Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, AZ, USA.
Department of Emergency Medicine and Department of Psychiatry, University of Arizona College of Medicine/Banner University Medical Center, Tucson, AZ, USA.
Am J Health Syst Pharm. 2024 Mar 7;81(6):171-182. doi: 10.1093/ajhp/zxad289.
The purpose of this review is to discuss important considerations when prescribing buprenorphine for opioid use disorder (OUD) in the intensive care unit (ICU) setting, recognizing the challenges of providing detailed recommendations in the setting of limited available evidence.
Buprenorphine is a partial mu-opioid receptor agonist that is likely to be increasingly prescribed for OUD in the ICU setting due to the relaxation of prescribing regulations. The pharmacology and pharmacokinetics of buprenorphine are complicated by the availability of several formulations that can be given by different administration routes. There is no single optimal dosing strategy for buprenorphine induction, with regimens ranging from very low-dose to high dose regimens. Faster induction with higher doses of buprenorphine has been studied and is frequently utilized in the emergency department. In patients admitted to the ICU who were receiving opioids either medically or illicitly, analgesia will not occur until their baseline opioid requirements are covered when their preadmission opioid is either reversed or interrupted. For patients in the ICU who are not on buprenorphine at the time of admission but have possible OUD, there are no validated tools to diagnose OUD or the severity of opioid withdrawal in critically ill patients unable to provide the subjective components of instruments validated in outpatient settings. When prescribing buprenorphine in the ICU, important issues to consider include dosing, monitoring, pain management, use of adjunctive medications, and considerations to transition to outpatient therapy. Ideally, addiction and pain management specialists would be available when buprenorphine is prescribed for critically ill patients.
There are unique challenges when prescribing buprenorphine for OUD in critically ill patients, regardless of whether they were receiving buprenorphine when admitted to the ICU setting for OUD or are under consideration for buprenorphine initiation. There is a critical need for more research in this area.
本综述旨在讨论在重症监护病房（ICU）环境中开具丁丙诺啡治疗阿片类药物使用障碍（OUD）时的重要注意事项，认识到在证据有限的情况下提供详细建议所面临的挑战。
丁丙诺啡是一种部分μ-阿片受体激动剂，由于处方规定的放宽，预计在 ICU 环境中越来越多地用于 OUD 的治疗。丁丙诺啡的药理学和药代动力学较为复杂，因为有几种不同的制剂可供选择，并且可以通过不同的给药途径给予。丁丙诺啡的诱导没有单一的最佳剂量策略，剂量方案从低剂量到高剂量。更快的诱导和更高剂量的丁丙诺啡已被研究并在急诊科中经常使用。对于在 ICU 接受阿片类药物治疗的患者，无论是医疗还是非法使用，在覆盖其入院前阿片类药物的基础阿片类药物需求之前，他们不会出现镇痛作用。对于入院时未使用丁丙诺啡但可能患有 OUD 的 ICU 患者，目前没有经过验证的工具可以诊断 OUD 或无法提供门诊环境中经过验证的仪器主观成分的重症患者的阿片类药物戒断严重程度。在 ICU 中开具丁丙诺啡时，需要考虑的重要问题包括剂量、监测、疼痛管理、辅助药物的使用以及过渡到门诊治疗的考虑。理想情况下，在为重症患者开具丁丙诺啡时，应提供成瘾和疼痛管理专家。
无论患者在入院时是否接受丁丙诺啡治疗 OUD 或是否考虑开始使用丁丙诺啡，在 ICU 环境中为 OUD 患者开具丁丙诺啡都存在独特的挑战。该领域急需更多的研究。
