Treatment Education for Attending Physicians & Residents Bup 101: Buprenorphine Basics Jeanmarie Perrone, MD, FACMT Professor of Emergency Medicine Director, Division of Medical Toxicology University of Pennsylvania @JMPerroneMD
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Treatment Education for Attending Physicians & Residents
Bup101:BuprenorphineBasics
JeanmariePerrone,MD,FACMTProfessorofEmergencyMedicineDirector,DivisionofMedicalToxicologyUniversityofPennsylvania@JMPerroneMD
TheEpidemicNow
Fentanyl,carfentanil &designeropioids
ChronicPain
PrescriptionDrugs
HEROIN
DEATHS42,250
CDC 2016
PhiladelphiaDept.ofPublicHealth,MedicalExaminer’sOffice 2017
OverdoseDeathsinPhiladelphia
Wiener: ACEP Research Forum 2017
TheBostonGlobe
Heroinoverdosedeathsduringexpansionofmethadoneandbuprenorphine
Baltimore1995-2009
Schwartz, AJPH, 2013Schwartz, AJPH, 2013
Schwartz AJPH
D’Onofrio:EmergencyDepartment-InitiatedBuprenorphine/NaloxoneTreatmentforOpioidDependence:ARandomizedClinicalTrial.JAMA2015
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Prop
ortio
n in
Tre
atm
ent a
t 30
Day
s
ReferralBriefIntervention
Buprenorphine
D’Onofrio:EDInitiatedBuprenorphine/NaloxoneTreatmentforOpioidDependence:ARandomizedClinicalTrial.JAMA2015
BarrierstoRxbuprenorphine– It’sjustoneaddictionforanother
– I’mnotpaying$200.00toRxadrugthatPharmacompaniesaremakingmoneyon
– I’mjustnotsurehowtodoit
– Idon’thavethe“xwaiver”trainingsoIdon’tfeelcomfortable
– Whataboutfollowup??
Whocanorderbuprenorphine?
72-hourrule
Allowstoadminister(butnotprescribe)narcoticdrugsforthepurposeofrelievingacutewithdrawalsymptomswhilearrangingforthepatient'sreferralfortreatment
Title21,CodeofFederalRegulations,Part1306.07(b)
• Notmorethan1-day'smedicationmaybeadministeredtoapatientatonetime
• PatientmustreturntoEDeachdayfornomorethan72hours
• This72-hourperiodcannotberenewedorextended.
BuprenorphinePharmacology
Buprenorphine-Naloxone (Suboxone)
• Buprenorphineisapartialmu-opioidagonist• Naloxoneisacompleteopioidantagonist
SUBLINGUALFILM TABLETS
ClinicalOpiateWithdrawalScale
ClinicalOpiateWithdrawalScale
Buprenorphineadministration
Buprenorphine
Adverseevents==Precipitatedwithdrawal(worseningwithdrawalsymptoms)
WarmHandoff
WarmHandoff
Summary
• Buprenorphineisanevidencebasedtx thatanyphysiciancanorderintheEDtotreatwithdrawalandbridgetofollowup.
• ACOWStoolishelpfultogaugewithdrawalseverityCOWS>8==buprenorphine
• Rxnaloxoneandwarmhandoff
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