The number of patients maintained on buprenorphine is steadily increasing. To date, no study has reported buprenorphine management practices for these patients during critical illness, nor its relationship with supplemental full-agonist opioid administration during their hospital stay. In this single-center retrospective study we have explored the incidence of buprenorphine continuation during critical illness among patients receiving buprenorphine for the treatment of opioid use disorder (OUD). Additionally, we investigated the relationship between non-buprenorphine opioid exposure and buprenorphine administration during the intensive care unit (ICU) and post-ICU phases of care. Our study included adults maintained on buprenorphine for OUD admitted to the ICU between December 1, 2014 and May 31, 2019. Non-buprenorphine, full agonist opioid doses were converted to fentanyl equivalents (FEs). 51 (44%) patients received buprenorphine during the ICU phase of care with an average dose of 8 [8-12] mg/day. During the post-ICU phase of care, 68 (62%) received buprenorphine with an average dose of 10 [7-14] mg/day. Lack of mechanical ventilation and acetaminophen use were also associated with buprenorphine use. Full agonist opioid use was more frequent on days when buprenorphine was not given (OR 6.2, 95% CI 2.3-16.4; p<.001). Additionally, the average cumulative dose of opioids given on non- buprenorphine administration days was significantly higher both in the ICU (1803 (1271-2553) vs 327 (152-708) FEs/day (p<.001)) and post ICU discharge (1476 (962-2265) vs 238 (150-377) FEs/day (p<.001)). Given these findings, buprenorphine continuation during critical illness should be considered, as it is associated with significantly decreased full agonist opioid utilization. This article is protected by copyright. All rights reserved.

Buprenorphine Continuation During Critical Illness Associated With Decreased Inpatient Opioid Utilization In Individuals Maintained On Buprenorphine For Opioid Use Disorder In A Retrospective Study.

<h3>Topic Importance</h3> Critical care clinicians are likely to see an increasing number of patients admitted to the ICU who are receiving US Food and Drug Administration-approved medications for opioid use disorder (MOUDs) given the well-documented benefits of these agents. Oral methadone, multiple formulations of buprenorphine, and extended-release naltrexone are the three types of MOUD most likely to be encountered by ICU clinicians; however, these drugs vary with respect to formulations, pharmacokinetics, and adverse effects. <h3>Review Findings</h3> No published clinical practice guidelines or consensus statements are available to guide decision-making in patients admitted to the ICU setting who are receiving MOUDs before admission. Additionally, no randomized trials and limited observational studies have evaluated issues related to MOUD use in the ICU. Therefore, ICU clinicians caring for patients admitted who are taking MOUDs must base their decision-making on data extrapolation from pharmacokinetic, pharmacologic, and clinical studies performed in non-ICU settings. <h3>Summary</h3> Despite the challenges in administering MOUDs in critically ill patients, extrapolation of data from other hospital settings suggests that the benefits of continuing MOUD therapy outweigh the risks in patients able to continue therapy. This article provides guidance for critical care clinicians caring for patients admitted to the ICU already receiving methadone, buprenorphine, or extended-release naltrexone. The guidance includes algorithms to aid clinicians in the clinical decision-making process, recognizing the inherent limitations of the existing evidence on which the algorithms are based and the need to account for patient-specific considerations. 

Management of Critically Ill Patients Receiving Medications for Opioid Use Disorder.

The opioid epidemic has resulted in increased opioid-related critical care admissions, presenting challenges in acute pain management. Limited guidance exists in the management of critically ill patients with opioid use disorder (OUD). This narrative review provides the intensive care unit clinician with guidance and treatment options, including nonopioid analgesia, for patients receiving medications for OUD and for patients actively misusing opioids. Verification and continuation of the patient's outpatient medications for OUD regimen, specifically buprenorphine and methadone formulations; assessment of pain and opioid withdrawal; and treatment of acute pain with nonopioid analgesia, nonpharmacologic strategies, and short-acting opioids as needed, are all essential to adequate management of acute pain in patients with OUD. A multidisciplinary approach to treatment and discharge planning in patients with OUD may be beneficial to engage patients with OUD early in their hospital stay to prevent withdrawal, stabilize their OUD, and reduce the risk of unplanned discharge and other associated morbidity. 

Pain Management Considerations in Patients With Opioid Use Disorder Requiring Critical Care

Opioid misuse is common, as is opioid agonist treatment of opioid dependence. Almost 3% of Australians and over 3.5% of those living in New Zealand report misuse of analgesics. Over 50,000 Australians receive opioid agonist treatment with methadone or buprenorphine for management of severe opioid use disorder. The perioperative period is an opportunity to identify pre-existing opioid misuse, and to introduce interventions to reduce the risk of development of opioid use disorder. Challenges of acute perioperative pain management or intensive care management of patients receiving opioid agonist treatment include opioid tolerance and ongoing prescribing of methadone or buprenorphine. There has been some ambiguity about the optimal perioperative management of buprenorphine, a partial agonist at the mu receptor. In this article, a framework to identify emerging opioid misuse problems, identify risk of overdose and to manage the opioid-dependent patient on opioid agonist treatment perioperatively or in the intensive care unit is provided. Diagnostic criteria and risk stratification criteria are presented. Management strategies include trauma-informed care, care planning and care coordination with community practitioners and opioid agonist treatment providers. Continuing methadone or buprenorphine perioperatively with additional opioid and non-opioid analgesia is generally recommended. Increased opioid agonist treatment doses may be required on discharge. An algorithm for decisions about opioid agonist treatment management in the intensive care unit based on the risks of opioid withdrawal and toxicity is considered. Strategies for managing the opioid-dependent patient who is not in treatment are also discussed.

Opioid use disorder in anaesthesia and intensive care: Prevention, diagnosis and management

OBJECTIVES
To describe practice patterns surrounding the use of medications to treat opioid use disorder (MOUD) in critically ill patients.


DESIGN
Retrospective, multicenter, observational study using the Premier AI Healthcare Database.


SETTING
The study was conducted in U.S. ICUs.


PATIENTS
Adult (≥ 18 yr old) patients with a history of opioid use disorder (OUD) admitted to an ICU between 2016 and 2020.


INTERVENTIONS
None.


MEASUREMENTS AND MAIN RESULTS
Of 108,189 ICU patients (658 hospitals) with a history of OUD, 20,508 patients (19.0%) received MOUD. Of patients receiving MOUD, 13,745 (67.0%) received methadone, 2,950 (14.4%) received buprenorphine, and 4,227 (20.6%) received buprenorphine/naloxone. MOUD use occurred in 37.9% of patients who received invasive mechanical ventilation. The median day of MOUD initiation was hospital day 2 (interquartile range [IQR] 1-3) and the median duration of MOUD use was 4 days (IQR 2-8). MOUD use per hospital was highly variable (median 16.0%; IQR 10-24; range, 0-70.0%); admitting hospital explained 8.9% of variation in MOUD use. A primary admitting diagnosis of unintentional poisoning (aOR 0.41; 95% CI, 0.38-0.45), presence of an additional substance use disorder (aOR 0.66; 95% CI, 0.64-0.68), and factors indicating greater severity of illness were associated with reduced odds of receiving MOUD in the ICU.


CONCLUSIONS
In a large multicenter, retrospective study, there was large variation in the use of MOUD among ICU patients with a history of OUD. These results inform future studies seeking to optimize the approach to MOUD use during critical illness.

Variation in Use of Medications for Opioid Use Disorder in Critically Ill Patients Across the United States.

A national survey of approaches to manage the ICU patient with opioid use disorder

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A national survey of approaches to manage the ICU patient with opioid use disorder

A Comprehensive List of Critical Needs in Emerging Trends in Health IT

Emerging Trends in Health Information Technology: Results from a Horizon Scan