buprenorphine (Transtec Pro / Transtec)

Framework for the Opioid Use Disorder Cascade of Care: Adaptation and Application for a Large Municipal Health System.

Kalmin Mariah M MM, Crowley Christina C, Pak Lia L, McCullough Colleen M CM et al.

Most people with opioid use disorder (OUD) do not receive effective treatments despite their existence. The OUD cascade of care framework can be used to inform quality improvement efforts to address this gap, but data access and linkage requirements may limit its use. We sought to adapt the framework under the constraints of electronic health record data and identify patient populations at risk for OUD treatment discontinuity. We extracted data on patients with OUD from the Los Angeles County Department of Health Services from July 2022 through June 2023. We adapted the cascade of care to include probable OUD diagnosis, receipt of naloxone prescription, and receipt of ≥1 and ≥2 buprenorphine prescriptions. We then stratified and conducted statistical analyses for associations by sex, race and ethnicity, and facility type (inpatient, primary care, emergency, or urgent care). Of 3881 patients identified with probable OUD, 49% received a naloxone prescription and 30% and 17% had ≥1 and ≥2 buprenorphine prescriptions, respectively, in 1 year. Non-Hispanic Black and Hispanic patients were less likely to receive buprenorphine prescriptions than were non-Hispanic White patients and patients of other or unknown race and ethnicity. We observed larger gaps in care between receipt of ≥1 and ≥2 buprenorphine prescriptions for patients using urgent care and emergency departments compared with patients in other settings. This study illustrates substantial gaps between OUD diagnosis and treatment. This adapted framework for the OUD cascade of care can serve as a quality-monitoring tool to aid clinicians and health care administrators in narrowing the treatment gap for people with OUD.

Adjunct Medications for Single-Injection Pediatric Regional Blocks: Implications for Peripheral Nerve Blocks.

Jha Sachin Sunny SS

Single-injection peripheral nerve blocks (PNBs) provide excellent perioperative analgesia in children but are limited by finite duration. Pediatric populations were excluded from the major adult adjunct reviews. This narrative review synthesizes the evidence for adjuncts added to local anesthetics for single-injection PNBs and caudal blocks in patients aged 0 to 18 years, including dexamethasone, dexmedetomidine, clonidine, conventional opioids, buprenorphine, magnesium sulfate, midazolam, ketamine, neostigmine, tramadol, nalbuphine, and epinephrine. Across 58 studies, dexmedetomidine (0.5 to 1 mcg/kg) and dexamethasone (0.1 mg/kg perineural) were the best-supported agents, each roughly doubling analgesic duration with acceptable safety. Two network meta-analyses ranked neostigmine highest for caudal duration, but its postoperative nausea and vomiting burden limits use. Clonidine has the longest safety record. Ketamine and midazolam show robust caudal efficacy but unresolved neurotoxicity concerns. Nalbuphine and buprenorphine are promising but under-studied. Tramadol carries pediatric regulatory restrictions, while epinephrine and conventional opioids add little. Dexmedetomidine and dexamethasone are the preferred adjuncts in pediatric regional anesthesia. Adult evidence should not be extrapolated directly given developmental pharmacology and pediatric-specific safety considerations. Prospective trials in true pediatric PNBs and pediatric rebound-pain studies remain the critical evidence gaps.

7-Hydroxymitragynine Withdrawal Treated With Buprenorphine-Naloxone.

Held Jacob T JT, Varicat Francisco P FP

A retrospective cohort study of a novel short-acting opioid protocol for opioid withdrawal.

Sauers Elizabeth G EG, Rafeq Rachel R, Salzman Matthew M, Fett David D

Hospitalized patients with opioid use disorder commonly experience undertreated withdrawal, leading to increases in patient-directed discharge and readmission. Short-acting opioids can mitigate withdrawal in patients who are unwilling to trial buprenorphine or methadone, or need additional symptom control during up-titration. This study assessed the safety and efficacy of a short-acting opioid protocol for opioid withdrawal. A retrospective cohort study was conducted on hospitalized patients with opioid use disorder who received a short-acting opioid protocol for withdrawal with intravenous hydromorphone or oral oxycodone. The primary endpoint was the incidence of severe withdrawal. Secondary endpoints included naloxone use, patient-directed discharge, and length of stay. A paired cohort was analyzed where patients' hospital outcomes were compared pre- versus post-protocol. Naloxone use after protocol initiation was 0% and severe withdrawal occurred in one patient (1%). The patient-directed discharge and 30-day readmission rates were 38% and 30%, respectively. Fifty-one percent of patients had a prior hospitalization within two years without use of the short-acting opioid protocol and were included in the paired cohort analysis. The pre- versus post-protocol patient-directed discharge rate was 47% vs. 43% (p = 0.774) and length of stay was 3 vs. 5 days (p = 0.180). Our findings provide preliminary evidence for the safety of a short-acting opioid protocol for opioid withdrawal. There was no significant difference in patient-directed discharge rate or length of stay in the paired cohort of patients' encounters with or without short-acting opioid protocol use. Larger studies are necessary to draw conclusions regarding safety and efficacy.