High-Dose Buprenorphine Initiation in the Emergency Department Among Patients Using Fentanyl and Other Opioids

Snyder, Hannah; Chau, Brendon; Kalmin, Mariah M; Speener, Melissa; Campbell, Arianna; Moulin, Aimee; Herring, Andrew A.

doi:10.1001/jamanetworkopen.2023.1572

Cited by 12 publications

(7 citation statements)

References 5 publications

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“…8 High-dose buprenorphine is another initiation strategy where opioid discontinuation is followed by rapid HDB (≥8 mg starting dose). 11,12 This strategy is based on the premise that increasing initial doses of buprenorphine beyond 8 mg sublingual (SL) will result in increasing agonist MOR activation and strengthening opioid blockade-both conferring significant advantages. Typically, HDB expects a period of opioid abstinence, which is highly variable.…”

Section: Consideration Statements Kq1: What Specific Clinical Situati...mentioning

confidence: 99%

“…4 In addition, 2 retrospective cohort studies of HDB across 16 EDs reported no increased adverse events compared with standard initiation; however, 1 study occurred before widespread HPSO, and the other reported a low incidence of HPSO use. 11,12…”

Section: Consideration Statements Kq1: What Specific Clinical Situati...mentioning

confidence: 99%

“…A prospective cohort study of ED patients with >75% confirmed HPSO exposure reported precipitated OWS in <1% after receiving buprenorphine initial doses of 8 mg or greater 4 . In addition, 2 retrospective cohort studies of HDB across 16 EDs reported no increased adverse events compared with standard initiation; however, 1 study occurred before widespread HPSO, and the other reported a low incidence of HPSO use 11,12 …”

Section: Narrative Literature Searchmentioning

confidence: 99%

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ASAM Clinical Considerations: Buprenorphine Treatment of Opioid Use Disorder for Individuals Using High-potency Synthetic Opioids

et al. 2023

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Treatment of opioid use disorder (OUD) with buprenorphine has evolved considerably in the last decade as the scale of the OUD epidemic has increased along with the emergence of high-potency synthetic opioids (HPSOs) and stimulants in the drug supply. These changes have outpaced the development of prospective research, so a clinical consideration document based on expert consensus is needed to address pressing clinical questions. This clinical considerations document is based on a narrative literature review and expert consensus and will specifically address considerations for changes to the clinical practice of treatment of OUD with buprenorphine for individuals using HPSO. An expert panel developed 6 key questions addressing buprenorphine initiation, stabilization, and long-term treatment for individuals with OUD exposed to HPSO in various treatment settings. Broadly, the clinical considerations suggest that individualized strategies for buprenorphine initiation may be needed. The experience of opioid withdrawal negatively impacts the success of buprenorphine treatment, and attention to its management before and during buprenorphine initiation should be proactively addressed. Buprenorphine dose and dosing frequency should be individualized based on patients’ treatment needs, the possibility of novel components in the drug supply should be considered during OUD treatment, and all forms of opioid agonist treatment should be offered and considered for patients. Together, these clinical considerations attempt to be responsive to the challenges and opportunities experienced by frontline clinicians using buprenorphine for the treatment of OUD in patients using HPSOs and highlight areas where prospective research is urgently needed.

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Section: Consideration Statements Kq1: What Specific Clinical Situati...mentioning

confidence: 99%

Section: Consideration Statements Kq1: What Specific Clinical Situati...mentioning

confidence: 99%

Section: Narrative Literature Searchmentioning

confidence: 99%

See 1 more Smart Citation

ASAM Clinical Considerations: Buprenorphine Treatment of Opioid Use Disorder for Individuals Using High-potency Synthetic Opioids

et al. 2023

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“…A qualitative study of hospitalist perspectives on buprenorphine identified a lack of training, inpatient management resources, and community referral networks as barriers to prescribing 7 . Hospitalists may also be concerned about precipitating opioid withdrawal in the setting of lipophilic opioids like fentanyl 8 . Finally, stigma is a barrier to prescribing buprenorphine among clinicians 9 .…”

Section: Policy In Clinical Practicementioning

confidence: 99%

“…7 Hospitalists may also be concerned about precipitating opioid withdrawal in the setting of lipophilic opioids like fentanyl. 8 Finally, stigma is a barrier to prescribing buprenorphine among clinicians. 9 Efforts to address these barriers include educational interventions, prescribing champions, toolkits with training resources, institutional protocols and order sets, and addiction consult teams.…”

Section: Terminology and Acronyms Background And Historymentioning

confidence: 99%

Policy in clinical practice: Elimination of the buprenorphine “X‐waiver”

Haber,

Nguyen,

Taub

et al. 2023

Journal of Hospital Medicine

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Precipitated Withdrawal in the Era of Street Fentanyl—The Important Thing Is to Not Stop Questioning

Soares,

Schoenfeld,

Friedmann

2024

JAMA Netw Open

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High-Dose Buprenorphine Initiation in the Emergency Department Among Patients Using Fentanyl and Other Opioids

Abstract: This cohort study examines buprenorphine treatment initiation, response, and follow-up among patients presenting to California emergency departments (EDs) who reported fentanyl or other opioid use.

Cited by 12 publications

References 5 publications

ASAM Clinical Considerations: Buprenorphine Treatment of Opioid Use Disorder for Individuals Using High-potency Synthetic Opioids

ASAM Clinical Considerations: Buprenorphine Treatment of Opioid Use Disorder for Individuals Using High-potency Synthetic Opioids

Policy in clinical practice: Elimination of the buprenorphine “X‐waiver”

Precipitated Withdrawal in the Era of Street Fentanyl—The Important Thing Is to Not Stop Questioning

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