PDF(Pubmed)
Abstract：
Buprenorphine has been successfully used for decades in the treatment of opioid use disorder, yet there are complexities to its use that warrant attention to maximize its utility. While the package insert of the combination product buprenorphine\\naloxone continues to recommend a maximum dose of 16 mg daily for maintenance, the emergence of fentanyl and synthetic analogs in the current drug supply may be limiting the effectiveness of this standard dose. Many practitioners have embraced and appropriately implemented novel practices to mitigate the sequelae of our current crisis. It has become common clinical practice to stabilize patients with 24 - 32 mg of buprenorphine daily at treatment initiation. Many of these patients, however, are maintained on these high doses (>16 mg/d) indefinitely, even after prolonged stability. Although this may be a necessary strategy in the short term, there is little evidence to support its safety and efficacy, and these high doses may be exposing patients to more complications and side effects than standard doses. Commonly known side effects of buprenorphine that are likely dose-related include hyperhidrosis, sedation, decreased libido, constipation, and hypogonadism. There are also complications related to the active metabolite of buprenorphine (norbuprenorphine) which is a full agonist at the mu opioid receptor and does not have a ceiling on respiratory suppression. Such side effects can lead to medical morbidity as well as decreased medication adherence, and we, therefore, recommend that after a period of stabilization, practitioners consider a trial of decreasing the dose of buprenorphine toward standard dose recommendations. Some patients\' path of recovery may never reach this stabilization phase (i.e., several months of adherence to medications, opioid abstinence, and other clinical indicators of stability). Side effects of buprenorphine may not have much salience when patients are struggling for survival and safety, but for those who are fortunate enough to advance in their recovery, the side effects become more problematic and can limit quality of life and adherence.
摘要：
丁丙诺啡已成功用于阿片类药物使用障碍的治疗数十年，然而，它的使用存在复杂性，需要注意最大化其效用。虽然组合产品丁丙诺啡的包装说明书继续推荐每日16毫克的最大剂量用于维持，目前药物供应中芬太尼和合成类似物的出现可能限制了该标准剂量的有效性.许多从业者接受并适当实施了新的做法，以减轻我们当前危机的后遗症。在治疗开始时每天使用24-32mg丁丙诺啡稳定患者已成为常见的临床实践。很多病人,然而,无限期地维持这些高剂量(>16mg/d)，即使在长期稳定之后。尽管这在短期内可能是必要的策略，几乎没有证据支持它的安全性和有效性，与标准剂量相比，这些高剂量可能会使患者面临更多的并发症和副作用。通常已知的丁丙诺啡可能与剂量相关的副作用包括多汗症，镇静,性欲下降，便秘,和性腺功能减退.还存在与丁丙诺啡(去甲丁丙诺啡)的活性代谢物相关的并发症,所述活性代谢物是μ阿片受体的完全激动剂并且对呼吸抑制没有上限。这种副作用可能导致医疗发病率以及药物依从性下降，而我们,因此,建议在稳定一段时间后，医师考虑将丁丙诺啡的剂量降低至标准剂量建议的试验.一些患者的康复路径可能永远不会达到这个稳定阶段(即，坚持几个月的药物治疗，阿片类药物禁欲，和其他临床稳定性指标）。当患者为生存和安全而挣扎时，丁丙诺啡的副作用可能没有太大显着性。但是对于那些有幸康复的人来说，副作用变得更成问题，并可能限制生活质量和依从性。
