Implementation of an education session on buprenorphine induction in the emergency department, a resident-led initiative.

INTRODUCTION: Many physicians including emergency medicine physicians report insufficient training and education on prescribing buprenorphine for opioid use disorder. As emergency departments implement buprenorphine induction protocols, educational sessions can provide physicians with further familiarity with the treatment of opioid use disorder. This quality improvement project aimed to address the barrier of physician education in the implementation of buprenorphine initiation in the emergency department and presents a model for resident-led education sessions of emergency medicine physicians. METHODS: The project was a resident-led educational quality improvement project on educating members of the Department of Emergency Medicine on buprenorphine induction. The thirty-minute educational session included a pre-test survey, lecture, practice case workshop, questions, post-test survey, and a discussion. The survey questions were designed for physicians including residents and faculty, but medical students were invited to complete the session. RESULTS: Physicians including faculty and resident physicians responded positively to the educational survey, with an increase from 42.5 to 100% responding that they understood the risks and benefits of prescribing buprenorphine in the emergency department pre and post-survey respectively. Based on post-survey results, 88.5% of physicians responded that they planned to prescribe buprenorphine in the emergency department for patients meeting clinical criteria after completing the educational session. CONCLUSION: The results suggest that a resident-led training session can encourage peer involvement in buprenorphine induction to treat opioid use disorder in the emergency department.

Low-dose buprenorphine initiation during pregnancy: a case report.

Buprenorphine is recommended for pregnant patients with opioid use disorder. Traditional buprenorphine initiation requires moderate withdrawal symptoms to prevent precipitating withdrawal. Low-dose buprenorphine initiation is newly emerging and does not require withdrawal prior to initiation. Case 1 is a 30-year-old pregnant patient with opioid use disorder. Inpatient rapid buprenorphine initiation precipitated withdrawal. Low-dose buprenorphine initiation was started twice, 1 outpatient and 1 inpatient with nonprescribed opioid use between. Case 2 is a 28-year-old pregnant patient with opioid use disorder. The patient started an inpatient low-dose buprenorphine initiation and planned its completion at home after discharge. Neither patient experienced precipitated withdrawal during their low-dose initiations. These buprenorphine initiations in pregnant patients guided by a low-dose initiations protocol using only split buprenorphine-naloxone films represent an alternative opioid use disorder treatment method with potentially high acceptability. Future work is warranted to advance the evidence base informing clinicians on how to optimally individualize buprenorphine initiations in pregnancy.

Number of buprenorphine induction attempts impacts maternal and neonatal outcomes: a multicenter cohort study.

BACKGROUND: Buprenorphine can be used to treat maternal opioid use disorder effectively and decrease obstetrical risks. Compared with the use of other medications to treat opioid use disorder, the use of buprenorphine results in improved neonatal outcomes; however, its use is associated with higher rates of treatment attrition. Initiation of buprenorphine, termed "induction," is a high-risk time for treatment dropout and can require repeated attempts. OBJECTIVE: This study aimed to evaluate the effect of multiple buprenorphine induction attempts on maternal and neonatal outcomes. STUDY DESIGN: This was a retrospective cohort study of all pregnant patients who underwent sublingual buprenorphine induction for the treatment of opioid use disorder from June 18, 2018, to January 1, 2021, at 3 tertiary care centers. Patients who required only 1 attempt for successful buprenorphine induction were compared with those who required multiple attempts but ultimately were successful in the treatment initiation during pregnancy, confirmed by urine drug screening. The primary outcome was nonprescribed opioid use at the time of delivery. The secondary outcomes included obstetrical and neonatal outcomes associated with opioid use disorder. Background characteristics were compared using Fisher exact, chi-square, Mann-Whitney U, and Student t tests. The outcomes were compared using multivariable logistic regression, and time to delivery after initiation of prenatal care was compared between groups using Kaplan-Meier curves and a Cox proportional-hazards model. RESULTS: Overall, 63 patients undergoing buprenorphine induction during pregnancy were included, with 38 (60.3%) patients with 1 attempt and 25 patients (39.7%) with multiple attempts. There was no statistical difference between the 2 groups in terms of background characteristics. Compared with a single successful attempt, multiple attempts at buprenorphine induction were associated with a significantly increased odds of nonprescribed opioid use at the time of delivery (76.0% vs 15.8%; adjusted odds ratio, 30.00; 95% confidence interval, 5.50-163.90), increased risk of preterm birth (48.0% vs 15.8%; adjusted hazard ratio, 3.24; 95% confidence interval, 1.17-8.95), and decreased rate of breastfeeding at both maternal discharge (24.0% vs 78.9%; adjusted odds ratio, 0.06; 95% confidence interval, 0.00-0.30) and infant discharge (24.0% vs 55.3%; adjusted odds ratio, 0.23; 95% confidence interval, 0.10-0.80). CONCLUSION: Requiring multiple attempts for buprenorphine induction significantly increases the odds of nonprescribed opioid use at the time of delivery and preterm birth and decreases the odds of breastfeeding. As the buprenorphine induction process may affect obstetrical outcomes for patients induced during pregnancy, investigating the techniques that increase the likelihood of successful induction is crucially needed to improve outcomes in patients with maternal opioid use disorder.

Use of intravenous buprenorphine microdosing to initiate medication for opioid use disorder in a patient with co-occurring pain: case report.

INTRODUCTION: Buprenorphine is used to treat opioid use disorder (OUD). However, therapy is often disrupted during acute pain episodes, and re-initiation is often deferred due to intolerable interruption in opioid analgesics. This case report describes a unique strategy for inducing buprenorphine without stopping opioid analgesics. CASE: One patient with OUD and acute pain was initiated on buprenorphine using intravenous microdosing without precipitated withdrawal or pain exacerbation. Full agonist opioids were successfully weaned after discharge and the patient was linked with a community-based treatment program. CONCLUSION: This case describes use of intravenous buprenorphine to treat OUD and acute pain without adverse consequences.

Buprenorphine dose induction in non-opioid-tolerant pre-release prisoners.

BACKGROUND: In a previously reported randomized controlled trial, formerly opioid-dependent prisoners were more likely to enter community drug abuse treatment when they were inducted in prison onto buprenorphine/naloxone (hereafter called buprenorphine) than when they received counseling without buprenorphine in prison (47.5% vs. 33.7%, p=0.012) (Gordon et al., 2014). In this communication we report on the results of the induction schedule and the adverse event profile seen in pre-release prisoners inducted onto buprenorphine. METHOD: This paper examines the dose induction procedure, a comparison of the proposed versus actual doses given per week, and side effects reported for 104 adult participants who were randomized to buprenorphine treatment in prison. Self-reported side effects were analyzed using generalized estimated equations to determine changes over time in side effects. RESULTS: Study participants were inducted onto buprenorphine at a rate faster than the induction schedule. Of the 104 (72 males, 32 females) buprenorphine recipients, 64 (37 males, 27 females) remained on medication at release from prison. Nine participants (8.6%) discontinued buprenorphine because of unpleasant opioid side effects. There were no serious adverse events reported during the in-prison phase of the study. Constipation was the most frequent symptom reported (69 percent). CONCLUSION: Our findings suggest that buprenorphine administered to non-opioid-tolerant adults should be started at a lower, individualized dose than customarily used for adults actively using opioids, and that non-opioid-tolerant pre-release prisoners can be successfully inducted onto therapeutic doses prior to release.

Induction of pregnant women onto opioid-agonist maintenance medication: an analysis of withdrawal symptoms and study retention.

BACKGROUND: Induction onto buprenorphine during pregnancy may be more challenging than induction onto methadone. This study explores factors predicting withdrawal intensities and compares trajectories of withdrawal during the induction phase between opioid-dependent women randomly assigned to methadone or buprenorphine. METHODS: A secondary analysis was conducted on data from 175 opioid-dependent pregnant women inducted onto buprenorphine or methadone subsequent to stabilization on morphine sulfate. ANOVA analyses were conducted to determine differences between mean peak CINA scores by medication and completion status. General linear mixed models were fitted to compare trajectories of CINA scores between methadone and buprenorphine conditions, and between study dropouts and completers within the buprenorphine condition. RESULTS: Both buprenorphine and methadone patients experienced withdrawal categorized as minimal by the CINA scoring system. Significant differences in mean peak CINA scores for the first 72 hours of induction were found between the methadone (4.5; SD=0.4) and buprenorphine conditions (6.9; SD=0.4), with buprenorphine patients exhibiting higher mean peak CINA scores [F (3, 165)=9.70, p<0.001]. The trajectory of CINA scores showed buprenorphine patients exhibiting a sharper increase in mean CINA scores than methadone patients [F (1, 233)=8.70, p=0.004]. There were no differences in mean peak CINA scores [F (3, 77)=0.08, p=0.52] or in trajectory of CINA scores [F (1, 166)=0.42, p=0.52] between buprenorphine study dropouts and completers. CONCLUSION: While mean peak CINA score was significantly higher in the buprenorphine condition than the methadone condition, neither medication condition experienced substantial withdrawal symptoms. Further research on factors related to successful induction to buprenorphine treatment in pregnant women is needed.