A practical review of buprenorphine utilization for the emergency physician in the era of decreased prescribing restrictions.

INTRODUCTION: Opioid abuse and overdose deaths have reached epidemic proportions in the last couple decades. In response to rational prescribing initiatives, utilization of prescription opioids has decreased; however, the number of deaths due to opioid overdoses continues to rise, largely driven by fentanyl analogues in adulterated heroin. Solutions to the opioid crisis must be multifaceted and address underlying opioid addiction. In recent years, buprenorphine has become a cornerstone in the treatment of opioid use disorder (OUD) and initiation of therapy in the emergency department (ED) has become increasingly common. There have also been calls by many organizations to remove the requirement for additional training and X-waiver to prescribe buprenorphine. In April 2021, the Biden Administration eased prescribing restrictions on the drug. These initiatives are expected to increase ED utilization of the buprenorphine. The purpose of this paper is to provide an updated overview of the role and use of buprenorphine in the ED setting so physicians may adapt to the changing practice environment. OBJECTIVES: This is a narrative review describing the role of buprenorphine in the ED. A PubMed search was conducted using the keywords "opioid epidemic" "buprenorphine," and "medication assisted therapy", and "emergency department". All the articles that contained information on the opioid epidemic, medication assisted therapy, and the biological effects of buprenorphine, that were also relevant to pain management and the ED, were included in the review. DISCUSSION: Multiple studies have pointed to the effective use of buprenorphine as a treatment for OUDs in ED patients and are superior to standard care; however, there are various barriers to its use in the ED setting. CONCLUSION: Emergency physicians can influence opioid related morbidity and mortality, by familiarizing themselves with the use of buprenorphine to treat opioid withdrawal and addiction, particularly now that prescribing restrictions have been eased. Further ED research is necessary to assess the optimal use of buprenorphine in this care setting.

Reduced pain perception in patients with schizophrenia; A missed case of hand fracture.

Altered pain perception among patients with schizophrenia is often underrecognized in the medical community. The cause is not known, and medical professionals are not sure whether these patients experience less pain or are simply unable to express it. There are documented cases of patients with schizophrenia presenting to hospital settings with serious injuries without obvious (expected) pain. Research into the underlying cause(s) is underway; meanwhile, ensuring awareness of this issue among medical providers is of upmost importance. We report a case of a patient with schizophrenia who presented voluntarily to the emergency department (ED) with a hand fracture that went unrecognized in the ED and further discuss the implications of reduced pain perception. Additionally, we summarize existing hypotheses regarding the source of this reduced pain perception in this population.