buprenorphine and Critical-Illness

The number of patients maintained on buprenorphine is steadily increasing. To date, no study has reported buprenorphine management practices for these patients during critical illness, nor its relationship with supplemental full-agonist opioid administration during their hospital stay. In this single-center retrospective study, we have explored the incidence of buprenorphine continuation during critical illness among patients receiving buprenorphine for the treatment of opioid use disorder. Additionally, we investigated the relationship between nonbuprenorphine opioid exposure and buprenorphine administration during the intensive care unit (ICU) and post-ICU phases of care. Our study included adults maintained on buprenorphine for opioid use disorder admitted to the ICU between December 1, 2014, and May 31, 2019. Nonbuprenorphine, full agonist opioid doses were converted to fentanyl equivalents (FEs). Fifty-one (44%) patients received buprenorphine during the ICU phase of care, with an average dose of 8 (8-12) mg/day. During the post-ICU phase of care, 68 (62%) received buprenorphine, with an average dose of 10 (7-14) mg/day. Lack of mechanical ventilation and acetaminophen use were also associated with buprenorphine use. Full agonist opioid use was more frequent on days when buprenorphine was not given (odds ratio [OR], 6.2 [95% CI, 2.3-16.4]; P < .001). Additionally, the average cumulative dose of opioids given on nonbuprenorphine administration days was significantly higher both in the ICU (OR, 1803 [95% CI, 1271-2553] vs OR, 327 [95% CI, 152-708] FEs/day; P < 0.001) and after ICU discharge (OR, 1476 [95% CI, 962-2265] vs OR, 238 [95% CI, 150-377] FEs/day; P < .001). Given these findings, buprenorphine continuation during critical illness should be considered, as it is associated with significantly decreased full agonist opioid use.

Topics: Adult; Analgesics, Opioid; Buprenorphine; Critical Illness; Humans; Inpatients; Opioid-Related Disorders; Retrospective Studies

Buprenorphine/naloxone has been shown to be an effective treatment of opioid use disorder. According to the Canadian National clinical practice guideline on the management of opioid use disorders, given the superior safety profile of buprenorphine/naloxone and its potential for flexible take-home dosing in comparison to other opioid agonist medication it is strongly recommended to initiate opioid agonist treatment with buprenorphine/naloxone as the preferred first-line treatment when possible. Due to its pharmacological properties induction can be challenging, requiring the cessation of all opioids for a certain amount of time to avoid the risk of precipitated withdrawal symptoms. For this reason, buprenorphine/naloxone is not initiated for the treatment of opioid use disorder in critically ill patients where continuous infusion of opioids are required for maintenance of sedation resulting in a missed opportunity for first line treatment of that patient's opioid use disorder.. We present a case of a 29-year-old female with opioid use disorder admitted for infective endocarditis and septic shock requiring intubation for hypoxic respiratory failure secondary to bilateral lung septic emboli with a high opioid debt requiring higher than typical doses of fentanyl and dexmedetomidine infusions to maintain sedation with clinical objective sign of inadequate treatment of her pain and opioid withdrawal. She was successfully started on buprenorphine/naloxone using a rapid micro-induction technique that did not cause precipitated withdrawal or require cessation of her fentanyl infusion.. This case illustrates a new method for starting buprenorphine/naloxone in a critically ill intubated patient, where buprenorphine/naloxone was never a consideration in this specific patient population.. This method can be used to minimize barriers to opioid agonist therapy in intubated patients.

Topics: Adult; Analgesics, Opioid; Buprenorphine; Buprenorphine, Naloxone Drug Combination; Canada; Critical Illness; Female; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders

Opioid associated admissions to the Intensive Care Unit (ICU) are increasing, but how institutions manage the care of these patients is unknown. We studied the availability of protocols and guidelines in Intensive Care Units (ICUs) for the management of the critically ill patient with opioid use disorder.. A survey was sent to a random sampling of ICU clinicians at acute care hospitals in the United States.. Of the 300 hospitals contacted, 118 agreed to participate and 58 submitted surveys (49%, 58/118 response rate). While a majority of ICUs has a guideline to titrate sedative analgesics, only 7% reported a guideline that addresses the sedation needs of patients with opioid use disorder. Only one respondent identified a guideline for the continuation of medication-assisted treatment such as methadone. Most respondents did not have, or were unaware of, a guideline to manage opioid withdrawal or to prevent over-reversal with naloxone. Outpatient resources were offered to patients by 36% of institutions, while even fewer reported the use of a dedicated addiction care team.. Few institutional guidelines exist to provide clinicians with the tools necessary to prevent harm and promote recovery for this growing and vulnerable ICU population.

Topics: Analgesics, Opioid; Buprenorphine; Critical Care; Critical Illness; Hospitalization; Hospitals; Humans; Hypnotics and Sedatives; Intensive Care Units; Methadone; Naloxone; Opioid-Related Disorders; Outpatients; Practice Guidelines as Topic; Surveys and Questionnaires; United States

This case report presents an old hemiparetic male admitted to hospital from nursing home due to dark-coloured emesis. Transdermal buprenorphine 5 mcg/h had been instigated without laxatives in the preceding month. Upon arrival, an enlarged tense abdomen was found. A CT-scan dem-on-strated a 19 cm wide faecal colon impaction. Limited effect of enemas and endoscopic disimpaction resulted in surgery. The patient died shortly after discharge. The case stresses the prevention of constipation when using opioids; in particular in immobilized patients.

Topics: Aged, 80 and over; Analgesics, Opioid; Buprenorphine; Critical Illness; Fatal Outcome; Fecal Impaction; Humans; Laxatives; Male; Tomography, X-Ray Computed