Jenna Clark, BCCCP, PharmD
Clinical pharmacy specialist
University of Rochester Medical Center
Rochester, NY
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.
Kaylee Maynard, PharmD, BCCCP
Clinical Pharmacy Specialist
University of Rochester Medical Center, United States
Disclosure information not submitted.
Stephen Rappaport, PharmD
Clinical Pharmacy Specialist
University of Rochester Medical Center, United States
Disclosure information not submitted.
Trevor Clarkson, DO
Intensivist
Johnson City Medical Center, United States
Disclosure information not submitted.
Benjamin McKinney, DO
Intensivist
MedStar Washington Hospital, 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.
Nicole Acquisto, BCCCP, PharmD
Emergency Medicine Clinical Pharmacy Specialist
Strong Memorial Hospital of the University of Rochester
Rochester, NY
Disclosure information not submitted.
Title:Safety and efficacy of buprenorphine microinduction in critically ill patients
Introduction: Management of opioid withdrawal in critically ill patients requiring analgesia and sedation is challenging. Since buprenorphine may precipitate opioid withdrawal, standard induction may not be feasible in those unable to tolerate a washout of full agonists. We developed an approach using buprenorphine microinduction (BUP-MI) (150 mcg every 6 hours titrated to ≥4 mg/day over 5 days) to administer buprenorphine to patients receiving full opioid agonists. We evaluated the efficacy and safety of this method in the intensive care unit (ICU).
Methods: This was a single-center, retrospective, observational study of ICU patients at an academic medical center on full opioid agonists who received BUP-MI with the intent of increasing to maintenance doses from March 2011 to October 2020. The primary outcome was percentage of patients who completed successful BUP-MI (end dose ≥4 mg/day) and secondary endpoints were incidence of precipitated withdrawal and difference between total morphine milligram equivalents (MME) pre- and post-BUP-MI.
Results: A total of 41 patients were included. Median age was 37 years (IQR 34-46), 73% were male, and 76% had a history of opioid use disorder (OUD). Most were medical (66%) or burn/trauma (27%) admissions. Indications for buprenorphine were history of OUD (80%) and iatrogenic dependence (20%). BUP-MI was successfully completed in 71% of patients with 5% requiring 2 attempts. Completion was unsuccessful mainly due to patient refusal (15%) or a switch to standard induction (15%). Of those that completed BUP-MI (n=29), 90% were intubated and on opioid infusions at initiation and 83% were on continuous sedatives. Median duration of scheduled opioids pre-BUP-MI was 5 days [IQR 2-13.5]. There was no precipitated withdrawal documented. Median MME pre- and post-BUP-MI was 1662 mg (IQR 843-2180) and 45 mg (IQR 0-892, p< 0.001). Duration of mechanical ventilation (n=26) was 12 days (IQR 6.5-26.5) and 46% were extubated during BUP-MI. ICU and hospital length of stay were 15 (IQR 8-38) and 31 (IQR 14.5-54.5) days.
Conclusion: BUP-MI can be safely and successfully initiated in critically ill patients who are mechanically ventilated, receiving continuous opioids without a washout period and may be associated with a reduction in opioid exposure. Further prospective studies are warranted.