Initial Analgesia and Sedation Requirements in Intensive Care Unit Patients on Prior-to-Admission Buprenorphine/Naloxone

Background: To our knowledge, there are no data assessing sedation requirements in patients on buprenorphine/naloxone (Bup/Nx) prior to admission (PTA). Objective: The purpose of this study was to determine the analgesia and sedation requirements in medical intensive care unit (MICU) patients who were on Bup/Nx PTA. Methods: A retrospective, observational cohort, Institutional Review Board (IRB) approved trial of adult MICU patients on Bup/Nx PTA who were intubated on a fentanyl infusion vs those who were opioid naïve PTA. The primary outcome evaluated the total amount of fentanyl in morphine milligram equivalents (MME) in the first 72 hours after infusion initiation. Secondary outcomes included the total amount of additional opioids (in MME) and non-opioids in the first 72 hours, the time that Critical Care Pain Observation Tool (CPOT) score was >3 and the Richmond Agitation and Sedation Score (RASS) was >0 in the first 72 hours, the Bup/Nx dose at discharge, and intensive care unit (ICU) and hospital lengths of stay. Results: Baseline characteristics were similar between the groups with the exception of the Bup/Nx group being younger. Seventy patients were included in the final analysis (35 in each group). Overall, the Bup/Nx group required more sedation than the control group over 72 hours, with a significantly higher amount of fentanyl used in the first 24 hours (191.2 MME vs 119.0 MME, P = 0.033). Although not significant, there was also increased propofol, dexmedetomidine, midazolam, and ketamine use in the Bup/Nx group. The CPOT and RASS were higher for the Bup/Nx group compared to the control group in the first 72 hours (percentage of time CPOT score >3 in 33.3% vs 28.6% [ P = 0.245] and percentage of time RASS >0 in 22.2% vs 12.5% [ P = 0.183]). Conclusion and Relevance: This study demonstrated an increased opioid and non-opioid sedation requirement in patients taking Bup/Nx PTA as compared to the opioid-naïve control group. These data suggest a multimodal sedation and analgesic approach may be appropriate for this patient population.