In response to the rising efficacy of the illicit opioid drug supply and often observed delays in access to follow-up therapy, emergency departments (EDs) occasionally utilize a high-dose buprenorphine induction method for the treatment of opioid use disorder (OUD). The objective of this study is to investigate the safety and tolerability of high-dose (>12 mg) buprenorphine induction for patients with OUD presenting to an ED.
Data were manually extracted from electronic health records for all ED patients with OUD treated with buprenorphine at a single, urban, safety-net hospital in Oakland, California, during the calendar year 2018. Data was analysed from April 2020 until March 2021.
A high-dose sublingual buprenorphine induction technique was taught to ED doctors and advanced practice practitioners and subsequently clinically implemented. 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).
Among a total of 391 unique patients age, ([29-48] years), representing 579 encounters, 68.3% were male and 43.5% were Black. Homelessness 22.5% and psychiatric disorders 41.2% were common. A high dose of sublingual buprenorphine (>12 mg) was administered by 54 unique clinicians during 63.2% encounters, including 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. The median length of stay was 2.4 hours.
These data indicate that high-dose buprenorphine induction, used by various physicians in a single urban ED, was safe and well tolerated in patients with untreated OUD. These conclusions would be strengthened by more prospective studies done at different sites.