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Substance Abuse during Pregnancy
Published in “Bert” Bertis Britt Little, Drugs and Pregnancy, 2022
Naltrexone has been used to treat several substance dependencies during pregnancy without apparent untoward effects, but no long-term follow-up studies have been published (Hulse et al., 2001). An alternative therapy with little or no potential for abuse is buprenorphine/naloxone (Suboxone), but there are no studies of its use during pregnancy. Disulfiram (Antabuse), a deterrent for alcohol abuse, should not be used at any time during pregnancy because of its strong copper-chelating properties. Copper is essential to normal fetal neuronal formation and migration, and any impediment in these processes may result in fetal brain malformations. Notably, this is a theoretical risk.
Substance Use Disorders
Published in Vincenzo Berghella, Maternal-Fetal Evidence Based Guidelines, 2022
Suboxone is a combination of buprenorphine and naltrexone in a 4:1 ratio. The addition of naltrexone is meant to deter parenteral use and lowers the risk of diversion. Previous guidelines recommended use of the buprenorphine monoproduct during pregnancy due to the theoretical risk of naloxone exposure and withdrawal from misuse. A recent systematic review (n=5 studies, 291 buprenorphine-naloxone exposed dyads) demonstrated similar pregnancy outcomes compared to other MOUD [102]. As additional data becomes available supporting the safety of the combination product, its use during pregnancy is likely to continue to increase. There is no reason to preferentially start a pregnant patient on the monoproduct or switch to the monoproduct in a patient previously stable on the combination product.
Systemic Routes of Opioid Administration
Published in Pamela E. Macintyre, Stephan A. Schug, Acute Pain Management, 2021
Pamela E. Macintyre, Stephan A. Schug
Buprenorphine is used for the management of acute pain and as an alternative to methadone in the treatment of opioid addiction. It is commonly given sublingually as a tablet and is as effective as conventional opioids for the management of acute pain (White et al, 2018; Vlok et al, 2019; Schug et al, 2020). The time to peak effect may be as long as three hours (Macintyre & Huxtable, 2017), so the dose intervals prescribed for “as needed” administration of sublingual buprenorphine need to be longer than those often used for conventional IR opioids. For patients requiring the buprenorphine–naloxone combination used in opioid addition treatment programs, sublingual mucoadhesive films are now more commonly administered than sublingual tablets.
Primary care management of Long-Term opioid therapy
Published in Annals of Medicine, 2022
Phillip O. Coffin, Rebecca S. Martinez, Brian Wylie, Bunny Ryder
Third, there are no absolute contraindications to buprenorphine treatment. Buprenorphine is proven to be safe and effective during pregnancy, although the mono-formulated buprenorphine is recommended over the co-formulated buprenorphine-naloxone simply because there is no therapeutic value to the naloxone component [57,71]. The mono-formulated product is also recommended for patients with significant liver disease due to poor hepatic metabolism of naloxone. While buprenorphine has a markedly low risk for respiratory depression due to the ceiling effect, the addition of benzodiazepines or alcohol can increase that risk. However, for patients already using depressants, the transition from full agonist opioids to buprenorphine is associated with a substantial reduction in the risk of opioid overdose. In a case-crossover study analysing a dataset of 14 million person-days for 23,036 persons who experienced drug poisoning events, high-dose benzodiazepine use was associated with increased poisoning events in combination with buprenorphine, but this was significantly lower than the risk of poisoning when benzodiazepines were used without buprenorphine [72]. The FDA and SAMHSA have clearly stated that use of sedatives or hypnotics is not a contraindication to treatment with buprenorphine [73]. While a clinician should continue to address the use of benzodiazepines or alcohol in a patient prescribed buprenorphine, such use should not impede buprenorphine therapy.
Management of opioid withdrawal and initiation of medications for opioid use disorder in the hospital setting
Published in Hospital Practice, 2022
Nico Carswell, Giselle Angermaier, Christopher Castaneda, Fabrizzio Delgado
The standard induction method requires the patient to wait until the onset of at least mild to moderate opioid withdrawal before initiating buprenorphine. As µ-opioid receptors become less saturated with agonists, induction of buprenorphine will be more likely to alleviate the withdrawal and be less likely to precipitate withdrawal. Withdrawal can be assessed objectively using the COWS scale. It is recommended by some that patients achieve a COWS score of 7 or higher before initiating buprenorphine treatment [49] while guidelines from the ASAM recommend a COWS score of 11–12 [34]. Additionally, it is important to obtain an accurate history of the patient’s recent opioid use including timing, substance(s), and route of administration before starting induction. Buprenorphine should be administered no earlier than 6–12 hours since the last use of short-acting opioids such as heroin and no earlier than 24–72 hours since the last use of long-acting opioids such as methadone [34].
Rapid buprenorphine microdosing for opioid use disorder in a hospitalized patient receiving very high doses of full agonist opioids for acute pain management: Titration, implementation barriers, and strategies to overcomes
Published in Substance Abuse, 2021
Jonathan P. DeWeese, James R. Krenz, Sarah E. Wakeman, Alyssa M. Peckham
Lastly, in this patient, micro-dose buprenorphine titration was halted once buprenorphine reached 8 mg TDD and was continued at this dose until a definitive discharge plan was in place. This was done because the length of hospital stay was unknown in this patient, and it was unclear whether additional full agonist opioids would be required. This strategy of holding buprenorphine at a lower dose than therapeutic for OUD mimics a commonly utilized perioperative practice when a patient on buprenorphine requires surgery given that it is not necessary to discontinue buprenorphine as it should not disrupt analgesic efforts.24 The purpose of this, both perioperatively and during micro-dose induction, is to administer buprenorphine to not only maintain buprenorphine exposure at MOR but also to avoid disruption of full agonist opioids with too high a buprenorphine dose. If therapeutic buprenorphine doses are urgently needed, like in the case of discharge plans arising sooner than anticipated, the dose can be rapidly increased as soon as the next day if needed.7 In the absence of buprenorphine, it is likely this would result in either full agonist opioid taper or cessation as an outpatient, which may increase the potential risk of opioid withdrawal and other adverse outcomes such as non-prescribed opioid use, OD, and death. As was seen in this case, the patient elected to leave the hospital prematurely, at which time an outpatient full agonist opioid taper was provided with instructions to continue with buprenorphine micro-dosing until safe to titrate to a stable dose of 24 mg daily (Table 1).