Buprenorphine precipitated opioid withdrawal: Prevention and management in the ED setting
Buprenorphine precipitated opioid withdrawal: Prevention and management in the ED setting
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DOI：
10.1016/j.ajem.2022.05.013
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发表时间：
2022-05-24
影响因子：
3.6
通讯作者：
Perrone, Jeanmarie
中科院分区：
文献类型：
--
作者：
Spadaro, Anthony;Long, Brit;Perrone, Jeanmarie
简介：丁丙诺啡沉淀阿片类药物戒断（BPOW）是急诊科（ED）丁丙诺啡起始治疗的一种罕见并发症，但它会给患者带来明显的不适和痛苦。随着急诊科继续照顾阿片类药物使用障碍（OUD）患者，临床医生应该意识到如何预防和治疗BPOW。目的：这篇叙述性综述为急诊临床医生提供了BPOW流行病学、预防策略和管理的循证更新。讨论：BPOW是在开始使用丁丙诺啡后阿片类药物戒断症状的迅速恶化。BPOW可以通过等待出现中度阿片类药物戒断症状和自上次完全使用阿片类药物后足够的时间再给予丁丙诺啡来预防。BPOW的危险因素包括慢性芬太尼使用、美沙酮使用和同时使用苯二氮卓类药物。备选给药策略，如低剂量或“微剂量”和高剂量或“大剂量”是可能影响BPOW发展的丁丙诺啡的选择。用丁丙诺啡治疗BPOW的策略有药理基础，在病例报告中是有效的。额外的管理是基于症状和支持性的。虽然大多数病例有良性病程，但患者将来使用丁丙诺啡治疗OUD或因药物使用障碍寻求治疗的可能性可能会显著降低。结论：适当开始丁丙诺啡对预防BPOW有重要意义。丁丙诺啡的剂量应基于患者的阿片类药物使用模式和对治疗的反应。BPOW的管理应以症状为基础，但包括额外的丁丙诺啡和辅助药物。
Introduction: Buprenorphine precipitated opioid withdrawal (BPOW) is an uncommon complication of buprenorphine initiation in the emergency department (ED), but it can produce significant discomfort and be distressing to patients. As EDs continue to care for those with opioid use disorder (OUD), clinicians should be aware of how to prevent and treat BPOW. Objective: This narrative review provides an evidence-based update of the epidemiology, prevention strategies, and management of BPOW for the emergency clinician. Discussion: BPOW is a rapid worsening of opioid withdrawal symptoms upon initiating buprenorphine. BPOW can be prevented by waiting for the onset of moderate Clinical Opioid Withdrawal Scale (COWS) > 13 opioid withdrawal symptoms and a sufficient amount of time since last full opioid agonist use before buprenorphine administration. Risk factors for BPOW include chronic fentanyl use, methadone use, and concurrent benzodiazepine use. Alternative dosing strategies such as low-dose or "microdosing" and high-dose or "macrodosing" are options for buprenorphine that may impact the development of BPOW. The strategy of treating BPOW with more buprenorphine has a pharmacological basis and has been effective in case reports. Additional management is symptom-based and supportive. Although most cases have a benign course, patients may be significantly less likely to use buprenorphine for OUD in the future or seek care for substance use disorder. Conclusions: Appropriate initiation of buprenorphine is important to prevent BPOW. Dosing buprenorphine should be based on the patient's patterns of opioid use and response to therapy. Management of BPOW should be symptom-based but include additional buprenorphine and adjunctive medications.