ACEP E-QUAL Podcast: Buprenorphine After Opiate Overdose

The opiate epidemic continues to be a frontline issue for healthcare systems across the country. The American College of Physicians (ACEP) Emergency Quality (E-QUAL) Network, through its Opioid Initiative Goal, strives to promote the implementation of alternatives to opioids, improved opioid prescribing safety, and adoption of harm reduction strategies such as naloxone prescribing and medication-assisted therapies (MAT). In a two-part series of the ACEP E-QUAL Network Podcast, host Dr. Jason Woods discussed buprenorphine initiation after an opioid overdose in the Emergency Department (ED) with Dr. Andrew Herring, Associate Director of Research and Medical Director of the Substance Use Disorder Treatment Program at Highland Hospital in Alameda County California. Below are show notes reviewing basic concepts of buprenorphine and recommendations for dosing in the ED.

Where do I get a DEA X-waiver?

With the rising interest in MAT, several programs are beginning to provide increased access to training and certification. ACEP will be working in partnership with the Providers Clinical Support System to provide online training. Dates can be found here.

What do I need to know about buprenorphine?

Buprenorphine is a potent opioid that is used to treat pain and for MAT in opiate use disorder (OUD).

Buprenorphine is slow to bind opiate receptors but has a high enough affinity that it can outcompete other opiates like fentanyl and methadone, and can even outcompete naloxone.

Buprenorphine has a ceiling effect in analgesia and respiratory depression that makes cumulative and higher initial dosing relatively safe.

Who is buprenorphine right for?

Buprenorphine as MAT for OUD is intended for clear stories of an opiate overdose not complicated by additional medical or social factors.

The ideal patient is one that is beginning to experiencing withdrawal symptoms of mild to moderate severity following reversal with naloxone or due to absence of use. The patient should be awake and alert enough to participate in shared decision-making about the initiation of therapy.

It is best to initiate buprenorphine while patients are experiencing some degree of withdrawal so that the agonist effects produce a net-positive feeling, providing patients with a sense of relief and comfort likely to strengthen motivation for continued engagement.

Buprenorphine should not be given to patients who are already on methadone, as this could lead to worse withdrawal reactions. It should also be avoided in patients who appear “sick,” suggesting underlying metabolic or infectious processes, intoxication, or co-ingestion. It should not be used as primary therapy for severe withdrawal.

Although studies have demonstrated utility for validated scoring systems to assess withdrawal severity, it is sufficient to evaluate a patient’s overall clinical appearance and decide to treat based on gestalt.

What is the best dose to initiate buprenorphine treatment?

There is no single agreed-upon dosing regimen. Many X-waiver courses promote a “by-the-book” approach of 2-4 mg every 2 hours to a max of 8 mg on the day of initiation.

Taking into account that prescription medications and street drugs continue to increase in potency, however, starting with small doses may leave the patient continuing to feel symptomatic and discourage use. The goal of treatment should be to create a positive experience that will facilitate continued MAT.

Evolving dosing regimens recommend taking into account the patient’s level of use to determine an initial dose. Data supports that individuals are rather good about classifying themselves as light, medium, or heavy users.

Light user: 4 mg
Medium user: 8 mg
Heavy user: 16 mg

If the decision is made to start on the lower end, a commitment should be made to re-evaluate the patient 30 minutes after the first dose to determine the need for additional medication. Avoid leaving your patients suffering in continued withdrawal.

Remember, even though the patient may end up in a good place, the initial displacement of the opiate or reversal agent may inherently cause discomfort or pain as the opiate receptor is unbound.

What issues remain?

Improved reversal practices and more appropriate dosing of reversal agents will improve the patient experience as triggered withdrawal symptoms can be lessened in severity. There exists a large variability in the amount of naloxone given by pre-hospital and ED providers.

Interested in more of the ACEP-EQUAL Podcast?

By Moises Gallegos, MD MPH|2021-09-15T11:31:08-07:00Dec 18, 2020|Academic, ACEP E-QUAL|

ACEP E-QUAL: ACEP Non-STEMI Clinical Policy

In 2018, the American College of Physicians (ACEP) released a Clinical Policy with management recommendations for patients presenting to the emergency department (ED) with concern for non-ST-elevation myocardial infarction (NSTEMI). Dr. Jason Woods hosted an episode of the ACEP E-QUAL Network podcast highlighting key aspects of the new policy. Dr. Woods was joined by lead writer Dr. Christian Tomaszewski from the University of California San Diego, and Dr. Michael Ross, Director of the Chest Pain Center at Emory University. Below are show notes reviewing the recommendations and the process involved in creating the clinical policy.

How is a clinical policy different than a practice guideline?

The National Guideline Clearinghouse (NGC), a public resource initiative of the Agency for Healthcare Research and Quality (AHRQ), provides rules and frameworks for evidence-based clinical practice guidelines. ACEP refers to clinical practice guidelines in Emergency Medicine (EM) as policies to denote the more prescriptive design process.

What was the process of drafting the policy?

Development of the 2018 ACEP NSTEMI Clinical Policy was a 2-year “labor of love.” Writers, methodologies, and committee members were required to be free from both financial and intellectual conflict of interest.

The clinical policy is a result of a systematic review and critical analysis of available medical literature. Clinical studies were graded on robustness, design, and class of evidence according to the ACEP policy development process which includes internal and external review.

Recommendations were categorized as reflecting high clinical certainty (Level A), moderate clinical certainty (Level B), or mixed clinical certainty (Level C) due to the heterogeneity of results, unclear effect magnitude, bias, among other factors.

What questions did the policy address?

Four critical questions were decided by consensus methods to address the evaluation and management of adult patients presenting to the ED with concern for NSTEMI.

1) If ST-elevation myocardial infarction is excluded, can a combination of bedside and laboratory evaluation in the ED identify patients at low risk for major adverse cardiac events (MACE)?
Level B recommendation: History, ECG, Age, Risk Factors, Troponin (HEART) score < 3 can be used as a clinical prediction tool for a 30-day MACE miss rate between 0-2%.
Level C recommendation: Thrombolysis in Myocardial Infarction (TIMI) score can be used to predict risk of 30-day MACE.

2) Can repeat Troponin testing in the ED be used to identify patients at low risk for MACE?
Level C recommendations:

- Conventional troponin testing at hour 0 and 3 in low risk (HEART score < 3) patients can predict and acceptable low risk for 30-day MACE.
- A single high-sensitivity troponin less than the detectable limit on arrival to the ED or negative serial high-sensitivity troponin at hour 0 and 2 is predictive of a low rate of MACE.
- Patients deemed to be low risk with a non-ischemic ECG and negative high-sensitivity troponin at 0 and 2 hours can be considered low risk for 30-day MACE, allowing for accelerated discharge from the ED.

3) In patients who have been ruled out for acute coronary syndromes (ACS), does advanced cardiac provocative testing prior to discharge from the ED reduce MACE?
Level B recommendation: Do not routinely use advanced cardiac testing in low-risk patients who have been ruled out for ACS to further reduce 30-day MACE.
Level C recommendation: Arrange follow-up in 1-2 weeks for low-risk patients in whom ACS has been ruled out. If unable to arrange follow-up, consider observation and advanced testing prior to discharge.

4) Should patients with NSTEMI receive antiplatelet therapy in addition to aspirin in the ED?
Level C recommendation: P2Y12 inhibitors and glycoprotein IIb/IIIa inhibitors can be given in the ED or delayed until cardiac catheterization.

What questions remain?

The clinical policy does not address the “delta factor” involved in assessing changes to the cardiac marker levels that may be seen with repeat testing at set time points.
Duration of pain was not discretely addressed, and differences in real-world practice can exist depending on whether the time of onset or time of presentation is considered for defining repeat testing and observation length.
Shared decision-making was not factored into the selection of management steps.

Important points for consideration:

The 2018 ACEP Clinical Policy for NSTEMI was written for the evaluation of patients with suspicion for ACS who presented with chest pain. It does not apply to those presentations of ACS that are considered atypical in nature.

Read a more in-depth summary of the ACEP Clinical Policy on ALiEM.

Interested in more of the ACEP-EQUAL Podcast?

By Moises Gallegos, MD MPH|2021-09-15T11:34:21-07:00Dec 7, 2020|Academic, ACEP E-QUAL, Cardiovascular|