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Background: Less than 20% of individuals with opioid use disorder (OUD) are receiving a medication treatment for OUD in the United States. Though nurses can assume critical roles in outpatient models of OUD care, there are no published reports of buprenorphine standing orders for nurses that guide a nuanced response for patients returning as expected versus those re-engaging after a treatment lapse, without requiring real-time prescriber consultation.
Methods: Standing orders for buprenorphine were created with multiple stakeholders within an urban community health center that includes traditional clinics as well as non-traditional homeless care sites. After more than two years of use, an anonymous survey assessed staff perception of usability and safety of the standing orders using the validated system usability scale (SUS) and a 5-item Likert scale. Patient retention rates at 12 and 18 months were compared for sites that were early- and late-adopters of the standing orders.
Results: Of 24 clinicians and 7 nurses who responded to the survey, 46% had used the standing orders. More than 85% reported a perception that the standing orders improved team-based care and increased access to buprenorphine refills. None reported any safety concerns. The median SUS score was 75.0 (SD 15.4), rated as “excellent”. There was no statistically significant difference in 12- or 18-month retention rates between early- and late-adopter sites of the standing orders.
Conclusions: Nurse standing orders for buprenorphine follow-up and re-engagement care are feasible, usable and perceived as safe in varied community health center settings.
Gabapentin Increasingly Implicated
in Overdose Deaths
Postmortem toxicology tests detected gabapentin in almost 1 in 10 US overdose deaths
between 2019 and 2020.In about half of the
cases, a medical examiner or coroner ruled
the drug was a cause of the death, according to a report from the CDC’s Division of
Overdose Prevention.
The US Food and Drug Administration
(FDA) approved gabapentin for treating seizures and pain associated with shingles. But
growing off-label prescribing of gabapentin for nerve pain and other conditions contributed to its prescription rate doubling
from about 13 to 27 per 1000 insurance beneficiaries between 2009 and 2016. In fact,
by 2019, gabapentin had become the
seventh most prescribed drug in the US.
Gabapentin is sometimes used to amplify the effects of illicit opioids. In late 2019,
the FDA warned that gabapentin might
cause serious breathing difficulties when
usedwith drugs that depress the central nervous system, such as opioids, antianxiety
medications, and antidepressants.
Now, data from the State Unintentional
Drug Overdose Reporting System from 23
states and the District of Columbia suggest
that gabapentin’s role inUS overdose deaths
may be growing.Overall, toxicology tests detected gabapentin in 5687 overdose deaths
between 2019 and 2020—about 10% of all
cases with test results available. Overdose
deaths in which gabapentin was detected
doubled from 449 in the first quarter of 2019
to 959 in the second quarter of 2020.
The proportion of these cases thatmedical examiners ruled were caused by the drug
increased from 50% in early 2019 to 55% by
late 2020. About 90% of these cases also involved opioids, primarily illicitly manufactured fentanyl. About 83% of deaths caused
by gabapentin occurred amongWhite adults
aged 35 to 54 years.
“Personswho use illicit opioidswith gabapentinshouldbeeducatedabouttheincreased
risk for respiratorydepressionanddeath,” the
authors wrote. − Bridget M. Kuehn, MSJ
