key: cord-0019153-gdr9pmk3
authors: Herring, Andrew A.; Vosooghi, Aidan A.; Luftig, Joshua; Anderson, Erik S.; Zhao, Xiwen; Dziura, James; Hawk, Kathryn F.; McCormack, Ryan P.; Saxon, Andrew; D’Onofrio, Gail
title: High-Dose Buprenorphine Induction in the Emergency Department for Treatment of Opioid Use Disorder
date: 2021-07-15
journal: JAMA Netw Open
DOI: 10.1001/jamanetworkopen.2021.17128
sha: b6c94f9d788b3dbc623743afce56cc367f4be5f7
doc_id: 19153
cord_uid: gdr9pmk3

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.

Please review the entire clinical chart and note if any of the following signs or symptoms of withdrawal were documented within 6 hours after first buprenorphine administration. (1) Which of the following signs or symptoms of withdrawal were documented after the first 6 hours following first buprenorphine administration until discharge? 

1' 1097 return_gi_7 Show the field ONLY if: [return_wd_7] = '1' 1098 return_anxiety_7 Show the field ONLY if: [return_wd_7] = '1' Section Header: Return Intoxication 7 Which of the following signs or symptoms of intoxication were documented?

Which of the following gastrointestinal signs or symptoms were documented in the discharge summary notes?Section Header: Admit AnxietyWhich of the following signs or symptoms of anxiety were documented in the discharge summary notes?Section Header: Admit WithdrawalWhich of the following signs or symptoms of withdrawal were documented in the discharge summary notes? Did the patient or provider mention opioid cravings during the visit?Did the patient complaint about or exhibit any signs or symptoms of withdrawal during this visit?If the patient received buprenorphine during this visit, only select signs/symptoms documented BEFORE buprenorphine administration.Section Header: Return Sedation 5Which of the following signs or symptoms of sedation were documented?Section Header: Return Intoxication 5Which of the following signs or symptoms of intoxication were documented? yesno 1 Yes Which of the following gastrointestinal signs or symptoms were documented?Section Header: Return Anxiety 5Which of the following signs or symptoms of anxiety were documented?Section Header: Return Withdrawal 5Which of the following signs or symptoms of withdrawal were documented?