A case of buprenorphine-precipitated withdrawal managed with high-dose buprenorphine

Abstract

Background Buprenorphine–naloxone has a very high affinity for the mu-receptor and can cause precipitated opioid withdrawal, typically more severe than withdrawal that occurs naturally, when administered while a full mu-opioid receptor agonist remains in a person’s system. To avoid precipitated withdrawal, one needs to be in mild to moderate opioid withdrawal at the time of buprenorphine-naloxone induction. Recently, there have been reported cases of precipitated withdrawal occurring in patients taking fentanyl knowingly or unknowingly, despite them being in adequate opioid withdrawal at the time of induction. When this occurs, the current recommendation is to provide 2 mg of buprenorphine–naloxone every 1–2 hours. Objectives Describe a case of successful management of buprenorphine-precipitated withdrawal with escalation of the dose of buprenorphine and highlight implications for future management. Methods We present a case of a patient with a history of opioid use disorder who was in moderate opioid withdrawal at the time of buprenorphine–naloxone induction and experienced precipitated withdrawal after buprenorphine–naloxone administration. Results High-dose buprenorphine–naloxone was given to the patient and precipitated withdrawal subsided after receiving a total of 20 mg. On the next day, the patient had no symptoms of opioid withdrawal and is currently maintained on 16 mg/day. Conclusion With the rising prevalence of fentanyl-laced drugs, increased instances of precipitated withdrawal are likely to be encountered. In cases of precipitated withdrawal, giving a high dose of buprenorphine–naloxone rapidly is safe and will allow rapid reversal of withdrawal symptoms.

Synergistic Effect of Ketamine and Buprenorphine Observed in the Treatment of Buprenorphine Precipitated Opioid Withdrawal in a Patient With Fentanyl Use

“…Each of these treatment strategies for BPOW has limitations. Supportive care like clonidine and antiemetics, may help in mild cases of BPOW but are inadequate in severe cases 2,7,10 . Administration of additional buprenorphine is limited by both the current Federal Drug Agency recommendations that no more than 12 mg SL buprenorphine be administered on day 1 of induction and the ceiling effect resulting from buprenorphine’s partial agonism (low intrinsic efficacy) at μORs 8 .…”

Signals of increasing co-use of stimulants and opioids from online drug forum data

“…For persons using stimulants to counteract the depressant-type effects of opioids [ 36 ], the stronger potency of fentanyl may also be driving increased interest in stimulant use. Recent literature also suggests that PWUO/PTMOUD who knowingly or unknowingly consume fentanyl tend to have more severe withdrawal symptoms when taking MOUD [ 37 ], which may partially explain the greater interest over time in stimulants among Redditors discussing both MOUD and fentanyl. Our results suggest that as availability and use of synthetic opioids such as fentanyl continue to increase, interest in and co-use of stimulants could persist.…”

Trends in Co-mention of Stimulants and Opioids: A Natural Language Processing Driven Analysis of Reddit Forums

“…30 For persons using stimulants to counteract the depressant-type effects of opioids, 31 the stronger potency of fentanyl may also be driving increased interest in stimulant use. Recent literature also suggests that PWUO/PTMOUD who knowingly or unknowingly consume fentanyl, tend to have more severe withdrawal symptoms when taking MOUD, 32 which may partially explain the greater interest over time in stimulants among Redditors discussing both MOUD and fentanyl. Our results suggest that as availability and use of synthetic opioids such as fentanyl continue to increase, interest in and co-use of stimulants could persist.…”