High-Dose Buprenorphine a Game Changer for Opioid Addiction

Administering high-dose buprenorphine in the emergency department (ED) to individuals with untreated opioid use disorder (OUD) is safe, well tolerated, and may help get more patients into treatment after discharge.

“Emergency departments are at the front lines of treating people with OUD and helping them overcome barriers to recovery such as withdrawal,” Nora D. Volkow, MD, director of the National Institute on Drug Abuse, which funded the study, said in a news release.

Providing buprenorphine in EDs presents “an opportunity to expand access to treatment, especially for underserved populations, by supplementing urgent care with a bridge to outpatient services that may ultimately improve long-term outcomes,” Volkow added.

Buprenorphine is approved in the United States to treat OUD. Giving lower doses of the drug is the current standard of care.

Giving higher doses of buprenorphine in the ED may provide a longer period of relief to people after discharge, which may help them navigate barriers to access to follow-up care before they experience withdrawal symptoms, the researchers note.

“This study enhances the evidence we know about ED buprenorphine induction and could be a game changer, particularly for vulnerable populations who would likely benefit from a rapid induction at the time of the visit,” study investigator Gail D’Onofrio, MD, of Yale University, New Haven, Connecticut, said in the news release.

The research was published online July 15 in JAMA Network Open. 

A Momentum Builder

Some EDs already give higher doses of buprenorphine for the treatment of opioid withdrawal symptoms in response to the increasing potency of the illicit opioid drug supply and commonly encountered delays in access to follow-up care.

To investigate further, the researchers analyzed data from electronic health records documenting 579 ED visits made in 2018 by 391 adults (mean age 36 years, 68% male, 44% Black) with OUD at a single, urban, safety net hospital in Oakland, California.

Many of the patients were from vulnerable populations: 23% experienced homelessness and 41% had a psychiatric disorder.

In 63% of cases, ED physicians administered a high dose of buprenorphine (> 12 mg) during the ED visit; in 23% of cases, patients were given 28 mg or more.

The higher doses of buprenorphine were safe, with no cases of respiratory depression or sedation, the investigators report.

The five (0.8%) cases of precipitated withdrawal had no association with the buprenorphine dose; four cases occurred after 8-mg doses of the medication.

There were three serious adverse events unrelated to buprenorphine therapy. Nausea or vomiting was rare (2% to 6% of cases). Patients spent a median of 2.4 hours in the ED.

“These findings suggest that high-dose buprenorphine induction, adopted by multiple clinicians in a single-site, urban emergency department, was safe and well tolerated in patients with untreated opioid use disorder,” the authors write.

“Once discharged, many people have difficulty linking to follow-up medical care,” study chief Andrew Herring, MD, of the Department of Emergency Medicine, Highland Hospital, in Oakland, California, said in the release.

“Adjusting the timing and dosage of buprenorphine in the emergency department, along with resources and counseling aimed at facilitating the transition to outpatient services may provide the momentum needed to access continuing care,” he added.

The study was supported by the National Institute on Drug Abuse. A complete list of author disclosures is available with the original article.

JAMA Netw Open. Published online July 15, 2021. Full text

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