Journal of hospital medicine : an official publication of the Society of Hospital Medicine
Why is this important?
Buprenorphine (Subutex, Tamgesic, Suboxone, Norspan) is a partial opioid agonist with high mu-receptor affinity, though limited by a ceiling effect. Because of its favourable safety profile it is used for opioid dependence, chronic and, increasingly, acute pain.1
Patients historically often have regular buprenorphine (BUP) ceased post-operatively when needing opioid analgesia. It was assumed that because of it’s high mu-receptor affinity, BUP blocks the efficacy of additional opioid analgesics. In reality, ceasing buprenorphine creates more complexity and may precipitate acute withdrawal.
Haber, DeFries & Martin point out that despite the high receptor affinity of BUP, there are still additional receptors remaining for full-agonist opioids to bind and activate. This is supported by the literature (Kornfeld 2010 & Harrison 2018). Even in the post-operative period buprenorphine can be easily continued, although with patients sometimes needing higher doses of acute opioid analgesics (Goel 2019 & Hansen 2016).
“Temporarily discontinuing buprenorphine introduces unnecessary complexity to a hospitalization, places the patient at risk of exacerbation of pain, opioid withdrawal...“
If buprenorphine is regularly being taken then it should not be ceased for hospital admission. Additional short-acting opioids can be added if needed. Doses required may be higher, but this is primarily due to opioid tolerance rather than receptor competition with BUP. Alternatively, a maintenance BUP dose can be split into 3-4 divided doses and/or increased to cover acute analgesic needs.
Buprenorphine is also a kappa and delta receptor antagonist, a weak partial NOP/Nociceptin receptor agonist, and has potent local anaesthetic effects. It behaves as a full agonist for analgesia in the opioid-naive, but a partial agonist for respiratory depression. ↩
Inspired by the ABIM Foundation's Choosing Wisely® campaign, the "Things We Do for No Reason™" (TWDFNR) series reviews practices that have become common parts of hospital care but may provide little value to our patients. Practices reviewed in the TWDFNR series do not represent "black and white" conclusions or clinical practice standards but are meant as a starting place for research and active discussions among hospitalists and patients. We invite you to be part of that discussion.
Differences between hospital-presenting sepsis (HPS) and emergency department-presenting sepsis (EDPS) are not well described. ⋯ HPS differed from EDPS by admission source, comorbidities, and clinical presentation. These patients received markedly less timely initial resuscitation; this disparity explained a moderate proportion of mortality differences.
Hypoglycemia is a serious complication following treatment of hyperkalemia with intravenous insulin. The aims of this study were to determine the incidence of hypoglycemia (≤3.9 mmol/l, 70 mg/dL) and severe hypoglycemia (<3.0 mmol/l, 54 mg/dL) in noncritical care inpatients following treatment of hyperkalemia and to establish the risk factors predisposing to this complication. This was a single-center observational study reviewing the Electronic Patient Records of hyperkalemia treatment with intravenous insulin on the general wards of a large UK teaching hospital. ⋯ Lower pretreatment capillary blood glucose level, older age, and lower bodyweight were associated with a higher risk of posttreatment hypoglycemia. The incidence of hypoglycemia following hyperkalemia treatment in hospitalized patients is unacceptably high. Identifying individuals at high risk of hypoglycemia and adjusting prescriptions may reduce the incidence.
In the Hospital Readmission Reduction Program (HRRP), the Centers for Medicare & Medicaid Services (CMS) utilizes a planned/unplanned algorithm to prevent hospitals from being penalized for scheduled rehospitalizations. We evaluated version 3.0 of the CMS planned readmission algorithm and hypothesized that some readmissions categorized as planned by the HRRP algorithm may actually be unplanned. ⋯ The majority of these planned readmissions (723 [57.8%]) had an "emergent" or "urgent" admission type listed on the readmission claim, and many (513 [41.0%]) had emergency department charges, suggesting unanticipated returns to the hospital. HRRP should consider using the admission type variable and/or the presence of emergency department charges as a source of information when determining whether a readmission is planned or unplanned.