Microdosing and standard-dosing take-home buprenorphine from the emergency department: A feasibility study

Jessica Moe, Katherin Badke, Megan Pratt, Raymond Y Cho, Pouya Azar, Heather Flemming, K Anne Sutherland, Barbara Harvey, Lara Gurney, Julie Lockington, Penny Brasher, Sam Gill, Emma Garrod, Misty Bath, Andy Kestler, Jessica Moe, Katherin Badke, Megan Pratt, Raymond Y Cho, Pouya Azar, Heather Flemming, K Anne Sutherland, Barbara Harvey, Lara Gurney, Julie Lockington, Penny Brasher, Sam Gill, Emma Garrod, Misty Bath, Andy Kestler

Abstract

Objective: Emergency department (ED)-initiated buprenorphine may prevent overdose. Microdosing is a novel approach that does not require withdrawal, which can be a barrier to standard inductions. We aimed to evaluate the feasibility of an ED-initiated buprenorphine/naloxone program providing standard-dosing and microdosing take-home packages and of randomizing patients to either intervention.

Methods: We broadly screened patients ≥18 years old for opioid use disorder at a large, urban ED. In a first phase, we provided consecutive patients with 3-day standard-dosing packages, and then we provided a subsequent group with 6-day microdosing packages. In a second phase, we randomized patients to standard dosing or microdosing. We attempted 7-day telephone follow-ups and 30-day in-person community follow-ups. The primary feasibility outcome was number of patients enrolled and accepting randomization. Secondary outcomes were numbers screened, follow-up rates, and 30-day opioid agonist therapy retention.

Results: We screened 3954 ED patients and identified 94 with opioid use disorders. Of the patients, 26 (27.7%) declined participation: 10 identified a negative prior experience with buprenorphine/naloxone as the reason, 5 specifically cited precipitated withdrawal, and none cited randomization. We enrolled 68 patients. A total of 14 left the ED against medical advice, 8 were excluded post-enrollment, 21 received standard dosing, and 25 received microdosing. The 7-day and 30-day follow-up rates were 9/46 (19.6%) and 15/46 (32.6%), respectively. At least 5/21 (23.8%) provided standard dosing and 8/25 (32.0%) provided microdosing remained on opioid agonist therapy at 30 days.

Conclusions: ED-initiated take-home standard-dosing and microdosing buprenorphine/naloxone programs are feasible, and a randomized controlled trial would be acceptable to our target population.

Keywords: Bernese method; buprenorphine; drug overdose; emergency service hospital; microdosing; micro‐induction; naloxone drug combination; opiate substitution therapy; opioid addiction; opioid‐related disorders.

Conflict of interest statement

The authors declare no conflicts of interest.

© 2020 The Authors. JACEP Open published by Wiley Periodicals LLC on behalf of the American College of Emergency Physicians.

Figures

FIGURE 1
FIGURE 1
Study flow diagram

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Source: PubMed

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