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Background <p>Iatrogenic opioid dependence, withdrawal, and opioid accumulation can impede neurologic assessment and delay liberation from invasive mechanical ventilation (IMV) in neurocritical care. We evaluated whether low-dose buprenorphine (BUP) initiation was associated with improved sedation and ventilator outcomes.</p> Methods <p>We conducted a retrospective matched cohort/case–control study of adults in the neurocritical care unit (NCCU) receiving parenteral opioids while on IMV ≥ 24&#xa0;h. Patients receiving low-dose BUP initiation (≤ 2&#xa0;mg cumulative in the first 8&#xa0;h with ≥ 1 sublingual dose; <i>n</i> = 19) were matched by demographics and diagnosis to patients not receiving BUP (NO-BUP; <i>n</i> = 18). Outcomes included ventilator days/time to liberation, daily intravenous (IV) morphine milligram equivalents (MME), time-in-target range Richmond Agitation-Sedation Scale (RASS − 2 to 0), continuous sedative infusion exposure, opioid withdrawal, and BUP-attributable adverse events [precipitated opioid withdrawal (POW) or respiratory depression].</p> Results <p>BUP patients had fewer ventilator days than NO-BUP patients (17.7 ± 13.9 vs. 29.3 ± 13.9&#xa0;days; mean difference − 11.65, 95% CI − 20.9 to − 2.4; Cohen’s <i>d</i> = 0.84; <i>p</i> = 0.008) and earlier median liberation (16.0 vs. 23.5&#xa0;days; <i>p</i> = 0.021). After BUP initiation, daily IV MME decreased (597.6 ± 617.5 to 6.8 ± 18.3&#xa0;mg; <i>p</i> = 0.001), target RASS time increased (63.9 ± 27.8% to 81.6 ± 22.0%; <i>p</i> = 0.0001), and continuous sedative infusions declined (73.7% to 31.6%; <i>p</i> = 0.021). No BUP patient experienced POW or respiratory depression temporally related to BUP; opioid withdrawal occurred in 0/19 BUP vs. 6/18 NO-BUP patients (33.3%; <i>p</i> = 0.008). The intensive care unit (ICU) length of stay was similar (30.2 ± 18.6 vs. 31.8 ± 14.9&#xa0;days; <i>p</i> = 0.385).</p> Conclusions <p>In this pilot retrospective matched cohort study, low-dose BUP initiation as part of an opioid/sedative-weaning strategy was feasible and associated with higher documented time-in-target RASS, reduced opioid/sedative exposure, and faster IMV liberation without documented POW. Given the small sample size, co-interventions, retrospective design, and residual confounding, these findings should be considered hypothesis-generating and require prospective validation.</p>

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Low-Dose Buprenorphine Initiations During Opioid and Sedative Weaning in Mechanically Ventilated Neurocritical Care Patients: A Retrospective Pilot Cohort Study

  • 期刊论文

  • 发表日期：

    2026年6月30日

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  • David K. Carroll,
  • Andrew M. King,
  • Brandtly Yakey,
  • Mark K. Greenwald,
  • Eric A. Woodcock,
  • Andrew R. Isaacson,
  • Bram A. Dolcourt,
  • Arun Sherma,
  • Maria Muzammil

摘要

Background

Iatrogenic opioid dependence, withdrawal, and opioid accumulation can impede neurologic assessment and delay liberation from invasive mechanical ventilation (IMV) in neurocritical care. We evaluated whether low-dose buprenorphine (BUP) initiation was associated with improved sedation and ventilator outcomes.

Methods

We conducted a retrospective matched cohort/case–control study of adults in the neurocritical care unit (NCCU) receiving parenteral opioids while on IMV ≥ 24 h. Patients receiving low-dose BUP initiation (≤ 2 mg cumulative in the first 8 h with ≥ 1 sublingual dose; n = 19) were matched by demographics and diagnosis to patients not receiving BUP (NO-BUP; n = 18). Outcomes included ventilator days/time to liberation, daily intravenous (IV) morphine milligram equivalents (MME), time-in-target range Richmond Agitation-Sedation Scale (RASS − 2 to 0), continuous sedative infusion exposure, opioid withdrawal, and BUP-attributable adverse events [precipitated opioid withdrawal (POW) or respiratory depression].

Results

BUP patients had fewer ventilator days than NO-BUP patients (17.7 ± 13.9 vs. 29.3 ± 13.9 days; mean difference − 11.65, 95% CI − 20.9 to − 2.4; Cohen’s d = 0.84; p = 0.008) and earlier median liberation (16.0 vs. 23.5 days; p = 0.021). After BUP initiation, daily IV MME decreased (597.6 ± 617.5 to 6.8 ± 18.3 mg; p = 0.001), target RASS time increased (63.9 ± 27.8% to 81.6 ± 22.0%; p = 0.0001), and continuous sedative infusions declined (73.7% to 31.6%; p = 0.021). No BUP patient experienced POW or respiratory depression temporally related to BUP; opioid withdrawal occurred in 0/19 BUP vs. 6/18 NO-BUP patients (33.3%; p = 0.008). The intensive care unit (ICU) length of stay was similar (30.2 ± 18.6 vs. 31.8 ± 14.9 days; p = 0.385).

Conclusions

In this pilot retrospective matched cohort study, low-dose BUP initiation as part of an opioid/sedative-weaning strategy was feasible and associated with higher documented time-in-target RASS, reduced opioid/sedative exposure, and faster IMV liberation without documented POW. Given the small sample size, co-interventions, retrospective design, and residual confounding, these findings should be considered hypothesis-generating and require prospective validation.