Journal Article Annotations
2023, 2nd Quarter
Annotations by Scott A. Simpson, MD, MPH
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.
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.