Withdrawal during outpatient low dose buprenorphine initiation in people who use fentanyl: a retrospective cohort study.

Buprenorphine Fentanyl Low dose buprenorphine initiation Opioid agonist therapy Opioid use disorder Opioid withdrawal Opioids Precipitated withdrawal

Journal

Harm reduction journal
ISSN: 1477-7517
Titre abrégé: Harm Reduct J
Pays: England
ID NLM: 101153624

Informations de publication

Date de publication:
09 Apr 2024
Historique:
received: 03 01 2024
accepted: 02 04 2024
medline: 10 4 2024
pubmed: 10 4 2024
entrez: 9 4 2024
Statut: epublish

Résumé

Buprenorphine is an effective treatment for opioid use disorder (OUD); however, buprenorphine initiation can be complicated by withdrawal symptoms including precipitated withdrawal. There has been increasing interest in using low dose initiation (LDI) strategies to reduce this withdrawal risk. As there are limited data on withdrawal symptoms during LDI, we characterize withdrawal symptoms in people with daily fentanyl use who underwent initiation using these strategies as outpatients. We conducted a retrospective chart review of patients with OUD using daily fentanyl who were prescribed 7-day or 4-day LDI at 2 substance use disorder treatment clinics in San Francisco. Two addiction medicine experts assessed extracted chart documentation for withdrawal severity and precipitated withdrawal, defined as acute worsening of withdrawal symptoms immediately after taking buprenorphine. A third expert adjudicated disagreements. Data were analyzed using descriptive statistics. There were 175 initiations in 126 patients. The mean age was 37 (SD 10 years). 71% were men, 26% women, and 2% non-binary. 21% identified as Black, 16% Latine, and 52% white. 60% were unstably housed and 75% had Medicaid insurance. Substance co-use included 74% who used amphetamines, 29% cocaine, 22% benzodiazepines, and 19% alcohol. Follow up was available for 118 (67%) initiations. There was deviation from protocol instructions in 22% of these initiations with follow up. 31% had any withdrawal, including 21% with mild symptoms, 8% moderate and 2% severe. Precipitated withdrawal occurred in 10 cases, or 8% of initiations with follow up. Of these, 7 had deviation from protocol instructions; thus, there were 3 cases with follow up (3%) in which precipitated withdrawal occurred without protocol deviation. Withdrawal was relatively common in our cohort but was mostly mild, and precipitated withdrawal was rare. Deviation from instructions, structural barriers, and varying fentanyl use characteristics may contribute to withdrawal. Clinicians should counsel patients who use fentanyl that mild withdrawal symptoms are likely during LDI, and there is still a low risk for precipitated withdrawal. Future studies should compare withdrawal across initiation types, seek ways to support patients in initiating buprenorphine, and qualitatively elicit patients' withdrawal experiences.

Sections du résumé

BACKGROUND BACKGROUND
Buprenorphine is an effective treatment for opioid use disorder (OUD); however, buprenorphine initiation can be complicated by withdrawal symptoms including precipitated withdrawal. There has been increasing interest in using low dose initiation (LDI) strategies to reduce this withdrawal risk. As there are limited data on withdrawal symptoms during LDI, we characterize withdrawal symptoms in people with daily fentanyl use who underwent initiation using these strategies as outpatients.
METHODS METHODS
We conducted a retrospective chart review of patients with OUD using daily fentanyl who were prescribed 7-day or 4-day LDI at 2 substance use disorder treatment clinics in San Francisco. Two addiction medicine experts assessed extracted chart documentation for withdrawal severity and precipitated withdrawal, defined as acute worsening of withdrawal symptoms immediately after taking buprenorphine. A third expert adjudicated disagreements. Data were analyzed using descriptive statistics.
RESULTS RESULTS
There were 175 initiations in 126 patients. The mean age was 37 (SD 10 years). 71% were men, 26% women, and 2% non-binary. 21% identified as Black, 16% Latine, and 52% white. 60% were unstably housed and 75% had Medicaid insurance. Substance co-use included 74% who used amphetamines, 29% cocaine, 22% benzodiazepines, and 19% alcohol. Follow up was available for 118 (67%) initiations. There was deviation from protocol instructions in 22% of these initiations with follow up. 31% had any withdrawal, including 21% with mild symptoms, 8% moderate and 2% severe. Precipitated withdrawal occurred in 10 cases, or 8% of initiations with follow up. Of these, 7 had deviation from protocol instructions; thus, there were 3 cases with follow up (3%) in which precipitated withdrawal occurred without protocol deviation.
CONCLUSIONS CONCLUSIONS
Withdrawal was relatively common in our cohort but was mostly mild, and precipitated withdrawal was rare. Deviation from instructions, structural barriers, and varying fentanyl use characteristics may contribute to withdrawal. Clinicians should counsel patients who use fentanyl that mild withdrawal symptoms are likely during LDI, and there is still a low risk for precipitated withdrawal. Future studies should compare withdrawal across initiation types, seek ways to support patients in initiating buprenorphine, and qualitatively elicit patients' withdrawal experiences.

Identifiants

DOI: 10.1186/s12954-024-00998-9 PMID: 38594721
pubmed: 38594721
doi: 10.1186/s12954-024-00998-9
pii: 10.1186/s12954-024-00998-9
doi:

Types de publication

Journal Article

Langues

eng

Sous-ensembles de citation

IM

Pagination

80

Subventions

Organisme : NIDA NIH HHS
ID : K24DA042720
Pays : United States

Informations de copyright

© 2024. The Author(s).

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Auteurs

Benjamin L H Jones (BLH)

Medical Student Center, UCSF School of Medicine, 533 Parnassus Avenue, S-245, San Francisco, CA, 94143, USA. benjamin.jones@ucsf.edu.

Michelle Geier (M)

San Francisco Department of Public Health, 101 Grove Street, San Francisco, CA, 94102, USA.

John Neuhaus (J)

Department of Epidemiology and Biostatistics, University of California San Francisco, 550 16th Street, 2nd Floor, San Francisco, CA, 94158, USA.

Phillip O Coffin (PO)

San Francisco Department of Public Health, 101 Grove Street, San Francisco, CA, 94102, USA.
Department of Medicine, University of California San Francisco, 505 Parnassus Avenue, San Francisco, CA, 94143, USA.

Hannah R Snyder (HR)

Department of Family and Community Medicine, University of California San Francisco, 995 Potrero Avenue, San Francisco, CA, 94110, USA.

Christine S Soran (CS)

Division of General Internal Medicine, San Francisco General Hospital, 1001 Potrero Avenue, San Francisco, CA, 94110, USA.
Division of Substance Abuse and Addiction Medicine, San Francisco General Hospital, University of California San Francisco, 1001 Potrero Avenue, San Francisco, CA, 94110, USA.

Kelly R Knight (KR)

Department of Humanities and Social Sciences, University of California San Francisco, 490 Illinois Street, 7th Floor, San Francisco, CA, 94143, USA.

Leslie W Suen (LW)

Department of Medicine, University of California San Francisco, 505 Parnassus Avenue, San Francisco, CA, 94143, USA.
Division of General Internal Medicine, San Francisco General Hospital, 1001 Potrero Avenue, San Francisco, CA, 94110, USA.
Division of Substance Abuse and Addiction Medicine, San Francisco General Hospital, University of California San Francisco, 1001 Potrero Avenue, San Francisco, CA, 94110, USA.

Classifications MeSH