Hughes Terence, Nasser Nicholas, Mitra Avir
The Mount Sinai Hospital, 1 Gustav Levy Place, New York, NY, 10029-6574, USA.
Mount Sinai Beth Israel, 281 1st Ave, New York, NY, 10003, USA.
Int J Emerg Med. 2024 Feb 19;17(1):23. doi: 10.1186/s12245-024-00593-6.
In recent decades, opioid overdoses have increased dramatically in the United States and peer countries. Given this, emergency medicine physicians have become adept in reversing and managing complications of acute overdose. However, many remain unfamiliar with initiating medication for opioid use disorder such as buprenorphine, a high-affinity partial opioid agonist. Emergency department-based buprenorphine initiation is supported by a significant body of literature demonstrating a marked reduction in mortality in addition to increased engagement in care. Buprenorphine initiation is also safe, given both the pharmacologic properties of buprenorphine that reduce the risk of diversion or recreational use, and previously published literature demonstrating low rates of respiratory depression, sedation, and precipitated withdrawal. Further, barriers to emergency department-based initiation have been reduced in recent years, with publicly available dosing and up-titration schedules, numerous publications overviewing best practices for managing precipitated withdrawal, and removal of USA policies previously restricting patient access and provider prescribing, with the removal of the X-waiver via the Medication Access and Training Expansion Act. Despite reductions in barriers, buprenorphine initiation in the emergency room remains underutilized. Poor uptake has been attributed to numerous individual and systemic barriers, including inadequate education, provider stigma, and insufficient access to outpatient follow-up care. The following practice innovation aims to summarize previously published evidence-based best practices and provide an accessible, user-friendly initiation guide to increase emergency physician comfortability with buprenorphine initiation going forward.
近几十年来，美国及其他同类国家的阿片类药物过量使用情况急剧增加。鉴于此，急诊医学医生已熟练掌握逆转和处理急性过量用药并发症的方法。然而，许多医生仍不熟悉启动针对阿片类药物使用障碍的药物治疗，如丁丙诺啡，一种高亲和力的阿片类部分激动剂。大量文献支持在急诊科启动丁丙诺啡治疗，这些文献表明，除了增加护理参与度外，死亡率还显著降低。鉴于丁丙诺啡的药理特性降低了药物转移或用于消遣的风险，且先前发表的文献显示呼吸抑制、镇静和戒断反应的发生率较低，所以启动丁丙诺啡治疗也是安全的。此外，近年来急诊科启动治疗的障碍有所减少，有公开可用的给药和滴定方案，众多出版物概述了处理戒断反应的最佳做法，并且美国取消了先前限制患者获取药物和医生处方的政策，通过《药物获取和培训扩展法案》取消了X豁免。尽管障碍有所减少，但急诊科启动丁丙诺啡治疗的情况仍未得到充分利用。使用率低归因于许多个人和系统障碍，包括教育不足、医生的偏见以及门诊后续护理的获取不足。以下实践创新旨在总结先前发表的循证最佳做法，并提供一份易于理解、用户友好的启动指南，以提高急诊医生对未来启动丁丙诺啡治疗的舒适度。
