Journal Article Annotations
2023, 2nd Quarter

Emergency Psychiatry

Annotations by Scott A. Simpson, MD, MPH
July, 2023

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

PUBLICATION #1 — Emergency psychiatry

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

Andrew A Herring, Aidan A Vosooghi, Joshua Luftig, Erik S Anderson, Xiwen Zhao, James Dziura, Kathryn F Hawk, Ryan P McCormack, Andrew Saxon, Gail D’Onofrio

Abstract: JAMA Netw Open. 2021 Jul 1;4(7):e2117128. doi: 10.1001/jamanetworkopen.2021.17128.

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 follow-up 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 participants:
In 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 measures:
Vital 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).

Results:
Among 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 relevance:
These 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.

Annotation

The finding:
Emergency department (ED)-initiated buprenorphine has become common, but this intervention is complicated by the increasing potency of the illicit opioid supply, particularly with fentanyl, that may decrease the effectiveness and increase potential risks associated with ED induction. One proposed adaptation of ED-initiated buprenorphine is to increase the dose of buprenorphine administered in the ED. This retrospective review describes 579 cases from a single site, including 366 inductions in which patients received more than 12mg buprenorphine and 138 receiving more than 28mg. Despite high rates of medical, social, and psychiatric comorbidity, there were no serious adverse events associated with administration. The rate of precipitated withdrawal was 0.8%: 4 of the 5 cases occurred after dosing of 8mg.

Strength and weaknesses:
This is a large, real-world review of an implementation of ED-initiated buprenorphine program. Accordingly, the patient population is diverse and comorbid. However, all data were obtained from the ED encounter, and follow-up engagement rates were unavailable. The definition of precipitated withdrawal was narrow—an increase of a COWS score within 1 hour after buprenorphine administration or a diagnosis. The authors helpfully include the described protocol, which requires patients to have not used in at least the past 12 hours.

Relevance:
The study demonstrates that higher doses of buprenorphine appear to be well-tolerated and safe when clinically indicated. The benefits of higher dose treatment are less certain. Higher doses can help with acute withdrawal symptoms, but whether this reduces the risk of relapse or overdose, or improves treatment engagement, is not demonstrated here. In addition, the described protocol suggests patients should have not used for 12 hours or longer. Longer abstention makes precipitated withdrawal less likely, but many patients present sooner, and better evidence is needed to direct clinicians in selecting among buprenorphine in high doses, microdosing, or methadone.