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High-dose buprenorphine for opioid withdrawal

Higher doses of buprenorphine in the hospital could help people transition more easily to outpatient drug treatment. Jupiterimages / PHOTOS.com / Getty Images Plus

Deaths from opioid overdoses in the U.S. continue to climb. They cost almost 70,000 lives in 2020 alone. Approved medications can treat the symptoms of acute opioid withdrawal and save lives with ongoing treatment. One such drug is called buprenorphine.

Health care providers who have received special training can give buprenorphine to people experiencing withdrawal in settings outside of standard drug treatment programs. This can allow treatment to start in a doctor’s office or emergency department.

Existing guidelines recommend doses of up to 12 mg of buprenorphine. Such low doses are known to be safe. But they take several days to provide maximum relief. Many people who use the emergency department, such as those experiencing homelessness or lacking health insurance, may struggle to fill a prescription. If people can’t access a medication needed to reduce cravings, they may use illicit drugs again and potentially experience a fatal overdose.

Doctors have begun experimenting with higher doses of buprenorphine (between 12 and 32 mg) in the emergency department. These can provide symptom relief within a few hours and offer sustained treatment for several days. But the safety of using these high doses in the emergency department has not been studied.

To fill this gap, researchers led by Dr. Andrew Herring from Highland Hospital in Oakland, California looked at a year’s worth of medical records from their institution. They identified 366 cases in which people received high-dose buprenorphine for opioid withdrawal symptoms. All were non-pregnant adults, aged 65 or younger, without other serious medical problems and not intoxicated from alcohol or other substances.

The researchers looked for serious side effects caused by high-dose buprenorphine, including trouble breathing, low blood oxygen levels, or the need for additional medications to manage withdrawal.

The study was funded in part by NIH’s National Institute on Drug Abuse (NIDA). Results were published on July 1, 2021, in JAMA Network Open.

About three-quarters of those treated with high-dose buprenorphine were men. Just under a quarter were currently homeless, and about 40% had concurrent mental health conditions.

With high doses of buprenorphine, people stayed in the emergency department for an average of less than 3 hours—no longer than with lower doses. No serious side effects linked to high-dose buprenorphine were observed, either in the emergency department or the day after discharge.

Only one case of sudden, severe withdrawal was seen with a high dose of the medication. More than 80% of people who received the high dose were able to access follow-up treatment soon after discharge.

“Adjusting the timing and dosage of buprenorphine in the emergency department, along with resources and counseling aimed at facilitating the transition to outpatient services, may provide the momentum needed to access continuing care,” Herring says.

High doses of buprenorphine may not be safe for some people, such as those with breathing problems or who use more than one drug at the same time. Additional studies are needed to confirm the safety of high-dose buprenorphine and to compare long-term outcomes with standard low doses of the medication.