bup nlx other draft

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These topics are reviewed in separate modules and will not be covered in this module.

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For patients who have missed doses of buprenorphine/naloxone but have no other opioid use, there is concern for possible tolerance loss. There is no definitive answer to how much buprenorphine should be reduced after missed doses, but the BCCSU provides the following suggestions.

ED providers can consider a simplified approach- If missed 6-7 days, consider test dose at half the amount rounded up to the

nearest multiple of 2- If missed greater than 1 week, consider test dose at 4mg and titrate up to effect

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Greenwald et al – 3+ consecuQve days based on >50% mu receptor availability between 52-76 hour since last dose in this study.

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One limitation can be the lack of witnessed ingestion. Review with the patient when their last dose was taken, and why it is important to know this.

OAT = opioid agonist therapy

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Urine drug test can be a valuable tool to guide management. However, the results are not available in a timely fashion to guide treatment in the ED due to the lack of point of care testing (POCT). In patients where history remains unclear, it can help guide which category they fall into – concern for tolerance loss (UDT will be negative for opioids and/or fentanyl) or concern for precipitated withdrawal (UDT will be positive for opioids and/or fentanyl).

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For more information: https://www.bccsu.ca/wp-content/uploads/2020/05/Bulletin-Sublocade_0511.pdf

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Herring AA, Schultz CW, Yang E, Greenwald MK. Rapid induction onto sublingual buprenorphine after opioid overdose and successful linkage to treatment for opioid use disorder. Am J Emerg Med. 2019 Dec;37(12):2259-2262. doi: 10.1016/j.ajem.2019.05.053. Epub 2019 May 29. PMID: 31239086.

https://cabridge.org/resource/starting-buprenorphine-immediately-after-reversal-of-opioid-overdose-with-naloxone/

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COWS = Clinical Opiate Withdrawal Scale

Herring AA, Schultz CW, Yang E, Greenwald MK. Rapid induction onto sublingual buprenorphine after opioid overdose and successful linkage to treatment for opioid use disorder. Am J Emerg Med. 2019 Dec;37(12):2259-2262. doi: 10.1016/j.ajem.2019.05.053. Epub 2019 May 29. PMID: 31239086.

https://cabridge.org/resource/starting-buprenorphine-immediately-after-reversal-of-opioid-overdose-with-naloxone/

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Herring AA, Schultz CW, Yang E, Greenwald MK. Rapid induction onto sublingual buprenorphine after opioid overdose and successful linkage to treatment for opioid use disorder. Am J Emerg Med. 2019 Dec;37(12):2259-2262. doi: 10.1016/j.ajem.2019.05.053. Epub 2019 May 29. PMID: 31239086.

https://cabridge.org/resource/starting-buprenorphine-immediately-after-reversal-of-opioid-overdose-with-naloxone/

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Average starQng doses in US were 2 mg in many studies.

Rzasa Lynn R, Galinkin JL. Naloxone dosage for opioid reversal: current evidence and clinical implicaQons. Ther Adv Drug Saf. 2018;9(1):63-88. doi:10.1177/2042098617744161

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Herring AA, Vosooghi AA, Luftig J, Anderson ES, Zhao X, Dziura J, et al. High-Dose Buprenorphine Induction in the Emergency Department for Treatment of Opioid Use Disorder. Jama Netw Open. 2021;4(7):e2117128.

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Herring AA, Vosooghi AA, Luftig J, Anderson ES, Zhao X, Dziura J, et al. High-Dose Buprenorphine Induction in the Emergency Department for Treatment of Opioid Use Disorder. Jama Netw Open. 2021;4(7):e2117128.

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Herring AA, Vosooghi AA, Luftig J, Anderson ES, Zhao X, Dziura J, et al. High-Dose Buprenorphine Induction in the Emergency Department for Treatment of Opioid Use Disorder. Jama Netw Open. 2021;4(7):e2117128.

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This is their protocol.

Herring AA, Vosooghi AA, Lumig J, Anderson ES, Zhao X, Dziura J, et al. High-Dose Buprenorphine InducQon in the Emergency Department for Treatment of Opioid Use Disorder. Jama Netw Open. 2021;4(7):e2117128.

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