Advertisement

Approach to buprenorphine use for opioid withdrawal treatment in the emergency setting

Published:October 11, 2018DOI:https://doi.org/10.1016/j.ajem.2018.10.013

      Abstract

      Introduction

      Opioid use disorder (OUD) is increasing in prevalence throughout the world, with approximately three million individuals in the United States affected. Buprenorphine is a medication designed, researched, and effectively used to assist in OUD recovery.

      Objective

      This narrative review discusses an approach to initiating buprenorphine in the emergency department (ED) for opioid-abuse recovery.

      Discussion

      Buprenorphine is a partial mu-opioid receptor agonist with high affinity and low intrinsic activity. Buprenorphine's long half-life, high potency, and ‘ceiling effect’ for both euphoric sensation and adverse effects make it an optimal treatment alternative for patients presenting to the ED with opioid withdrawal. While most commonly provided as a sublingual film or tablet, buprenorphine can also be delivered via transbuccal, transdermal, subdermal (implant), subcutaneous, and parenteral routes. Prior to ED administration, caution is recommended to avoid precipitation of buprenorphine-induced opioid withdrawal. Following the evaluation of common opioid withdrawal symptoms, a step-by-step approach to buprenorphine can by utilized to reach a sustained withdrawal relief. A multimodal medication-assisted treatment (MAT) plan involving pharmacologic treatment, as well as counseling and behavioral therapy, is essential to maintaining opioid remission. Patients may be safely discharged with safe-use counseling, close outpatient follow-up, and return precautions for continued management of their OUD. Establishing a buprenorphine program in the ED involves a multifactorial approach to establish a pro-buprenorphine culture.

      Conclusions

      Buprenorphine is an evidence-based, safe, effective treatment option for OUD in an ED-setting. Though successfully utilized by many ED-based treatment programs, the stigma of ‘replacing one opioid with another’ remains a barrier. Evidence-based discussions on the safety and benefits of buprenorphine are essential to promoting a culture of acceptance and optimizing ED OUD treatment.

      Keywords

      To read this article in full you will need to make a payment
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to The American Journal of Emergency Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Porter J.
        • Jick H.
        Addiction rare in patients treated with narcotics.
        N Engl J Med. 1980; 302: 123
        • Soyka M.
        New developments in the management of opioid dependence: focus on sublingual buprenorphine-naloxone.
        Subst Abus Rehabil. 2015; 6: 1-14
        • Ahmad F.
        • Rossen L.
        • Spencer M.
        • Warner M.
        • Sutton P.
        NCfH Statistics Provisional drug overdose death counts. Center for Disease Control and Prevention, 2018
        • Gowing L.
        • Ali R.
        • White J.
        Buprenorphine for the management of opioid withdrawal.
        Cochrane Database Syst Rev. 2006; 2CD002025
        • Mattick R.P.
        • Breen C.
        • Kimber J.
        • Davoli M.
        Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence.
        Cochrane Database Syst Rev. 2014; 2CD002207
        • Khanna I.K.
        • Pillarisetti S.
        Buprenorphine - an attractive opioid with underutilized potential in treatment of chronic pain.
        J Pain Res. 2015; 8: 859-870
        • Mercadante S.
        • Casuccio A.
        • Tirelli W.
        • Giarratano A.
        Equipotent doses to switch from high doses of opioids to transdermal buprenorphine.
        Support Care Cancer. 2009; 17: 715-718
        • Davis M.P.
        Twelve reasons for considering buprenorphine as a frontline analgesic in the management of pain.
        J Support Oncol. 2012; 10: 209-219
        • Tzschentke T.M.
        Behavioral pharmacology of buprenorphine, with a focus on preclinical models of reward and addiction.
        Psychopharmacology (Berl). 2002; 161: 1-16
        • White L.D.
        • Hodge A.
        • Vlok R.
        • Hurtado G.
        • Eastern K.
        • Melhuish T.M.
        Efficacy and adverse effects of buprenorphine in acute pain management: systematic review and meta-analysis of randomised controlled trials.
        Br J Anaesth. 2018; 120: 668-678
        • Megarbane B.
        • Marie N.
        • Pirnay S.
        • Borron S.W.
        • Gueye P.N.
        • Risede P.
        • et al.
        Buprenorphine is protective against the depressive effects of norbuprenorphine on ventilation.
        Toxicol Appl Pharmacol. 2006; 212: 256-267
        • Dahan A.
        • Yassen A.
        • Romberg R.
        • Sarton E.
        • Teppema L.
        • Olofsen E.
        • et al.
        Buprenorphine induces ceiling in respiratory depression but not in analgesia.
        Br J Anaesth. 2006; 96: 627-632
        • Walsh S.L.
        • Preston K.L.
        • Stitzer M.L.
        • Cone E.J.
        • Bigelow G.E.
        Clinical pharmacology of buprenorphine: ceiling effects at high doses.
        Clin Pharmacol Ther. 1994; 55: 569-580
        • Schuckit M.A.
        Treatment of opioid-use disorders.
        N Engl J Med. 2016; 375: 1596-1597
        • Raffa R.B.
        • Haidery M.
        • Huang H.M.
        • Kalladeen K.
        • Lockstein D.E.
        • Ono H.
        • et al.
        The clinical analgesic efficacy of buprenorphine.
        J Clin Pharm Ther. 2014; 39: 577-583
        • Vadivelu N.
        • Hines R.L.
        Buprenorphine: a unique opioid with broad clinical applications.
        J Opioid Manag. 2007; 3: 49-58
        • Kay B.
        A double-blind comparison of morphine and buprenorphine in the prevention of pain after operation.
        Br J Anaesth. 1978; 50: 605-609
        • Corli O.
        • Montanari M.
        • Deandrea S.
        • Greco M.T.
        • Villani W.
        • Apolone G.
        An exploratory analysis on the effectiveness of four strong opioids in patients with cancer pain.
        Pain Med. 2012; 13: 897-907
        • FDA
        FDA approves first generic versions of Suboxone sublingual film, which may increase access to treatment for opioid dependence.
        (Available from)
        • Voelker R.
        Generic for opioid use disorder.
        JAMA. 2018; 320: 228
        • Welsh C.
        • Valadez-Meltzer A.
        Buprenorphine: a (relatively) new treatment for opioid dependence.
        Psychiatry (Edgmont). 2005; 2: 29-39
        • Kuhlman Jr., J.J.
        • Lalani S.
        • Magluilo Jr., J.
        • Levine B.
        • Darwin W.D.
        Human pharmacokinetics of intravenous, sublingual, and buccal buprenorphine.
        J Anal Toxicol. 1996; 20: 369-378
        • Kobayashi K.
        • Yamamoto T.
        • Chiba K.
        • Tani M.
        • Shimada N.
        • Ishizaki T.
        • et al.
        Human buprenorphine N-dealkylation is catalyzed by cytochrome P450 3A4.
        Drug Metab Dispos. 1998; 26: 818-821
        • Brown S.M.
        • Holtzman M.
        • Kim T.
        • Kharasch E.D.
        Buprenorphine metabolites, buprenorphine-3-glucuronide and norbuprenorphine-3-glucuronide, are biologically active.
        Anesthesiology. 2011; 115: 1251-1260
        • Cone E.J.
        • Gorodetzky C.W.
        • Yousefnejad D.
        • Buchwald W.F.
        • Johnson R.E.
        The metabolism and excretion of buprenorphine in humans.
        Drug Metab Dispos. 1984; 12: 577-581
        • Zhang W.
        • Ramamoorthy Y.
        • Tyndale R.F.
        • Sellers E.M.
        Interaction of buprenorphine and its metabolite norbuprenorphine with cytochromes p450 in vitro.
        Drug Metab Dispos. 2003; 31: 768-772
        • Hammig R.
        • Kemter A.
        • Strasser J.
        • von Bardeleben U.
        • Gugger B.
        • Walter M.
        • et al.
        Use of microdoses for induction of buprenorphine treatment with overlapping full opioid agonist use: the Bernese method.
        Subst Abus Rehabil. 2016; 7: 99-105
        • Walsh S.L.
        • Eissenberg T.
        The clinical pharmacology of buprenorphine: extrapolating from the laboratory to the clinic.
        Drug Alcohol Depend. 2003; 70: S13-S27
        • Rosado J.
        • Walsh S.L.
        • Bigelow G.E.
        • Strain E.C.
        Sublingual buprenorphine/naloxone precipitated withdrawal in subjects maintained on 100mg of daily methadone.
        Drug Alcohol Depend. 2007; 90: 261-269
        • Ducharme S.
        • Fraser R.
        • Gill K.
        Update on the clinical use of buprenorphine: in opioid-related disorders.
        Can Fam Physician. 2012; 58: 37-41
        • Wesson D.R.
        • Ling W.
        The clinical opiate withdrawal scale (COWS).
        J Psychoactive Drugs. 2003; 35: 253-259
        • Jutras-Aswad D.
        • Widlitz M.
        • Scimeca M.M.
        Treatment of buprenorphine precipitated withdrawal: a case report.
        Am J Addict. 2012; 21: 492-493
        • Gangahar D.
        A case of rhabdomyolysis associated with severe opioid withdrawal.
        Am J Addict. 2015; 24: 400-402
        • Davies D.
        Buprenorphine versus methadone--safety first?.
        Br J Gen Pract. 2005; 55: 232-233
        • Sacerdote P.
        Opioid-induced immunosuppression.
        Curr Opin Support Palliat Care. 2008; 2: 14-18
        • Sacerdote P.
        • Franchi S.
        • Gerra G.
        • Leccese V.
        • Panerai A.E.
        • Somaini L.
        Buprenorphine and methadone maintenance treatment of heroin addicts preserves immune function.
        Brain Behav Immun. 2008; 22: 606-613
        • Neri S.
        • Bruno C.M.
        • Pulvirenti D.
        • Malaguarnera M.
        • Italiano C.
        • Mauceri B.
        • et al.
        Randomized clinical trial to compare the effects of methadone and buprenorphine on the immune system in drug abusers.
        Psychopharmacology (Berl). 2005; 179: 700-704
        • Franchi S.
        • Panerai A.E.
        • Sacerdote P.
        Buprenorphine ameliorates the effect of surgery on hypothalamus-pituitary-adrenal axis, natural killer cell activity and metastatic colonization in rats in comparison with morphine or fentanyl treatment.
        Brain Behav Immun. 2007; 21: 767-774
        • Fareed A.
        • Patil D.
        • Scheinberg K.
        • Blackinton Gale R.
        • Vayalapalli S.
        • Casarella J.
        • et al.
        Comparison of QTc interval prolongation for patients in methadone versus buprenorphine maintenance treatment: a 5-year follow-up.
        J Addict Dis. 2013; 32: 244-251
        • Poole S.A.
        • Pecoraro A.
        • Subramaniam G.
        • Woody G.
        • Vetter V.L.
        Presence or absence of QTc prolongation in buprenorphine-naloxone among youth with opioid dependence.
        J Addict Med. 2016; 10: 26-33
        • Anchersen K.
        • Clausen T.
        • Gossop M.
        • Hansteen V.
        • Waal H.
        Prevalence and clinical relevance of corrected QT interval prolongation during methadone and buprenorphine treatment: a mortality assessment study.
        Addiction. 2009; 104: 993-999
        • Micromedex
        Buprenorphine drug information. clinical knowledge: medication, disease and toxicology [internet].
        (Available at)
        • Zedler B.K.
        • Mann A.L.
        • Kim M.M.
        • Amick H.R.
        • Joyce A.R.
        • Murrelle E.L.
        • et al.
        Buprenorphine compared with methadone to treat pregnant women with opioid use disorder: a systematic review and meta-analysis of safety in the mother, fetus and child.
        Addiction. 2016; 111: 2115-2128
        • ACOG
        Opioid use and opioid use disorder in pregnancy.
        The American College of Obstetricians and Gynecologists
        Washington, DC
        Date: 2017
        (Available at)
        • Kraft W.K.
        • Adeniyi-Jones S.C.
        • Ehrlich M.E.
        Buprenorphine for the neonatal abstinence syndrome.
        N Engl J Med. 2017; 377: 997-998
        • Marquet P.
        • Chevrel J.
        • Lavignasse P.
        • Merle L.
        • Lachatre G.
        Buprenorphine withdrawal syndrome in a newborn.
        Clin Pharmacol Ther. 1997; 62: 569-571
        • Grimm D.
        • Pauly E.
        • Poschl J.
        • Linderkamp O.
        • Skopp G.
        Buprenorphine and norbuprenorphine concentrations in human breast milk samples determined by liquid chromatography-tandem mass spectrometry.
        Ther Drug Monit. 2005; 27: 526-530
        • Sachs H.C.
        • Committee On D
        The transfer of drugs and therapeutics into human breast milk: an update on selected topics.
        Pediatrics. 2013; 132: e796-e809
        • Likar R.
        • Sittl R.
        Transdermal buprenorphine for treating nociceptive and neuropathic pain: four case studies.
        Anesth Analg. 2005; 100 ([table of contents]): 781-785
        • Muriel Villoria C.
        • Perez-Castejon Garrote J.M.
        • Sanchez Magro I.
        • Neira Alvarez M.
        Effectiveness and safety of transdermal buprenorphine for chronic pain treatment in the elderly: a prospective observational study.
        Med Clin (Barc). 2007; 128: 204-210
        • Pergolizzi J.
        • Boger R.H.
        • Budd K.
        • Dahan A.
        • Erdine S.
        • Hans G.
        • et al.
        Opioids and the management of chronic severe pain in the elderly: consensus statement of an international expert panel with focus on the six clinically most often used World Health Organization step III opioids (buprenorphine, fentanyl, hydromorphone, methadone, morphine, oxycodone).
        Pain Pract. 2008; 8: 287-313
        • Davis M.P.
        Buprenorphine in cancer pain.
        Support Care Cancer. 2005; 13: 878-887
        • Vestergaard P.
        • Rejnmark L.
        • Mosekilde L.
        Fracture risk associated with the use of morphine and opiates.
        J Intern Med. 2006; 260: 76-87
        • Chang Y.
        • Moody D.E.
        Glucuronidation of buprenorphine and norbuprenorphine by human liver microsomes and UDP-glucuronosyltransferases.
        Drug Metab Lett. 2009; 3: 101-107
        • Ciccozzi A.
        • Angeletti C.
        • Baldascino G.
        • Petrucci E.
        • Bonetti C.
        • De Santis S.
        • et al.
        High dose of buprenorphine in terminally ill patient with liver failure: efficacy and tolerability.
        J Opioid Manag. 2012; 8: 253-259
        • Gastmeier K.
        • Freye E.
        High-dose buprenorphine for outpatient palliative pain therapy.
        Schmerz. 2009; 23: 180-186
        • Tegeder I.
        • Lotsch J.
        • Geisslinger G.
        Pharmacokinetics of opioids in liver disease.
        Clin Pharmacokinet. 1999; 37: 17-40
        • Boger R.H.
        Renal impairment: a challenge for opioid treatment? The role of buprenorphine.
        Palliat Med. 2006; 20: s17-s23
        • Post S.
        • Spiller H.A.
        • Casavant M.J.
        • Chounthirath T.
        • Smith G.A.
        Buprenorphine exposures among children and adolescents reported to US poison control centers.
        Pediatrics. 2018; 142
        • Schuckit M.A.
        Treatment of opioid-use disorders.
        N Engl J Med. 2016; 375: 357-368
        • Berg M.L.
        • Idrees U.
        • Ding R.
        • Nesbit S.A.
        • Liang H.K.
        • McCarthy M.L.
        Evaluation of the use of buprenorphine for opioid withdrawal in an emergency department.
        Drug Alcohol Depend. 2007; 86: 239-244
        • D'Onofrio G.
        • Chawarski M.C.
        • O'Connor P.G.
        • Pantalon M.V.
        • Busch S.H.
        • Owens P.H.
        • et al.
        Emergency department-initiated buprenorphine for opioid dependence with continuation in primary care: outcomes during and after intervention.
        J Gen Intern Med. 2017; 32: 660-666
        • Larochelle M.R.
        • Bernson D.
        • Land T.
        • Stopka T.J.
        • Wang N.
        • Xuan Z.
        • et al.
        Medication for opioid use disorder after nonfatal opioid overdose and association with mortality: a cohort study.
        Ann Intern Med. 2018; 169: 137-145
        • Goodnough A.
        • An E.R.
        That Treats Opioid Use as an Emergency New York, New York Times.
        Aug 18, 2018 (Available at)
        • Herring A.
        • Snyder H.
        • Moulin A.
        • Sampson A.
        • Luftig J.
        Buprenorphine guide.
        ED Bridge - Emergency Buprenorphine Treatment, 2018
        • Gowing L.
        • Farrell M.
        • Ali R.
        • White J.M.
        Alpha(2)-adrenergic agonists for the management of opioid withdrawal.
        Cochrane Database Syst Rev. 2016; 5CD002024
        • SAMHSA
        Buprenorphine waiver notification.
        Substance Abuse and Mental Health Services Administration
        Rockville, Maryland
        Date: 2018
        (Available at)
        • Bart G.
        Maintenance medication for opiate addiction: the foundation of recovery.
        J Addict Dis. 2012; 31: 207-225
        • Schuman-Olivier Z.
        • Hoeppner B.B.
        • Weiss R.D.
        • Borodovsky J.
        • Shaffer H.J.
        • Albanese M.J.
        Benzodiazepine use during buprenorphine treatment for opioid dependence: clinical and safety outcomes.
        Drug Alcohol Depend. 2013; 132: 580-586
        • Hakkinen M.
        • Launiainen T.
        • Vuori E.
        • Ojanpera I.
        Benzodiazepines and alcohol are associated with cases of fatal buprenorphine poisoning.
        Eur J Clin Pharmacol. 2012; 68: 301-309
      1. Nagel L. Emergency Narcotic Addiction Treatment. In: Justice USDo, editor. Springfield, Virginia Drug Enforcement Administration Diversion Control Division. Available at https://www.deadiversion.usdoj.gov/pubs/advisories/emerg_treat.htm. Accessed 01 August, 2018.

        • Estee S.
        • Wickizer T.
        • He L.
        • Shah M.F.
        • Mancuso D.
        Evaluation of the Washington state screening, brief intervention, and referral to treatment project: cost outcomes for Medicaid patients screened in hospital emergency departments.
        Med Care. 2010; 48: 18-24
        • Pringle J.L.
        • Kelley D.K.
        • Kearney S.M.
        • Aldridge A.
        • Dowd W.
        • Johnjulio W.
        • et al.
        Screening, brief intervention, and referral to treatment in the emergency department: an examination of health care utilization and costs.
        Med Care. 2018; 56: 146-152
        • Barbosa C.
        • Cowell A.J.
        • Landwehr J.
        • Dowd W.
        • Bray J.W.
        Cost of screening, brief intervention, and referral to treatment in health care settings.
        J Subst Abuse Treat. 2016; 60: 54-61
        • Horn B.P.
        • Crandall C.
        • Forcehimes A.
        • French M.T.
        • Bogenschutz M.
        Benefit-cost analysis of SBIRT interventions for substance using patients in emergency departments.
        J Subst Abuse Treat. 2017; 79: 6-11
        • Bray J.W.
        • Mallonee E.
        • Dowd W.
        • Aldridge A.
        • Cowell A.J.
        • Vendetti J.
        Program- and service-level costs of seven screening, brief intervention, and referral to treatment programs.
        Subst Abus Rehabil. 2014; 5: 63-73
        • American Psychiatric Association
        Publishing A.P. Diagnostic and statistical manual of mental disorders: DSM-5. 5th ed. 2013 ([541–60 p])

      CHORUS Manuscript

      View Open Manuscript