(112) Buprenorphine Microinduction in an Intubated and Sedated Patient

Background & Introduction: Buprenorphine is a partial opioid agonist approved to treat opioid use disorder (OUD). However, buprenorphine initiation may be challenging. If administered too soon after the use of a full opioid agonist, precipitated withdrawal may occur. Buprenorphine microinduction has become increasingly popular as a means of overcoming such barriers, especially as fentanyl becomes more prevalent in the drug supply1-3.

As rates of OUD, related complications, and overdose deaths continue to rise, it is crucial that the medical community explore alternative means to quickly and successfully initiate medications for OUD (MOUD) whenever patients interact with the healthcare system.

In this case report, we discuss a patient who started buprenorphine via a microinduction technique while intubated and receiving full opioid agonists in an intensive care unit (ICU) setting.

Case Description: A 53-year-old female with a past medical history of Wolf-Parkinson-White, multiple sclerosis, fibromyalgia, and OUD presented to an outside hospital for nausea, vomiting, diarrhea, and agitation for one day. In the outside hospital, she developed supraventricular tachycardia and was cardioverted multiple times. She subsequently was intubated after developing respiratory distress. She was transferred to our hospital for higher level of care. She underwent infectious workup due to continued tachycardia and tachypnea and was treated for pneumonia.

Addiction medicine was consulted on hospital day three due to concern for history of OUD, as well as high sedation requirements and agitation leading to difficulty weaning sedation for spontaneous breathing trials. At the time of initial consultation, the patient was receiving a hydromorphone infusion at 2mg/ hour, oxycodone per gastrostomy (G) tube 10mg every six hours, diazepam per G tube 10mg every 6 hours, midazolam infusion of 2mg/ hour, and propofol infusion of 2.5mcg/ kg/ hour.

On chart review, it was found that the patient had in the past month requested a buprenorphine/naloxone prescription from her primary physician. Prior notes documented a history of injection heroin and fentanyl use. Buprenorphine prescriptions were not found in the prescription drug monitoring program (PDMP).

The addiction medicine team recommended a buprenorphine microinduction per the protocol listed in Table 1, while continuing opioid agonists. This decision was based on: 1) the likely diagnosis of OUD with continued recent opioid use per chart review; 2) the patient’s prior expression of interest in buprenorphine as MOUD; and 3) for the purpose of controlling opioid withdrawal in order to promote patient comfort while allowing sedation infusion weaning, and 4) avoiding prolonged intubation.

The patient was extubated on hospital day four and successfully completed buprenorphine microinduction on hospital day five. On reevaluation by addiction medicine on hospital day six, it was determined that by history, the patient did meet criteria for severe OUD with active fentanyl use. She remained interested in buprenorphine as MOUD. She expressed gratitude for having been initiated on buprenorphine while sedated. She was provided a discharge prescription for buprenorphine/naloxone 8-2mg twice daily, and a follow up appointment was made for our outpatient clinic. She was discharged on hospital day six.

While she had intermittent periods of continued fentanyl use, after starting buprenorphine in the ICU, she was retained in care on buprenorphine for a period of over seven months.

Conclusion & Discussion: We discuss a patient who initiated buprenorphine while intubated in an ICU setting, which has traditionally been underutilized in starting MOUD4. To our knowledge, only one similar case is reported in the literature, with a key difference being the patient was able to consent to buprenorphine treatment prior to initiation5.

Initiating buprenorphine in intubated patients has advantages compared to delayed initiation. By continuing full opioid agonists, the patient can avoid opioid withdrawal, decreasing patient discomfort and increasing likelihood of successful initiation. Once therapeutic, buprenorphine may then ultimately control opioid withdrawal symptoms, reducing sedation requirements.

While one might argue that initiating buprenorphine prior to obtaining the patient’s consent would raise ethical concerns, we believe patient autonomy is not lost with this approach. Here, buprenorphine has additional utility in reducing sedation requirements. Just as consent is implied for other noninvasive and lifesaving medications, we apply the same to buprenorphine. Patients can simply elect to discontinue buprenorphine after extubation, or transition to methadone (which is appreciably less complicated than transition from methadone to buprenorphine).

As patients with OUD require increasing ICU admissions and mechanical ventilation, we suggest that the ICU could be a setting with new opportunity for MOUD initiation.

References: 1. Shearer D, Young S, Fairbairn N, Brar R. Challenges with buprenorphine inductions in the context of the fentanyl overdose crisis: A case series. Drug Alcohol Rev 2022;41(2):444-448. (In eng). DOI: 10.1111/dar.13394.
2. Sue KL, Cohen S, Tilley J, Yocheved A. A Plea From People Who Use Drugs to Clinicians: New Ways to Initiate Buprenorphine Are Urgently Needed in the Fentanyl Era. J Addict Med 2022;16(4):389-391. (In eng). DOI: 10.1097/adm.0000000000000952.
3. Ahmed S, Bhivandkar S, Lonergan BB, Suzuki J. Microinduction of Buprenorphine/Naloxone: A Review of the Literature. Am J Addict 2021;30(4):305-315. (In eng). DOI: 10.1111/ajad.13135.
4. Reichheld AM, Hills-Evans K, Sheehan JK, et al. A national survey of approaches to manage the ICU patient with opioid use disorder. J Crit Care 2019;54:42-47. (In eng). DOI: 10.1016/j.jcrc.2019.06.032.
5. Hamata B, Griesdale D, Hann J, Rezazadeh-Azar P. Rapid Micro-induction of Buprenorphine/Naloxone for Opioid Use Disorder in a Critically ill Intubated Patient: A Case Report. J Addict Med 2020;14(6):514-517. (In eng). DOI: 10.1097/adm.0000000000000675.