Jacob Anderson, MD, , MEd
Pediatric Critical Care Fellow
Golisano Children's Hospital University of Rochester
Rochester
Disclosure information not submitted.
Disi Chen, MD
MD
Golisano Children's Hospital University of Rochester, United States
Disclosure information not submitted.
Sierra Stauber, PharmD, BCPPS
Pediatric Critical Care Pharmacist
Golisano Children's Hospital University of Rochester, United States
Disclosure information not submitted.
Rachel Schult, PharmD
Pharmacist, Toxicology and Addiction Medicine
Golisano Children's Hospital University of Rochester, United States
Disclosure information not submitted.
Timothy Weigand, MD
Emergency Medicine and Toxicology Attending
Golisano Children's Hospital University of Rochester, United States
Disclosure information not submitted.
Erin Barker, MD
Pediatric Critical Care Intensivist
Golisano Children's Hospital University of Rochester, United States
Disclosure information not submitted.
Title: Buprenorphine Micro-dosing for Iatrogenic Opiate Dependence in the Pediatric ICU
Introduction: Iatrogenic opioid dependence is a common development when long-term sedation is required. Associated with increased length of stay and increased morbidity from withdrawal, and delirium.
Buprenorphine (BPN) is a high-affinity partial mu receptor agonist with a long duration of action and indicated for both analgesia and opioid use disorder. BPN has favorable properties compared to full agonists including fewer side effects, less tolerance, and is easier to wean. The transition from full opioid agonist to buprenorphine requires a washout period to avoid precipitated withdrawal. We describe the use of BPN in 2 PICU patients using a novel method of induction called micro-dosing to simplify sedation and opioid weaning regimens. Micro-dosing, where small doses of BPN are initiated before full agonists had been stopped, allowing BPN accumulation at the receptor without precipitated withdrawal. Microinduction is considered for patients requiring high doses of opiates and at risk of withdrawal but unable to stop full agonists.
Description: Case 1: 24 year old with global developmental delay, admitted for respiratory failure with COVID infection. Required 3-weeks sedation and attempts to wean unsuccessful. BPN was initiated over 4 days (150mcg, 300mcg, 1mg, 2mg) each dose given at 6-hour increments; the dose increased every 4 doses. Opiate agonist discontinued on day 4. They required an increase of their BPN dose two days later to 4mg. Sedation requirements and symptoms then improved after BPN initiation. The weaning phase was completed over 9 days and did not require rescue dosing.
Case 2: 13-month-old, 24-weeks premature, BPD, tracheostomy, ventilator dependence, failing sedation weans underwent micro-induction of 12.5mcg, 30mcg, 75mcg, 300mcg, 600mcg, 1mg, each dose given at 6-hour increments, the dose increased every 4 doses. Adjuvant medications were discontinued and weaned. She remained on full agonists concomitantly with BPN for analgesia but later tolerated weaning.
Discussion: BPN benefits of decreased withdrawal risk, fewer side effects, and fewer medication days can benefit the PICU population. BPN initiation in this novel way can simplify opiate weaning and lead to an improved treatment course and recovery. Further research is needed to investigate BPN in comparison to current sedation methods.