Opioid use disorder: Difference between revisions
(Formatting: moved intro, removed bold) |
(Strip excess bold) |
||
| Line 7: | Line 7: | ||
*Opioid use disorder (OUD) is a chronic, relapsing medical condition defined as a problematic pattern of opioid use leading to clinically significant impairment or distress<ref name="DSM5">American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Washington, DC: APA; 2013.</ref> | *Opioid use disorder (OUD) is a chronic, relapsing medical condition defined as a problematic pattern of opioid use leading to clinically significant impairment or distress<ref name="DSM5">American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Washington, DC: APA; 2013.</ref> | ||
*~87,000 opioid-related overdose deaths in the US annually (2023-2024 data); fentanyl is now the dominant illicit opioid<ref name="CDC2024">CDC. Overdose Prevention: Drug Overdose Deaths. https://www.cdc.gov/overdose-prevention/</ref> | *~87,000 opioid-related overdose deaths in the US annually (2023-2024 data); fentanyl is now the dominant illicit opioid<ref name="CDC2024">CDC. Overdose Prevention: Drug Overdose Deaths. https://www.cdc.gov/overdose-prevention/</ref> | ||
*Medications for opioid use disorder (MOUD) — [[Special:MyLanguage/buprenorphine|buprenorphine]], [[Special:MyLanguage/methadone|methadone]], and [[Special:MyLanguage/naltrexone|naltrexone]] — reduce all-cause mortality by | *Medications for opioid use disorder (MOUD) — [[Special:MyLanguage/buprenorphine|buprenorphine]], [[Special:MyLanguage/methadone|methadone]], and [[Special:MyLanguage/naltrexone|naltrexone]] — reduce all-cause mortality by 50-80%<ref name="Sordo2017">Sordo L, Barrio G, Bravo MJ, et al. Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies. BMJ. 2017;357:j1550.</ref> | ||
*ED-initiated buprenorphine '''increases 30-day treatment engagement ~5-fold''' compared to referral alone (D'Onofrio 2015 landmark RCT)<ref name="DOnofrio2015">D'Onofrio G, O'Connor PG, Pantalon MV, et al. Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial. JAMA. 2015;313(16):1636-1644.</ref> | *ED-initiated buprenorphine '''increases 30-day treatment engagement ~5-fold''' compared to referral alone (D'Onofrio 2015 landmark RCT)<ref name="DOnofrio2015">D'Onofrio G, O'Connor PG, Pantalon MV, et al. Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial. JAMA. 2015;313(16):1636-1644.</ref> | ||
*No X-waiver or special certification is required to prescribe buprenorphine (eliminated January 2023 by the Consolidated Appropriations Act)<ref name="CAA2023">Consolidated Appropriations Act, 2023, Pub. L. No. 117-328, § 1262.</ref> | *No X-waiver or special certification is required to prescribe buprenorphine (eliminated January 2023 by the Consolidated Appropriations Act)<ref name="CAA2023">Consolidated Appropriations Act, 2023, Pub. L. No. 117-328, § 1262.</ref> | ||
| Line 28: | Line 28: | ||
*Onset varies by substance: heroin 6-12 hrs, prescription opioids 8-24 hrs, fentanyl variable (lipophilic depot may delay onset), methadone 24-72 hrs | *Onset varies by substance: heroin 6-12 hrs, prescription opioids 8-24 hrs, fentanyl variable (lipophilic depot may delay onset), methadone 24-72 hrs | ||
*Pupils: | *Pupils: mydriasis (opposite of intoxication) | ||
*GI: nausea, vomiting, diarrhea, abdominal cramping | *GI: nausea, vomiting, diarrhea, abdominal cramping | ||
*Musculoskeletal: myalgias, arthralgias | *Musculoskeletal: myalgias, arthralgias | ||
| Line 92: | Line 92: | ||
*DSM-5 criteria: ≥2 of 11 criteria within a 12-month period (see below)<ref name="DSM5"/> | *DSM-5 criteria: ≥2 of 11 criteria within a 12-month period (see below)<ref name="DSM5"/> | ||
**Mild: 2-3 criteria; Moderate: 4-5 criteria; Severe: ≥6 criteria | **Mild: 2-3 criteria; Moderate: 4-5 criteria; Severe: ≥6 criteria | ||
*In the ED, a formal 11-criterion assessment is not necessary — | *In the ED, a formal 11-criterion assessment is not necessary — a clinical diagnosis based on history is sufficient to initiate treatment<ref name="ACEP2021"/> | ||
*Key ED diagnostic clues: recurrent overdoses, needle marks, withdrawal symptoms, requests for OUD treatment, opioid-positive UDS in clinical context | *Key ED diagnostic clues: recurrent overdoses, needle marks, withdrawal symptoms, requests for OUD treatment, opioid-positive UDS in clinical context | ||
*[https://www.mdcalc.com/cows-score-opiate-withdrawal | *[https://www.mdcalc.com/cows-score-opiate-withdrawal Clinical Opioid Withdrawal Scale (COWS)] — 11-item scoring tool to quantify withdrawal severity and guide induction timing: | ||
**0-4: No withdrawal | **0-4: No withdrawal | ||
**5-12: Mild withdrawal | **5-12: Mild withdrawal | ||
| Line 118: | Line 118: | ||
*See {{Suboxone protocol}} for induction strategies | *See {{Suboxone protocol}} for induction strategies | ||
Adjunctive symptom management (if buprenorphine not initiated or as supplemental therapy): | |||
*[[Special:MyLanguage/Clonidine|Clonidine]] 0.1-0.2 mg PO/SL q4-6h for autonomic symptoms (max 0.8 mg/day; monitor for [[Special:MyLanguage/hypotension|hypotension]]) | *[[Special:MyLanguage/Clonidine|Clonidine]] 0.1-0.2 mg PO/SL q4-6h for autonomic symptoms (max 0.8 mg/day; monitor for [[Special:MyLanguage/hypotension|hypotension]]) | ||
*[[Special:MyLanguage/Ondansetron|Ondansetron]] 4 mg IV/PO for nausea/vomiting | *[[Special:MyLanguage/Ondansetron|Ondansetron]] 4 mg IV/PO for nausea/vomiting | ||
| Line 130: | Line 130: | ||
===ED-Initiated Buprenorphine for OUD=== | ===ED-Initiated Buprenorphine for OUD=== | ||
This is the cornerstone of ED OUD management.<ref name="DOnofrio2015"/><ref name="ACEP2021"/><ref name="Hughes2024"/> | |||
*Three induction strategies exist depending on withdrawal status — standard, high-dose (macro), and low-dose (micro) | *Three induction strategies exist depending on withdrawal status — standard, high-dose (macro), and low-dose (micro) | ||
*See [[Special:MyLanguage/Buprenorphine|Buprenorphine]] page and {{Suboxone protocol}} for detailed induction protocols | *See [[Special:MyLanguage/Buprenorphine|Buprenorphine]] page and {{Suboxone protocol}} for detailed induction protocols | ||
Key principles: | |||
*Any patient with OUD who is willing to accept treatment should be offered buprenorphine | *Any patient with OUD who is willing to accept treatment should be offered buprenorphine | ||
*'''Do not delay initiation for lab results, urine drug screen, or social work evaluation''' | *'''Do not delay initiation for lab results, urine drug screen, or social work evaluation''' | ||
*COWS ≥8 is traditional threshold; post-overdose patients can be inducted earlier while naloxone is still active | *COWS ≥8 is traditional threshold; post-overdose patients can be inducted earlier while naloxone is still active | ||
*Precipitated withdrawal is managed with | *Precipitated withdrawal is managed with more buprenorphine (not less), plus adjunctive medications<ref name="Hughes2024"/> | ||
*Discharge with buprenorphine/naloxone prescription (16 mg/day × 7-14 day bridge supply) | *Discharge with buprenorphine/naloxone prescription (16 mg/day × 7-14 day bridge supply) | ||
*No X-waiver required<ref name="CAA2023"/> | *No X-waiver required<ref name="CAA2023"/> | ||
| Line 146: | Line 146: | ||
*Full mu-opioid agonist; available for OUD only through registered opioid treatment programs (OTPs) | *Full mu-opioid agonist; available for OUD only through registered opioid treatment programs (OTPs) | ||
*ED physicians may administer (not prescribe) methadone for up to 72 hours for acute withdrawal under the | *ED physicians may administer (not prescribe) methadone for up to 72 hours for acute withdrawal under the 72-hour rule (21 CFR §1306.07(b)) while arranging referral to an OTP<ref name="72hour">21 CFR §1306.07(b). Administering or dispensing of narcotic drugs.</ref> | ||
*Starting dose: 20-30 mg PO; may give additional 5-10 mg after 2-4 hours if withdrawal persists (max 40 mg day 1) | *Starting dose: 20-30 mg PO; may give additional 5-10 mg after 2-4 hours if withdrawal persists (max 40 mg day 1) | ||
*Caution: QTc prolongation risk, full agonist (no ceiling effect for respiratory depression), unpredictable half-life (8-59 hours) | *Caution: QTc prolongation risk, full agonist (no ceiling effect for respiratory depression), unpredictable half-life (8-59 hours) | ||
| Line 153: | Line 153: | ||
*Long-acting mu-opioid antagonist; blocks opioid effects | *Long-acting mu-opioid antagonist; blocks opioid effects | ||
*Must be opioid-free for | *Must be opioid-free for 7-10 days before initiation (risk of precipitated withdrawal) | ||
*Not practical for ED initiation but may be referenced in follow-up planning | *Not practical for ED initiation but may be referenced in follow-up planning | ||
*Available as oral (50 mg daily) or IM depot (Vivitrol 380 mg monthly) | *Available as oral (50 mg daily) or IM depot (Vivitrol 380 mg monthly) | ||
| Line 191: | Line 191: | ||
===Post-Overdose Observation=== | ===Post-Overdose Observation=== | ||
*Patients reversed with naloxone should be observed for | *Patients reversed with naloxone should be observed for at least 1 hour after last naloxone dose (longer if sustained-release opioid or fentanyl suspected, where re-sedation risk is higher)<ref name="ACEP2021"/> | ||
*Use the observation period to engage patient in OUD treatment discussion and buprenorphine initiation | *Use the observation period to engage patient in OUD treatment discussion and buprenorphine initiation | ||
Latest revision as of 09:13, 22 March 2026
Background
- Opioid use disorder (OUD) is a chronic, relapsing medical condition defined as a problematic pattern of opioid use leading to clinically significant impairment or distress[1]
- ~87,000 opioid-related overdose deaths in the US annually (2023-2024 data); fentanyl is now the dominant illicit opioid[2]
- Medications for opioid use disorder (MOUD) — buprenorphine, methadone, and naltrexone — reduce all-cause mortality by 50-80%[3]
- ED-initiated buprenorphine increases 30-day treatment engagement ~5-fold compared to referral alone (D'Onofrio 2015 landmark RCT)[4]
- No X-waiver or special certification is required to prescribe buprenorphine (eliminated January 2023 by the Consolidated Appropriations Act)[5]
- The ED is often the only point of healthcare contact for patients with OUD — every visit is an opportunity to initiate lifesaving treatment[6]
Clinical Features
Opioid Intoxication
- Miosis (pinpoint pupils — most reliable sign)
- Respiratory depression / bradypnea
- Altered mental status / sedation / coma
- Hypotension, bradycardia
- Hypothermia
- Decreased bowel sounds
- Needle marks / track marks (may be absent with intranasal or smoked use)
Opioid Withdrawal
- Onset varies by substance: heroin 6-12 hrs, prescription opioids 8-24 hrs, fentanyl variable (lipophilic depot may delay onset), methadone 24-72 hrs
- Pupils: mydriasis (opposite of intoxication)
- GI: nausea, vomiting, diarrhea, abdominal cramping
- Musculoskeletal: myalgias, arthralgias
- Autonomic: diaphoresis, piloerection ("goose flesh"), rhinorrhea, lacrimation, yawning
- Neuropsychiatric: restlessness, insomnia, anxiety, irritability, cravings
- Vital signs: tachycardia, hypertension (mild)
- Opioid withdrawal is extremely uncomfortable but NOT life-threatening in otherwise healthy adults (unlike alcohol or benzodiazepine withdrawal)
- Exception: neonatal abstinence syndrome, medically frail/pregnant patients — withdrawal may be dangerous in these populations
Complications of Chronic OUD
- Infective endocarditis (right-sided > left-sided in IVDU; Staphylococcus aureus most common)
- Soft tissue abscess, cellulitis, necrotizing fasciitis
- Sepsis / bacteremia
- DVT, septic thrombophlebitis
- Hepatitis B, hepatitis C, HIV
- Septic pulmonary emboli, lung abscess
- Wound botulism (especially skin-popping black tar heroin)
- Rhabdomyolysis (prolonged immobilization during intoxication)
- Non-cardiogenic pulmonary edema (post-overdose)
- Xylazine ("tranq")-associated skin wounds: necrotic, non-healing ulcers at sites distant from injection; not reversed by naloxone[7]
Differential Diagnosis
For Opioid Intoxication/Overdose
- Other toxidrome: sedative-hypnotics, clonidine / centrally-acting alpha-2 agonists, organophosphate poisoning (miosis + altered mental status)
- Hypoglycemia
- Stroke, intracranial hemorrhage
- Sepsis / meningitis
- Hypothermia
- Carbon monoxide poisoning
- Polysubstance ingestion (fentanyl commonly mixed with xylazine, benzodiazepines, stimulants)
For Opioid Withdrawal
- Gastroenteritis
- Sepsis / infection
- Thyrotoxicosis
- Stimulant intoxication (cocaine, amphetamine)
- Other withdrawal syndromes (alcohol, benzodiazepines)
- Anxiety / panic disorder
Evaluation
Workup
- No labs are required before initiating buprenorphine — do not delay treatment for test results[6][8]
- Focused evaluation for common complications:
- Point-of-care glucose (rule out hypoglycemia)
- ECG (if concern for QTc prolongation from methadone, co-ingestions, or endocarditis)
- CBC, BMP (if febrile, ill-appearing, or significant comorbidities)
- Lactate, blood cultures (if sepsis concern)
- LFTs (not required prior to buprenorphine initiation but may be helpful for outpatient follow-up)
- Urine drug screen: may inform clinical picture but should not be used as a prerequisite for treatment; note that standard immunoassays do NOT detect fentanyl (requires specific fentanyl assay)[6]
- Pregnancy test (informs formulation choice: buprenorphine monoproduct preferred in pregnancy)
- Screening for associated infections in IVDU patients when clinically indicated: hepatitis C, HIV, hepatitis B (can be performed as outpatient if not acutely relevant)
Diagnosis
- DSM-5 criteria: ≥2 of 11 criteria within a 12-month period (see below)[1]
- Mild: 2-3 criteria; Moderate: 4-5 criteria; Severe: ≥6 criteria
- In the ED, a formal 11-criterion assessment is not necessary — a clinical diagnosis based on history is sufficient to initiate treatment[6]
- Key ED diagnostic clues: recurrent overdoses, needle marks, withdrawal symptoms, requests for OUD treatment, opioid-positive UDS in clinical context
- Clinical Opioid Withdrawal Scale (COWS) — 11-item scoring tool to quantify withdrawal severity and guide induction timing:
- 0-4: No withdrawal
- 5-12: Mild withdrawal
- 13-24: Moderate withdrawal
- 25-36: Moderately severe withdrawal
- >36: Severe withdrawal
- COWS ≥8 is the traditional threshold for buprenorphine induction, though emerging protocols allow initiation at lower scores or without formal COWS scoring[9]
Management
Acute Opioid Overdose
- See Opioid overdose for complete management
- Naloxone 0.04-0.4 mg IV (titrate to respiratory effort, not consciousness) — higher doses (2-4 mg) may be needed for fentanyl
- Bag-valve mask ventilation is the primary intervention; naloxone is an adjunct
- Post-reversal: observe for re-sedation (fentanyl's duration may exceed naloxone's half-life of 30-90 min)
- Post-overdose is an ideal time to initiate buprenorphine — see below
Opioid Withdrawal Symptom Management
- Buprenorphine is the treatment of choice — treats withdrawal AND initiates OUD treatment simultaneously[6]
- See
- For Clinical Opioid Withdrawal Scale (COWS) ≥8: give 4 to 8mg of Buprenorphine, observe 30 to 45min
- Redose if COWS remains ≥8. Then discharge home with 16 mg a day to bridge until follow-up (an X-waiver is no longer required to prescribe buprenorphine).
- For Clinical Opioid Withdrawal Scale (COWS) 0-7: Consider observing the patient until their COWS score is >8 for the standard buprenorphine induction.
- If sublingual tablets/films unavailable then intravenous/intramuscular formulation (dose 0.3-0.9 mg every 6-12 hours) has been used for opioid withdrawal in the ED[14] and hospitalized[15] patients.
NIH National Institute on Drug Abuse ED Buprenorphine algorithm[16]
for induction strategies
Adjunctive symptom management (if buprenorphine not initiated or as supplemental therapy):
- Clonidine 0.1-0.2 mg PO/SL q4-6h for autonomic symptoms (max 0.8 mg/day; monitor for hypotension)
- Ondansetron 4 mg IV/PO for nausea/vomiting
- Loperamide 4 mg PO initially, then 2 mg after each loose stool (max 16 mg/day)
- NSAIDs or acetaminophen for myalgias
- Dicyclomine 10-20 mg PO for abdominal cramping
- Hydroxyzine 25-50 mg PO for anxiety/insomnia (avoid benzodiazepines if possible)
- IV fluids for dehydration
- Avoid: phenothiazines (lower seizure threshold), chronic benzodiazepine prescriptions
ED-Initiated Buprenorphine for OUD
This is the cornerstone of ED OUD management.[4][6][8]
- Three induction strategies exist depending on withdrawal status — standard, high-dose (macro), and low-dose (micro)
- See Buprenorphine page and
- For Clinical Opioid Withdrawal Scale (COWS) ≥8: give 4 to 8mg of Buprenorphine, observe 30 to 45min
- Redose if COWS remains ≥8. Then discharge home with 16 mg a day to bridge until follow-up (an X-waiver is no longer required to prescribe buprenorphine).
- For Clinical Opioid Withdrawal Scale (COWS) 0-7: Consider observing the patient until their COWS score is >8 for the standard buprenorphine induction.
- If sublingual tablets/films unavailable then intravenous/intramuscular formulation (dose 0.3-0.9 mg every 6-12 hours) has been used for opioid withdrawal in the ED[21] and hospitalized[22] patients.
NIH National Institute on Drug Abuse ED Buprenorphine algorithm[23]
for detailed induction protocols
Key principles:
- Any patient with OUD who is willing to accept treatment should be offered buprenorphine
- Do not delay initiation for lab results, urine drug screen, or social work evaluation
- COWS ≥8 is traditional threshold; post-overdose patients can be inducted earlier while naloxone is still active
- Precipitated withdrawal is managed with more buprenorphine (not less), plus adjunctive medications[8]
- Discharge with buprenorphine/naloxone prescription (16 mg/day × 7-14 day bridge supply)
- No X-waiver required[5]
Methadone in the ED
- Full mu-opioid agonist; available for OUD only through registered opioid treatment programs (OTPs)
- ED physicians may administer (not prescribe) methadone for up to 72 hours for acute withdrawal under the 72-hour rule (21 CFR §1306.07(b)) while arranging referral to an OTP[24]
- Starting dose: 20-30 mg PO; may give additional 5-10 mg after 2-4 hours if withdrawal persists (max 40 mg day 1)
- Caution: QTc prolongation risk, full agonist (no ceiling effect for respiratory depression), unpredictable half-life (8-59 hours)
Naltrexone
- Long-acting mu-opioid antagonist; blocks opioid effects
- Must be opioid-free for 7-10 days before initiation (risk of precipitated withdrawal)
- Not practical for ED initiation but may be referenced in follow-up planning
- Available as oral (50 mg daily) or IM depot (Vivitrol 380 mg monthly)
Harm Reduction
- Naloxone kit — prescribe or provide to every patient with OUD at discharge (and to household contacts)[6]
- Fentanyl test strips — where legal, offer to patients who use illicit substances
- Counsel on safer use practices (never use alone, carry naloxone, avoid mixing with benzodiazepines/alcohol)
- Provide information on syringe services programs and supervised consumption sites where available
- Offer hepatitis C and HIV testing or referral
Disposition
Discharge
- Most patients with uncomplicated OUD or opioid withdrawal can be discharged from the ED
- Discharge with:
- Buprenorphine/naloxone prescription (7-14 day supply, typically 16 mg/day)
- Naloxone kit (or prescription for naloxone)
- Outpatient follow-up appointment with addiction medicine, primary care, or federally qualified health center that provides MOUD
- Written withdrawal management instructions (if home induction planned)
- Harm reduction resources
- Ensure patient has had resolution or improvement of withdrawal symptoms before discharge
Admit
- Medically complicated withdrawal (significant dehydration, electrolyte abnormalities, comorbid medical illness)
- OUD-related complications requiring inpatient management: endocarditis, epidural or deep abscess, osteomyelitis, sepsis, necrotizing fasciitis
- Post-overdose with persistent respiratory depression, non-cardiogenic pulmonary edema, or aspiration
- Concurrent alcohol or benzodiazepine withdrawal requiring monitored detoxification
- Pregnancy with uncontrolled withdrawal (risk to fetus)
- Suicidal ideation or acute psychiatric emergency co-occurring with OUD
- Failed outpatient management or patient without safe discharge plan
Post-Overdose Observation
- Patients reversed with naloxone should be observed for at least 1 hour after last naloxone dose (longer if sustained-release opioid or fentanyl suspected, where re-sedation risk is higher)[6]
- Use the observation period to engage patient in OUD treatment discussion and buprenorphine initiation
Follow-Up Resources
- SAMHSA National Helpline: 1-800-662-4357 (referral and information, 24/7)
- PEPline (buprenorphine clinical questions): 1-888-448-4911
- SAMHSA Buprenorphine Practitioner Locator: https://www.samhsa.gov/medications-substance-use-disorders/find-help
See Also
- Opioid overdose
- Opioid withdrawal
- Buprenorphine
- Naloxone
- Methadone
- Naltrexone
- Endocarditis
- Toxidromes
External Links
- Yale ED-Initiated Buprenorphine Resource Center
- ACEP Opioid Use Disorder Resources
- COWS Score Calculator (MDCalc)
- SAMHSA Medications for Substance Use Disorders
References
- ↑ 1.0 1.1 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Washington, DC: APA; 2013.
- ↑ CDC. Overdose Prevention: Drug Overdose Deaths. https://www.cdc.gov/overdose-prevention/
- ↑ Sordo L, Barrio G, Bravo MJ, et al. Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies. BMJ. 2017;357:j1550.
- ↑ 4.0 4.1 D'Onofrio G, O'Connor PG, Pantalon MV, et al. Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial. JAMA. 2015;313(16):1636-1644.
- ↑ 5.0 5.1 Consolidated Appropriations Act, 2023, Pub. L. No. 117-328, § 1262.
- ↑ 6.0 6.1 6.2 6.3 6.4 6.5 6.6 6.7 Hawk K, Hoppe J, Ketcham E, et al. Consensus Recommendations on the Treatment of Opioid Use Disorder in the Emergency Department. Ann Emerg Med. 2021;78(3):434-442.
- ↑ Friedman J, Montero F, Bourgois P, et al. Xylazine spreads across the US: A growing component of the increasingly synthetic and polysubstance overdose crisis. Drug Alcohol Depend. 2022;233:109380.
- ↑ 8.0 8.1 8.2 Hughes T, Nasser N, Mitra A. Overview of best practices for buprenorphine initiation in the emergency department. Int J Emerg Med. 2024;17:23.
- ↑ Weimer MB, Herring AA, Kawasaki SS, et al. ASAM Clinical Considerations: Buprenorphine Treatment of OUD for Individuals Using High-potency Synthetic Opioids. J Addict Med. 2023;17(6):632-639.
- ↑ A Guide for Patients Beginning Buprenorphine Treatment at Home https://medicine.yale.edu/edbup/quickstart/Home_Buprenorphine_Initiation_338574_42801_v1.pdf
- ↑ A Patient’s Guide to Starting Buprenorphine at Home from ASAM https://www.asam.org/docs/default-source/education-docs/unobserved-home-induction-patient-guide.pdf
- ↑ Buprenorphine Home Induction Apple App Store https://apps.apple.com/us/app/buprenorphine-home-induction/id1449302173
- ↑ Starting Buprenorphine from Google Play Store https://play.google.com/store/apps/details?id=com.amstonstudio.bup&hl=en_US&gl=US
- ↑ Berg ML, et. al. Evaluation of the use of buprenorphine for opioid withdrawal in an emergency department. Drug Alcohol Depend. 2007 Jan 12;86(2-3):239-44. https://doi.org/10.1016/j.drugalcdep.2006.06.014. Epub 2006 Aug 22. PMID: 16930865.
- ↑ Welsh CJ, Suman M, Cohen A, et al. The use of intravenous buprenorphine for the treatment of opioid withdrawal in medically ill hospitalized patients. Am J Addict. 2002;11(2):135-40 https://doi.org/10.1080/105500490290087901
- ↑ https://d14rmgtrwzf5a.cloudfront.net/sites/default/files/algorithm.pdf
- ↑ A Guide for Patients Beginning Buprenorphine Treatment at Home https://medicine.yale.edu/edbup/quickstart/Home_Buprenorphine_Initiation_338574_42801_v1.pdf
- ↑ A Patient’s Guide to Starting Buprenorphine at Home from ASAM https://www.asam.org/docs/default-source/education-docs/unobserved-home-induction-patient-guide.pdf
- ↑ Buprenorphine Home Induction Apple App Store https://apps.apple.com/us/app/buprenorphine-home-induction/id1449302173
- ↑ Starting Buprenorphine from Google Play Store https://play.google.com/store/apps/details?id=com.amstonstudio.bup&hl=en_US&gl=US
- ↑ Berg ML, et. al. Evaluation of the use of buprenorphine for opioid withdrawal in an emergency department. Drug Alcohol Depend. 2007 Jan 12;86(2-3):239-44. https://doi.org/10.1016/j.drugalcdep.2006.06.014. Epub 2006 Aug 22. PMID: 16930865.
- ↑ Welsh CJ, Suman M, Cohen A, et al. The use of intravenous buprenorphine for the treatment of opioid withdrawal in medically ill hospitalized patients. Am J Addict. 2002;11(2):135-40 https://doi.org/10.1080/105500490290087901
- ↑ https://d14rmgtrwzf5a.cloudfront.net/sites/default/files/algorithm.pdf
- ↑ 21 CFR §1306.07(b). Administering or dispensing of narcotic drugs.