丁丙诺啡围手术期和重症监护管理现状评论。

IF 5.2 1区 医学 Q1 PSYCHIATRY Addiction Pub Date : 2023-09-28 DOI:10.1111/add.16346
Aurora Quaye, Charlotte Crist, Simba Matoi, Yi Zhang
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Conversely, when buprenorphine is used for OUD treatment, the diminished availability of opioid receptors resulting from the higher buprenorphine doses required can pose challenges for analgesic management [<span>6</span>]. Although routine practice involves continuing chronic pain buprenorphine formulations when acute pain is anticipated, the prevailing practice until recently has been withholding OUD dosed buprenorphine [<span>4, 7</span>]. Emerging evidence challenges these notions and supports opioid based analgesia can be achieved in parallel with OUD buprenorphine continuation [<span>5, 8, 9</span>].</p><p>In our previous retrospective study of surgical patients with OUD comparing patients where buprenorphine was continued or discontinued, we identified significantly higher outpatient opioid dispensing with buprenorphine discontinuation [<span>5</span>]. 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Premature discontinuation of buprenorphine is associated with an increased risk of opioid-induced relapse, making such practices concerning [<span>11, 12</span>].</p><p>The lack of clear guidance for buprenorphine management also extends to the critical care community. The 2018 Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility and Sleep Disruption in Adult Patients in the Intensive Care Unit did not provide recommendations for managing buprenorphine in patients maintained on this medication [<span>13</span>]. In our retrospective study evaluating the relationship between opioid exposure and buprenorphine administration in the intensive care unit, we identified the odds of receiving additional opioids were more than six times higher on days when buprenorphine was not administered compared to when it was given [<span>14</span>]. These findings support continuation of buprenorphine during critical illness, as it is associated with significantly decreased use of supplemental opioids, similar to current best practice established for perioperative populations.</p><p>The above information reveals that high-level evidence on the analgesic outcomes based on buprenorphine management need to be conducted to establish a consensus for managing patients maintained on this medication [<span>15</span>]. 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引用次数: 0

摘要

二十多年来,美国一直在努力应对当前阿片类药物使用障碍(OUD)的流行[1]。作为应对措施,丁丙诺啡用于治疗 OUD 的使用率大幅上升,部分原因在于其独特的药理特性[2, 3]。与其他阿片类药物相比,丁丙诺啡的半衰期长,与阿片受体的结合亲和力高,解离速度慢。因此,当与其他阿片类药物同时使用时,丁丙诺啡不会被这些受体取代[4]。用于慢性疼痛治疗的丁丙诺啡的治疗剂量大大低于治疗 OUD 所需的剂量;因此,当同时使用其他阿片类药物来增强镇痛效果时,阿片类受体仍可使用[5]。相反,当丁丙诺啡用于治疗 OUD 时,由于所需的丁丙诺啡剂量较高,阿片受体的可用性降低,会给镇痛管理带来挑战[6]。虽然常规做法是在预计会出现急性疼痛时继续使用慢性疼痛丁丙诺啡制剂,但直到最近,流行的做法一直是暂停使用 OUD 剂量的丁丙诺啡[4, 7]。新出现的证据对这些观点提出了质疑,并支持在继续使用 OUD 丁丙诺啡的同时,可以实现基于阿片类药物的镇痛[5, 8, 9]。在我们之前对患有 OUD 的手术患者进行的回顾性研究中,对比了继续使用或停用丁丙诺啡的患者,我们发现停用丁丙诺啡的患者门诊阿片类药物的配给量显著增加[5]。Li等人[8]也报告了类似的研究结果,与停用丁丙诺啡的患者相比,围手术期继续使用不同剂量丁丙诺啡的患者获得的阿片类药物处方明显减少。在接受调查的麻醉医师中,仅有 36% 的机构制定了丁丙诺啡管理方案,超过三分之一的麻醉医师认可在预计会出现中度至重度疼痛的情况下停用丁丙诺啡,或因缺乏机构方案而采取不一致的管理措施。过早停用丁丙诺啡与阿片类药物引起的复发风险增加有关,因此这种做法值得关注[11, 12]。2018 年《重症监护病房成人患者疼痛、躁动/镇静、谵妄、活动不便和睡眠障碍的预防和管理临床实践指南》并未提供关于丁丙诺啡管理的建议[13]。在我们评估重症监护病房阿片类药物暴露与丁丙诺啡用药之间关系的回顾性研究中,我们发现在未使用丁丙诺啡的日子里,接受额外阿片类药物的几率是使用丁丙诺啡的六倍以上[14]。这些发现支持在危重病期间继续使用丁丙诺啡,因为它与补充阿片类药物的使用显著减少有关,这与目前为围术期人群制定的最佳实践相似。上述信息表明,需要对基于丁丙诺啡管理的镇痛结果进行高级别的证据研究,以便就如何管理继续使用这种药物的患者达成共识[15]。面对阿片类药物危机,循证实践对于指导临床医生和政策制定者为使用丁丙诺啡的患者提供最佳护理至关重要:构思(主导);调查(平等);撰写-初稿(主导);撰写-审阅和编辑(平等)。夏洛特-克里斯特构思(辅助);调查(辅助);撰写原稿(辅助);撰写-审阅和编辑(辅助)。辛巴-马托伊(Simba Matoi):构思(支持);调查(支持);撰写原稿(支持);撰写-审阅和编辑(支持)。Yi Zhang:构思(等同);调查(等同);撰写原稿(等同);撰写-审阅和编辑(等同)。
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Commentary on the current state of perioperative and critical care buprenorphine management

For over two decades, the United States has grappled with our current opioid use disorder (OUD) epidemic [1]. In response, there has been a significant increase in the utilization of buprenorphine for OUD treatment, in part because of its distinctive pharmacologic properties [2, 3]. Compared to other opioids, buprenorphine has a long half-life, high binding affinity and slow dissociation from opioid receptors. Therefore, it resists displacement from these receptors when other opioids are used in conjunction [4]. The therapeutic doses of buprenorphine used for chronic pain treatment are significantly lower than those required for OUD treatment; therefore, opioid receptors are available when additional opioids are used concomitantly to enhance analgesia [5]. Conversely, when buprenorphine is used for OUD treatment, the diminished availability of opioid receptors resulting from the higher buprenorphine doses required can pose challenges for analgesic management [6]. Although routine practice involves continuing chronic pain buprenorphine formulations when acute pain is anticipated, the prevailing practice until recently has been withholding OUD dosed buprenorphine [4, 7]. Emerging evidence challenges these notions and supports opioid based analgesia can be achieved in parallel with OUD buprenorphine continuation [5, 8, 9].

In our previous retrospective study of surgical patients with OUD comparing patients where buprenorphine was continued or discontinued, we identified significantly higher outpatient opioid dispensing with buprenorphine discontinuation [5]. Similar findings were reported by Li et al., [8] where patients who continued buprenorphine perioperatively at various tapered doses received significantly fewer opioid prescriptions compared to those where buprenorphine was discontinued.

Despite these studies, our recent national survey revealed significant variation in perioperative buprenorphine management practices [10]. Among surveyed anesthesiologists, only 36% of institutions had a protocol for buprenorphine management, and over a third endorsed either discontinuing buprenorphine in situations where moderate to severe pain was anticipated or adopting inconsistent management practices because of the lack of an institutional protocol. Premature discontinuation of buprenorphine is associated with an increased risk of opioid-induced relapse, making such practices concerning [11, 12].

The lack of clear guidance for buprenorphine management also extends to the critical care community. The 2018 Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility and Sleep Disruption in Adult Patients in the Intensive Care Unit did not provide recommendations for managing buprenorphine in patients maintained on this medication [13]. In our retrospective study evaluating the relationship between opioid exposure and buprenorphine administration in the intensive care unit, we identified the odds of receiving additional opioids were more than six times higher on days when buprenorphine was not administered compared to when it was given [14]. These findings support continuation of buprenorphine during critical illness, as it is associated with significantly decreased use of supplemental opioids, similar to current best practice established for perioperative populations.

The above information reveals that high-level evidence on the analgesic outcomes based on buprenorphine management need to be conducted to establish a consensus for managing patients maintained on this medication [15]. In the face of the opioid crisis, evidence-based practices are crucial to guide clinicians and policymakers in providing the best possible care for patients maintained on buprenorphine.

Aurora Quaye: Conceptualization (lead); investigation (equal); writing—original draft (lead); writing—review and editing (equal). Charlotte Crist: Conceptualization (supporting); investigation (supporting); writing—original draft (supporting); writing—review and editing (supporting). Simba Matoi: Conceptualization (supporting); investigation (supporting); writing—original draft (supporting); writing—review and editing (supporting). Yi Zhang: Conceptualization (equal); investigation (equal); writing—original draft (equal); writing—review and editing (equal).

None.

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来源期刊
Addiction
Addiction 医学-精神病学
CiteScore
10.80
自引率
6.70%
发文量
319
审稿时长
3 months
期刊介绍: Addiction publishes peer-reviewed research reports on pharmacological and behavioural addictions, bringing together research conducted within many different disciplines. Its goal is to serve international and interdisciplinary scientific and clinical communication, to strengthen links between science and policy, and to stimulate and enhance the quality of debate. We seek submissions that are not only technically competent but are also original and contain information or ideas of fresh interest to our international readership. We seek to serve low- and middle-income (LAMI) countries as well as more economically developed countries. Addiction’s scope spans human experimental, epidemiological, social science, historical, clinical and policy research relating to addiction, primarily but not exclusively in the areas of psychoactive substance use and/or gambling. In addition to original research, the journal features editorials, commentaries, reviews, letters, and book reviews.
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