Precipitated opioid withdrawal after buprenorphine administration in patients presenting to the emergency department: A case series

Abstract

Objectives Buprenorphine is a highly effective medication for the treatment of opioid use disorder, but it can cause precipitated withdrawal (PW) from opioids. Incidence, risk factors, and best approaches to management of PW are not well understood. Our objective was to describe adverse outcomes after buprenorphine administration among emergency department (ED) patients and assess whether they met the criteria for PW. Methods This study is a case series using retrospective chart review in a convenience sample of patients from 3 hospitals in an urban academic health system. This study included patients who were reported by clinicians as potential cases of PW. Relevant clinical data were abstracted from the electronic health record using a structured retrospective chart review instrument. Results A total of 13 cases were included and classified into the following 3 categories: (1) PW after buprenorphine administration consistent with guidelines (n = 5), (2) PW after deviating from guidelines (n = 4), and (3) protracted opioid withdrawal with no increase in Clinical Opiate Withdrawal Scale score (n = 4). A total of 11 patients had urine drug testing positive for fentanyl, and 11 patients received additional doses of buprenorphine for symptom management. Of the patients, 5 had self‐directed hospital discharges, and 6 were ultimately discharged with prescriptions for buprenorphine. Conclusions Cases of adverse outcomes after buprenorphine administration in the ED and hospital meet criteria for PW, although some cases may have represented protracted opioid withdrawal. Further investigation into the incidence, risk factors, management of PW as well as patient perspectives is needed to expand and sustain the use of buprenorphine in EDs and hospitals.

Withdrawal during outpatient low dose buprenorphine initiation in people who use fentanyl: a retrospective cohort study

“…However, there was still known deviation from protocol instructions in a large percentage of our initiation attempts, including 7 of the 10 cases of precipitated withdrawal. Similarly, in a case series from the emergency department, deviation from guideline-based buprenorphine administration was present in 4 of 13 (31%) traditional initiations with suspected precipitated withdrawal, suggesting that protocol deviation may play a role in withdrawal risk [ 22 ]. Following protocol instructions may be challenging in outpatient LDIs, which have complicated, frequent dosing schedules using small, split tablets or films of buprenorphine [ 10 , 26 ].…”

“…They were instructed to use their clinical judgment to determine whether withdrawal symptoms were mild, moderate, or severe, and whether there was any concern for precipitated withdrawal from buprenorphine. Though some studies have used changes in Clinical Opiate Withdrawal Scale (COWS) [ 30 ] scores to describe precipitated withdrawal, there is no standardized operational definition [ 11 , 22 , 24 ]. We were unable to use objective scoring systems, so we defined precipitated withdrawal as documentation of the patient experiencing acute worsening of withdrawal symptoms immediately after taking buprenorphine [ 19 ].…”

“…Little is known about individual pharmacokinetics in people chronically using high doses of fentanyl, and the exact incidence of precipitated withdrawal during outpatient buprenorphine initiation in people using fentanyl is unknown [ 22 ]. Self-reported data from 1679 OUD patients across the U.S. revealed odds of severe withdrawal during buprenorphine initiation were 5.2 times higher in people with fentanyl use in the past 24 hours compared to those with use in the past month [ 23 ].…”

Methadone and neonatal abstinence syndrome (NAS): what we think we know, but do not

“…Furthermore, methadone, a full agonist, is pharmacologically, a more appropriate medication for use in medication induction in pregnancy during the current epidemic of fentanyl-dependent pregnant women. Methadone avoids the risks to the fetus of harm from precipitated buprenorphine withdrawal and the need for polypharmacy to manage such withdrawal (41)(42)(43). This emphasizes the critical importance of changing Federal regulations that prevent physicians, especially obstetricians and family medicine doctors trained in addiction medicine, from using a safer and more effective medication to manage severe dependence.…”

Things We Do for No Reason™: Avoiding methadone for opioid withdrawal

“…This includes methadone's analgesic and long‐acting properties, which we can leverage by splitting dosing to treat both acute pain and withdrawal. In addition, compared with a partial opioid agonist like buprenorphine, situations when patients may prefer methadone over buprenorphine include: (1) previous buprenorphine‐induced precipitated withdrawal; (2) regular fentanyl use, which may increase the risk of precipitated withdrawal with buprenorphine initiation; (3) methadone's full opioid agonism; and (4) acute pain 13 …”