PDF(Pubmed)
Abstract：
BACKGROUND: Buprenorphine is an effective treatment for opioid use disorder (OUD); however, buprenorphine initiation can be complicated by withdrawal symptoms including precipitated withdrawal. There has been increasing interest in using low dose initiation (LDI) strategies to reduce this withdrawal risk. As there are limited data on withdrawal symptoms during LDI, we characterize withdrawal symptoms in people with daily fentanyl use who underwent initiation using these strategies as outpatients.
METHODS: We conducted a retrospective chart review of patients with OUD using daily fentanyl who were prescribed 7-day or 4-day LDI at 2 substance use disorder treatment clinics in San Francisco. Two addiction medicine experts assessed extracted chart documentation for withdrawal severity and precipitated withdrawal, defined as acute worsening of withdrawal symptoms immediately after taking buprenorphine. A third expert adjudicated disagreements. Data were analyzed using descriptive statistics.
RESULTS: There were 175 initiations in 126 patients. The mean age was 37 (SD 10 years). 71% were men, 26% women, and 2% non-binary. 21% identified as Black, 16% Latine, and 52% white. 60% were unstably housed and 75% had Medicaid insurance. Substance co-use included 74% who used amphetamines, 29% cocaine, 22% benzodiazepines, and 19% alcohol. Follow up was available for 118 (67%) initiations. There was deviation from protocol instructions in 22% of these initiations with follow up. 31% had any withdrawal, including 21% with mild symptoms, 8% moderate and 2% severe. Precipitated withdrawal occurred in 10 cases, or 8% of initiations with follow up. Of these, 7 had deviation from protocol instructions; thus, there were 3 cases with follow up (3%) in which precipitated withdrawal occurred without protocol deviation.
CONCLUSIONS: Withdrawal was relatively common in our cohort but was mostly mild, and precipitated withdrawal was rare. Deviation from instructions, structural barriers, and varying fentanyl use characteristics may contribute to withdrawal. Clinicians should counsel patients who use fentanyl that mild withdrawal symptoms are likely during LDI, and there is still a low risk for precipitated withdrawal. Future studies should compare withdrawal across initiation types, seek ways to support patients in initiating buprenorphine, and qualitatively elicit patients\' withdrawal experiences.
METHODS: We conducted a retrospective chart review of patients with OUD using daily fentanyl who were prescribed 7-day or 4-day LDI at 2 substance use disorder treatment clinics in San Francisco. Two addiction medicine experts assessed extracted chart documentation for withdrawal severity and precipitated withdrawal, defined as acute worsening of withdrawal symptoms immediately after taking buprenorphine. A third expert adjudicated disagreements. Data were analyzed using descriptive statistics.
RESULTS: There were 175 initiations in 126 patients. The mean age was 37 (SD 10 years). 71% were men, 26% women, and 2% non-binary. 21% identified as Black, 16% Latine, and 52% white. 60% were unstably housed and 75% had Medicaid insurance. Substance co-use included 74% who used amphetamines, 29% cocaine, 22% benzodiazepines, and 19% alcohol. Follow up was available for 118 (67%) initiations. There was deviation from protocol instructions in 22% of these initiations with follow up. 31% had any withdrawal, including 21% with mild symptoms, 8% moderate and 2% severe. Precipitated withdrawal occurred in 10 cases, or 8% of initiations with follow up. Of these, 7 had deviation from protocol instructions; thus, there were 3 cases with follow up (3%) in which precipitated withdrawal occurred without protocol deviation.
CONCLUSIONS: Withdrawal was relatively common in our cohort but was mostly mild, and precipitated withdrawal was rare. Deviation from instructions, structural barriers, and varying fentanyl use characteristics may contribute to withdrawal. Clinicians should counsel patients who use fentanyl that mild withdrawal symptoms are likely during LDI, and there is still a low risk for precipitated withdrawal. Future studies should compare withdrawal across initiation types, seek ways to support patients in initiating buprenorphine, and qualitatively elicit patients\' withdrawal experiences.
摘要：
背景：丁丙诺啡是阿片类药物使用障碍（OUD）的有效治疗方法；然而，丁丙诺啡的开始可能是复杂的戒断症状，包括沉淀戒断。人们对使用低剂量起始（LDI）策略来降低这种戒断风险越来越感兴趣。由于LDI期间戒断症状的数据有限，我们将每日使用芬太尼并开始使用这些策略的患者的戒断症状描述为门诊患者.
方法：我们对在旧金山的2个药物使用障碍治疗诊所服用7天或4天LDI的OUD患者进行了回顾性分析。两名成瘾医学专家评估了戒断严重程度和加速戒断的图表文件，定义为服用丁丙诺啡后戒断症状立即急性恶化。第三位专家裁定存在分歧。数据采用描述性统计分析。
结果：126例患者中有175例开始。平均年龄为37岁（SD为10岁）。71%是男性,26%的女性,和2%非二进制。21%被认定为黑色，16%Latine,52%的白人60％的住房不稳定，75％的人有医疗补助保险。共同使用的物质包括74%使用苯丙胺的人，29%可卡因,22%苯二氮卓类药物，19%的酒精118次（67%）初始随访。在随访中，有22％的这些初始化与协议说明存在偏差。31%的人有任何提款，其中21%症状轻微,8%中度和2%重度。10例发生沉淀戒断，或8％的初始随访。其中,7偏离了协议说明；因此，有3例(3%)进行了随访,在没有方案偏差的情况下发生了沉淀停药.
结论：戒断在我们的队列中相对常见，但大多是轻度的，沉淀退出是罕见的。偏离说明,结构性障碍,和不同的芬太尼使用特征可能有助于戒断。临床医生应该建议使用芬太尼的患者在LDI期间可能出现轻度戒断症状，而且提前退出的风险仍然很低。未来的研究应该比较不同类型的戒断，寻求方法来支持患者开始丁丙诺啡，并定性地引出患者的戒断体验。
方法：我们对在旧金山的2个药物使用障碍治疗诊所服用7天或4天LDI的OUD患者进行了回顾性分析。两名成瘾医学专家评估了戒断严重程度和加速戒断的图表文件，定义为服用丁丙诺啡后戒断症状立即急性恶化。第三位专家裁定存在分歧。数据采用描述性统计分析。
结果：126例患者中有175例开始。平均年龄为37岁（SD为10岁）。71%是男性,26%的女性,和2%非二进制。21%被认定为黑色，16%Latine,52%的白人60％的住房不稳定，75％的人有医疗补助保险。共同使用的物质包括74%使用苯丙胺的人，29%可卡因,22%苯二氮卓类药物，19%的酒精118次（67%）初始随访。在随访中，有22％的这些初始化与协议说明存在偏差。31%的人有任何提款，其中21%症状轻微,8%中度和2%重度。10例发生沉淀戒断，或8％的初始随访。其中,7偏离了协议说明；因此，有3例(3%)进行了随访,在没有方案偏差的情况下发生了沉淀停药.
结论：戒断在我们的队列中相对常见，但大多是轻度的，沉淀退出是罕见的。偏离说明,结构性障碍,和不同的芬太尼使用特征可能有助于戒断。临床医生应该建议使用芬太尼的患者在LDI期间可能出现轻度戒断症状，而且提前退出的风险仍然很低。未来的研究应该比较不同类型的戒断，寻求方法来支持患者开始丁丙诺啡，并定性地引出患者的戒断体验。
