Rapid Transition From a Continuous Naloxone Infusion to Sublingual Buprenorphine After an Opioid Overdose: A Case Series.

Background: With increasing frequency, providers are encountering patients with opioid overdose who recrudesce after intermittent bolus dosing of naloxone. Some patients require a continuous infusion to maintain ventilation, which necessitates admission to a monitored setting. Buprenorphine could shorten the duration of a continuous naloxone infusion (CNI) or preclude the need altogether because its long-lasting partial agonist effects compete with and blunt the respiratory depressant effects of full agonist opioids. This case series describes the replacement by sublingual (SL) buprenorphine of a CNI in patients experiencing prolonged and recurrent respiratory depression from an opioid overdose.

Case series: We describe 3 patients presenting to the emergency department at a large urban academic hospital after an opioid overdose. All 3 patients received intranasal naloxone by emergency medical services prior to arrival. These patients received multiple intermittent bolus doses of intravenous naloxone for recurrent respiratory depression. Because of continued recurrence, they were started on CNIs. After consultation with medical toxicology, they each received 16 mg of SL buprenorphine, which allowed the successful discontinuation of the CNI without the need for additional naloxone, as well as initiating the transition to medication for opioid use disorder (MOUD) using buprenorphine.

Discussion: SL buprenorphine may be an option to facilitate discontinuation of a CNI. This strategy may be useful in select patients to reverse an acute opioid overdose, reduce hospital resource utilization, and initiate patients on MOUD.