Clinical question: Is low-dose buprenorphine initiation in hospitalized patients safe and effective for the management of opioid use disorder (OUD)?
Background: OUD is a chronic relapsing disease that has become an epidemic in the U.S. Medications for opioid use disorder (MOUD) have been shown to be effective in preventing overdose-related deaths. Buprenorphine has a good safety profile and accessibility. However, standard dose initiation has been limited by requiring complete cessation of opioids or a withdrawal period prior to initiation, which may not be feasible in the inpatient setting.
Study design: Retrospective cohort study
Setting: Urban, academic medical center
Synopsis: 68 patients seen by an addiction-medicine consult service were initiated on low-dose buprenorphine. Low-dose buprenorphine was chosen over standard dosing for the following reasons: co-occurring pain (91.7%), anxiety surrounding withdrawal (69.4%), history of precipitated withdrawal (9.7%), opioid withdrawal intolerance (6.9%), and other (18.1%). Of these, 50 patients (69.4%) completed initiation as an inpatient, nine patients (12.5%) transitioned to complete initiation as an outpatient, and 13 patients (18.1%) did not complete initiation. Patients experienced mild generalized symptoms, but the study was unable to conclude if they were related to low-dose buprenorphine or acute illness.
The authors describe specific practice considerations for low-dose buprenorphine initiation in the above scenarios. They found that low-dose initiation removed the barrier of a withdrawal period, provided more flexibility for buprenorphine initiation, did not result in increased pain, required less intensive nursing staff monitoring, supported methadone transitions, and allowed for rapid titration protocols.
Study limitations include limited patient diversity, performance at a single site, lack of follow-up after hospitalization, and applicability to other health care systems without an addiction-medicine consult service.
Bottom line: Low-dose buprenorphine is a safe and effective alternative to standard-dose buprenorphine initiation for hospitalized patients with OUD. Hospitalists have increasing options for OUD treatment and with shared decision making can safely initiate therapy in the inpatient setting.
Citation: Button D, et al. Low-dose buprenorphine initiation in hospitalized adults with opioid use disorder: a retrospective cohort analysis. J Addict Med. 2022;16(2):e105-e111. doi:10.1097/ADM.0000000000000864.
Dr. Nhan Vuong is an assistant clinical professor of medicine in the division of hospital medicine at the University of California, San Diego.