Comparison of Initial Sedation and Analgesia in Patients on Buprenorphine vs Opioid-Naive Patients

Introduction: An increasing number of patients with opioid use disorder (OUD) on medications for OUD such as buprenorphine (BUP) are admitted to intensive care units (ICU). Current guidelines recommend an analgesia-first approach using opioids to optimize sedation in intubated patients. However, data on analgesia and sedation needs in BUP-tolerant patients after intubation are limited, with some peri-operative studies suggesting higher opioid requirements. This study compared the initial analgesia and sedation requirements in patients on prior-to-admission (PTA) BUP vs. opioid naïve patients within the first 24 hours of invasive mechanical ventilation (IMV).


Methods: This was a retrospective, comparative cohort study of adult patients on IMV receiving continuous opioid infusions in medical ICUs from January 2018 to June 2024. Patients were either opioid-naïve or on PTA BUP. Patients were excluded if they underwent targeted temperature management, were diagnosed with status epilepticus or alcohol withdrawal, received continuous neuromuscular blockade, or received less than 24 hours of IMV. The primary outcome was the median morphine milligram equivalents (MME) administered in the first 24 hours of IMV. Secondary outcomes included adjunct sedative use, median Behavioral Pain Scale (BPS) and Richmond Agitation and Sedation Scale (RASS) scores, and time to BUP resumption.


Results: 95 patients were included; 19 on PTA BUP and 76 opioid naïve. Baseline characteristics were similar, except for a higher incidence of substance use and psychiatric disorders in the BUP group. Median MME administered within the first 24 hours of IMV was not significantly higher in the PTA BUP vs. opioid naïve group (765 vs. 975, P = 0.93). Adjunct sedative use and median BPS and RASS scores were similar between the groups. Patients on PTA BUP received a greater proportion of their MMEs from adjunct opioids (78.8 vs. 30 MME, P = 0.27) though not statistically significant. BUP was restarted in 42.1% of PTA BUP patients, with 62.5% restarting after transfer from ICU.


Conclusions: In this study, patients on PTA BUP received similar median MME in the first 24 hours of IMV compared to opioid-naïve patients and experienced a comparable degree of sedation and analgesia.