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.

FIGURE 1

Individual components of COWS score recorded before buprenorphine administration for individual patients by patient category. Each unique color represents a score for a specific individual study participant (N = 13). COWS components are arrayed from left to right, with the total score equaling the sum of the individual components (restlessness, anxiety, bone or joint aches, sweating, yawning, tremor, GI upset, gooseflesh, resting pulse rate, and pupil size). The top panel (blue shades) indicates patients in category 1 (n = 5, PW after guideline‐based buprenorphine administration), the middle panel (yellow shades) shows patients in category 2 (n = 4, PW after deviating from guideline‐based buprenorphine administration), and the bottom panel (green shades) shows patients in category 3 (n = 4, protracted opioid withdrawal). COWS, Clinical Opiate Withdrawal Scale; GI, gastrointestinal; PW, precipitated opioid withdrawal

FIGURE 2

Individual components of COWS score recorded after buprenorphine administration for individual patients by patient category. Each unique color represents a score for a specific individual study participant (N = 13). COWS components are arrayed from left to right, with the total score equaling the sum of the individual components (restlessness, anxiety, bone or joint aches, sweating, yawning, tremor, GI upset, gooseflesh, resting pulse rate, and pupil size). The top panel (blue shades) indicates patients in category 1 (n = 5, PW after guideline‐based buprenorphine administration), the middle panel (yellow shades) shows patients in category 2 (n = 4, PW after deviating from guideline‐based buprenorphine administration), and the bottom panel (green shades) shows patients in category 3 (n = 4, protracted opioid withdrawal). COWS, Clinical Opiate Withdrawal Scale; GI, gastrointestinal; PW, precipitated opioid withdrawal

FIGURE 3

Plot of recorded COWS, buprenorphine administrations, and discharge events over time (minutes) for patients categorized as precipitated opioid withdrawal (category 1). A black diamond indicates the recorded COWS score at the time (minutes) relative to the first dose of buprenorphine, the orange cross indicates the dose of buprenorphine (mg) at the time (minutes) relative to the first dose of buprenorphine, and the red vertical line indicates the time of departure from the ED or hospital. Note: Case 3 received 2 doses of 8–2 mg buprenorphine–naloxone 5 minutes apart after a recoded COWS score of 19. COWS, Clinical Opiate Withdrawal Scale

FIGURE 4

Plot of recorded COWS, buprenorphine administrations, and discharge events over time (minutes) for patients categorized as precipitated opioid withdrawal after non‐standard buprenorphine initiation (category 2). A black diamond indicates the recorded COWS score at the time (minutes) relative to the first dose of buprenorphine, the orange cross indicates the dose of buprenorphine (mg) at the time (minutes) relative to the first dose of buprenorphine, and the red vertical line indicates the time of departure from the acute care setting. COWS, Clinical Opiate Withdrawal Scale

FIGURE 5

Plot of recorded COWS, buprenorphine administrations, and discharge events over time (minutes) for patients categorized as protracted opioid withdrawal (category 3). A black diamond indicates the recorded COWS score at the time (minutes) relative to the first dose of buprenorphine, the orange cross indicates the dose of buprenorphine (mg) at the time (minutes) relative to the first dose of buprenorphine, and the red vertical line indicates the time of departure from the acute care setting. COWS, Clinical Opiate Withdrawal Scale