics using a specialty behavioral health pharmacy in San Francisco, California, from May 2021 to November 2022.ExposuresType of LDI protocol selected by individuals: 4-day or 7-day protocol.Main outcomes and measuresThe primary outcome was successful buprenorphine initiation, defined as self-reported LDI completion and pickup of a refill maintenance prescription, and buprenorphine retention. Logistic regression with generalized estimating equations assessed associations between LDI protocol (4-day vs 7-day) and successful initiation, adjusting for multiple attempts, age, gender identity, race and ethnicity, and housing status. Kaplan-Meier survival curves were used to estimate buprenorphine retention, and survival curves were adjusted using a fitted Cox proportional hazards regression model.ResultsA total of 126 individuals (median [IQR] age, 35 [29-44] years; 90 identified as men [71%]; 26 [21%] identified as Black or African American, 20 [16%] as Latine, and 66 [52%] as White individuals) with 175 initiation attempts were included. Across attempts, 72 (41%) had a 4-day LDI protocol and 103 (59%) had a 7-day protocol. Initiation was successful in 60 attempts (34%), including 27 (38%) among 4-day protocol and 29 (28%) among 7-day protocol attempts. Buprenorphine retention rate at 28 days was 21% for a 4-day protocol and 18% for a 7-day protocol. Logistic regression found no significant differences between LDI protocols and successful initiation, while repeated LDI attempts had lower odds of success (second attempt: adjusted odds ratio [AOR], 0.30 [95% CI, 0.14-0.66]; third or more attempt: AOR, 0.22 [95% CI, 0.09-0.53]). Unadjusted and adjusted survival models did not detect a significant difference in retention between LDI protocol types.Conclusions and relevanceThis cohort study found that among people with OUD using fentanyl and attempting outpatient LDI of buprenorphine, successful buprenorphine initiation and retention rates were low. Future studies should examine interventions to improve LDI success and increase buprenorphine uptake and retention.
| S-EPMC11762237 | biostudies-literature
Project description: Not available
| S-EPMC11254164 | biostudies-literature
Project description:ImportanceEmergency 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 follow-up care.ObjectiveTo 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.InterventionsED 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.
| S-EPMC8283555 | biostudies-literature
Project description:ImportanceBuprenorphine treatment of opioid use disorder (OUD) is safe and effective, but opioid withdrawal during treatment initiation is associated with poor retention in care. As fentanyl has replaced heroin in the drug supply, case reports and surveys have indicated increased concern for buprenorphine-precipitated withdrawal (PW); however, some observational studies have found a low incidence of PW.ObjectiveTo estimate buprenorphine PW incidence and assess factors associated with PW among emergency department (ED) or hospitalized patients.Design, setting, and participantsThis retrospective cohort study at 3 academic hospitals in Philadelphia, Pennsylvania, included adults with OUD who underwent traditional or high-dose buprenorphine initiation between January 1, 2020, and December 31, 2021. Exclusion criteria included low-dose buprenorphine initiation and missing documentation of opioid withdrawal severity within 4 hours of receiving buprenorphine.ExposureBuprenorphine initiation with an initial dose of at least 2 mg of sublingual buprenorphine after a Clinical Opiate Withdrawal Scale (COWS) score of 8 or higher. Additional exposures included 4 predefined factors potentially associated with PW: severity of opioid withdrawal before buprenorphine (COWS score of 8-12 vs ≥13), initial buprenorphine dose (2 vs 4 or ≥8 mg), body mass index (BMI) (<25 vs 25 to <30 or ≥30; calculated as weight in kilograms divided by height in meters squared), and urine fentanyl concentration (0 to <20 vs 20 to <200 or ≥200 ng/mL).Main outcome and measuresThe main outcome was PW incidence, defined as a 5-point or greater increase in COWS score from immediately before to within 4 hours after buprenorphine initiation. Logistic regression was used to estimate the odds of PW associated with the 4 aforementioned predefined factors.ResultsThe cohort included 226 patients (150 [66.4%] male; mean [SD] age, 38.6 [10.8] years). Overall, 26 patients (11.5%) met criteria for PW. Among patients with PW, median change in COWS score was 9 points (IQR, 6-13 points). Of 123 patients with confirmed fentanyl use, 20 (16.3%) had PW. In unadjusted and adjusted models, BMI of 30 or greater compared with less than 25 (adjusted odds ratio [AOR], 5.12; 95% CI, 1.31-19.92) and urine fentanyl concentration of 200 ng/mL or greater compared with less than 20 ng/mL (AOR, 8.37; 95% CI, 1.60-43.89) were associated with PW.Conclusions and relevanceIn this retrospective cohort study, 11.5% of patients developed PW after buprenorphine initiation in ED or hospital settings. Future studies should confirm the rate of PW and assess whether bioaccumulated fentanyl is a risk factor for PW.
| S-EPMC11437388 | biostudies-literature
Project description:BackgroundBuprenorphine is an effective treatment for opioid use disorder (OUD); however, buprenorphine initiation can be complicated by withdrawal symptoms including precipitated withdrawal. There has been increasing interest in using low dose initiation (LDI) strategies to reduce this withdrawal risk. As there are limited data on withdrawal symptoms during LDI, we characterize withdrawal symptoms in people with daily fentanyl use who underwent initiation using these strategies as outpatients.MethodsWe conducted a retrospective chart review of patients with OUD using daily fentanyl who were prescribed 7-day or 4-day LDI at 2 substance use disorder treatment clinics in San Francisco. Two addiction medicine experts assessed extracted chart documentation for withdrawal severity and precipitated withdrawal, defined as acute worsening of withdrawal symptoms immediately after taking buprenorphine. A third expert adjudicated disagreements. Data were analyzed using descriptive statistics.ResultsThere were 175 initiations in 126 patients. The mean age was 37 (SD 10 years). 71% were men, 26% women, and 2% non-binary. 21% identified as Black, 16% Latine, and 52% white. 60% were unstably housed and 75% had Medicaid insurance. Substance co-use included 74% who used amphetamines, 29% cocaine, 22% benzodiazepines, and 19% alcohol. Follow up was available for 118 (67%) initiations. There was deviation from protocol instructions in 22% of these initiations with follow up. 31% had any withdrawal, including 21% with mild symptoms, 8% moderate and 2% severe. Precipitated withdrawal occurred in 10 cases, or 8% of initiations with follow up. Of these, 7 had deviation from protocol instructions; thus, there were 3 cases with follow up (3%) in which precipitated withdrawal occurred without protocol deviation.ConclusionsWithdrawal was relatively common in our cohort but was mostly mild, and precipitated withdrawal was rare. Deviation from instructions, structural barriers, and varying fentanyl use characteristics may contribute to withdrawal. Clinicians should counsel patients who use fentanyl that mild withdrawal symptoms are likely during LDI, and there is still a low risk for precipitated withdrawal. Future studies should compare withdrawal across initiation types, seek ways to support patients in initiating buprenorphine, and qualitatively elicit patients' withdrawal experiences.
| S-EPMC11005253 | biostudies-literature
Project description:Buprenorphine initiation in the Emergency Department (ED) has been hailed as an evidence-based strategy to mitigate the opioid overdose crisis, but its implementation has been limited. This scoping review synthesizes barriers and facilitators to buprenorphine initiation in the ED, and uses the Consolidated Framework for Implementation Research and a critical lens to analyze the literature. Results demonstrate an immense effort across the U.S. and Canada to implement ED-initiated buprenorphine. Facilitators include multidisciplinary addiction teams and co-located, low-barrier, harm reduction-informed services to support transitions. Barriers include a failure to address structural stigma, client complexity, and an increasingly toxic drug supply. The literature also misses the opportunity to include the perspectives of service users, health administrators, and learners. Increased coordination of implementation efforts, and a shift to equitable and inclusive opioid agonist therapy initiation pathways are needed across the U.S. and Canada.
| S-EPMC11459582 | biostudies-literature
Project description: Not available
| S-EPMC10064247 | biostudies-literature
Project description:The United States is currently facing an epidemic of opioid-related deaths, increasingly associated with fentanyl use. Our objective was to characterize rates of fentanyl, general opioid and non-opioid pain medication prescription at a national level in both outpatient and emergency department settings. We used a retrospective cross-sectional research design using data from the 2006-2015 National Ambulatory Medical Care Surveys and National Hospital Ambulatory Medical Care Surveys. Between 2006-2015, 66,987 (17.4%) of 390,538 office-based outpatient visits (nationally-representative of 961 million visits) and 134,953 (45.0%) of 305,570 ED visits (nationally-representative of 130 million visits) listed a pain medication prescription. The proportion of all outpatient visits in which any pain medication was prescribed increased from 15.0% in 2006-2007 to 20.5% in 2014-2015 (p?<?0.001). The proportion of all outpatient visits in which any fentanyl product was prescribed remained stable at 0.3% and 0.4% (p?=?0.32), but increased among ED visits from 0.5% to 1.1% (p?=?0.006). In contrast, the proportion of all outpatient visits in which any opioid product was prescribed increased from 6.6% to 9.7% (p?<?0.001), but remained relatively stable among ED visits from 26.2% to 24.4% (p?=?0.07). Non-opioid pain medication prescription increased in both settings, from 9.7% to 13.7% (p?<?0.001) in the outpatient setting and from 25.6% to 27.6% (p?=?0.02) in the ED setting between 2006-2007 and 2014-2015, respectively. To address current opioid crisis, both clinical and public health interventions are needed, such as targeted education outreach on evidence-based opioid prescribing and non-opioid alternatives.
| S-EPMC6534435 | biostudies-literature
Project description:ObjectiveEmergency 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).MethodsIn 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.ResultsAll 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.ConclusionsIn 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.
| S-EPMC8630357 | biostudies-literature
Project description:ObjectiveIntranasal fentanyl (INF) quickly and noninvasively relieves severe pain, whereas intravenous hydromorphone (IVH) reliably treats severe cancer pain but requires vascular access. The trial evaluated the efficacy of INF relative to IVH for treating cancer patients with severe pain in an emergency department (ED) setting.MethodsWe randomized 82 patients from a comprehensive cancer center ED to receive INF (n = 42) or IVH (n = 40). Eligible patients reported severe pain at randomization (≥7, scale: 0 "none" to 10 "worst pain"). We conducted non-inferiority comparisons (non-inferiority margin = 0.9) of pain change from treatment initiation (T0) to one hour later (T60). T0 pain ratings were unavailable; therefore, we estimated T0 pain by comparing 1) T60 ratings, assuming similar group T0 ratings; 2) pain change, estimating T0 pain = randomization ratings, and 3) pain change, with T0 pain = 10 (IVH group) or T0 pain = randomization rating (INF group).ResultsAt T60, the upper 90% confidence limit (CL) of the mean log-transformed pain ratings for the INF group exceeded the mean IVH group rating by 0.16 points (>pain). Substituting randomization ratings for T0 pain, the lower 90% CL of mean pain change in the INF group extended 0.32 points below (<pain relief) mean change in the IVH group. Finally, assuming all subjects in the IVH group had maximum pain at T0 and that T0 pain for the INF group remained unchanged from randomization, the lower bound of the 90% CL for mean pain decrease in the INF group extended 1.37 points below (<pain relief) mean decrease in the IVH group. Time (minutes) from randomization until T0 was longer for the IVH (Median 23, IQR 12) versus INF (Median 15, IQR 11) group (P<0.001).ConclusionsTwo of three analyses supported non-inferiority of INF versus IVH, while one analysis was inconclusive. Compared to IVH, INF had the advantage of shorter time to administration.Trial registrationClinicalTrials.gov Identifier: NCT02459964.
| S-EPMC7351205 | biostudies-literature