Incidence of Precipitated Withdrawal During a Multisite Emergency Department–Initiated Buprenorphine Clinical Trial in the Era of Fentanyl

D’Onofrio, Gail; Hawk, Kathryn; Perrone, Jeanmarie; Walsh, Sharon; Lofwall, Michelle R.; Fiellin, David A.; Herring, Andrew A.

doi:10.1001/jamanetworkopen.2023.6108

Cited by 30 publications

(31 citation statements)

References 8 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…A supplemental analysis of randomized clinical trial data estimated incidence to be 1% across multiple EDs, whereas a survey of patients using fentanyl who were entering residential treatment found that 36.5% reported having experienced severe withdrawal after buprenorphine. 2,4,8,30,31 Going forward, it is essential to describe the full range of suboptimal outcomes after buprenorphine administration in real-world settings.…”

Section: Discussionmentioning

confidence: 99%

“…6,7 However, the incidence and risk factors for PW have not been well described in any population. 4,8 Emerging evidence suggests that the prevalence of fentanyl may further complicate buprenorphine induction. [7][8][9][10] In addition, inadequate treatment of withdrawal may discourage patients from future use of buprenorphine.…”

Section: Importancementioning

confidence: 99%

“…4,8 Emerging evidence suggests that the prevalence of fentanyl may further complicate buprenorphine induction. [7][8][9][10] In addition, inadequate treatment of withdrawal may discourage patients from future use of buprenorphine. 6 Newer strategies have altered traditional buprenorphine protocols in individuals who use fentanyl, including low-dose induction, high-dose induction, and deferral of treatment for longer periods of abstinence.…”

Section: Importancementioning

confidence: 99%

“…Adverse outcomes from buprenorphine induction are associated with poor retention in opioid use disorder (OUD) treatment for patients and may deter further implementation efforts 6,7 . However, the incidence and risk factors for PW have not been well described in any population 4,8 . Emerging evidence suggests that the prevalence of fentanyl may further complicate buprenorphine induction 7–10 .…”

Section: Introductionmentioning

confidence: 99%

See 3 more Smart Citations

Precipitated opioid withdrawal after buprenorphine administration in patients presenting to the emergency department: A case series

et al. 2023

View full text Add to dashboard Cite

Objectives Buprenorphine is a highly effective medication for the treatment of opioid use disorder, but it can cause precipitated withdrawal (PW) from opioids. Incidence, risk factors, and best approaches to management of PW are not well understood. Our objective was to describe adverse outcomes after buprenorphine administration among emergency department (ED) patients and assess whether they met the criteria for PW. Methods This study is a case series using retrospective chart review in a convenience sample of patients from 3 hospitals in an urban academic health system. This study included patients who were reported by clinicians as potential cases of PW. Relevant clinical data were abstracted from the electronic health record using a structured retrospective chart review instrument. Results A total of 13 cases were included and classified into the following 3 categories: (1) PW after buprenorphine administration consistent with guidelines (n = 5), (2) PW after deviating from guidelines (n = 4), and (3) protracted opioid withdrawal with no increase in Clinical Opiate Withdrawal Scale score (n = 4). A total of 11 patients had urine drug testing positive for fentanyl, and 11 patients received additional doses of buprenorphine for symptom management. Of the patients, 5 had self‐directed hospital discharges, and 6 were ultimately discharged with prescriptions for buprenorphine. Conclusions Cases of adverse outcomes after buprenorphine administration in the ED and hospital meet criteria for PW, although some cases may have represented protracted opioid withdrawal. Further investigation into the incidence, risk factors, management of PW as well as patient perspectives is needed to expand and sustain the use of buprenorphine in EDs and hospitals.

show abstract

Section: Discussionmentioning

confidence: 99%

Section: Importancementioning

confidence: 99%

Section: Importancementioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Precipitated opioid withdrawal after buprenorphine administration in patients presenting to the emergency department: A case series

et al. 2023

View full text Add to dashboard Cite

show abstract

“…Unfortunately, engagement in treatment at 30 days only increased from 10.2% (40 of 394 patients) to 16.3% (59 of 362 patients). 1 In essence, only 19 additional patients were in treatment at 30 days, and, notably, engagement decreased at 1 of the 4 study sites. Further study is needed to investigate this decreased engagement compared with the 2015 study, in particular the factors associated with the decreased engagement at 1 site.…”

Section: Successful Implementation and Sustainability Of Evidence-bas...mentioning

confidence: 99%

Accelerating Practice Change in the Emergency Department

Weiner

Hoppe

2023

JAMA Netw Open

View full text Add to dashboard Cite

Caring for Hospitalized Adults With Opioid Use Disorder in the Era of Fentanyl

Englander,

Thakrar,

Bagley

et al. 2024

JAMA Intern Med

View full text Add to dashboard Cite

ImportanceThe rise of fentanyl and other high-potency synthetic opioids across US and Canada has been associated with increasing hospitalizations and unprecedented overdose deaths. Hospitalization is a critical touchpoint to engage patients and offer life-saving opioid use disorder (OUD) care when admitted for OUD or other medical conditions.ObservationsClinical best practices include managing acute withdrawal and pain, initiating medication for OUD, integrating harm reduction principles and practices, addressing in-hospital substance use, and supporting hospital-to-community care transitions. Fentanyl complicates hospital OUD care. Fentanyl’s high potency intensifies pain, withdrawal, and cravings and increases the risk for overdose and other harms. Fentanyl’s unique pharmacology has rendered traditional techniques for managing opioid withdrawal and initiating buprenorphine and methadone inadequate for some patients, necessitating novel strategies. Further, co-use of opioids with stimulants drugs is common, and the opioid supply is unpredictable and can be contaminated with benzodiazepines, xylazine, and other substances. To address these challenges, clinicians are increasingly relying on emerging practices, such as low-dose buprenorphine initiation with opioid continuation, rapid methadone titration, and the use of alternative opioid agonists. Hospitals must also reconsider conventional approaches to in-hospital substance use and expand clinicians’ understanding and embrace of harm reduction, which is a philosophy and set of practical strategies that supports people who use drugs to be safer and healthier without judgment, coercion, or discrimination. Hospital-to-community care transitions should ensure uninterrupted access to OUD care after discharge, which requires special consideration and coordination. Finally, improving hospital-based addiction care requires dedicated infrastructure and expertise. Preparing hospitals across the US and Canada to deliver OUD best practices requires investments in clinical champions, staff education, leadership commitment, community partnerships, quality metrics, and financing.Conclusions and RelevanceThe findings of this review indicate that fentanyl creates increased urgency and new challenges for hospital OUD care. Hospital clinicians and systems have a central role in addressing the current drug crisis.

show abstract

Incidence of Precipitated Withdrawal During a Multisite Emergency Department–Initiated Buprenorphine Clinical Trial in the Era of Fentanyl

Abstract: This cohort study examines the incidence of precipitated withdrawal comparing traditional sublingual buprenorphine with a 7-day extended-release injectable initiated in the emergency department (ED).

Cited by 30 publications

References 8 publications

Precipitated opioid withdrawal after buprenorphine administration in patients presenting to the emergency department: A case series

Precipitated opioid withdrawal after buprenorphine administration in patients presenting to the emergency department: A case series

Accelerating Practice Change in the Emergency Department

Caring for Hospitalized Adults With Opioid Use Disorder in the Era of Fentanyl

Contact Info

Product

Resources

About