Buprenorphine therapy in the setting of induced opioid withdrawal from oral naltrexone: a case report
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CASE REPORT
Buprenorphine therapy in the setting of induced opioid withdrawal from oral naltrexone: a case report Laura M. Szczesniak1, Vincent J. Calleo2 and Ross W. Sullivan2*
Abstract Background: Patients with opioid use disorder (OUD) frequently present to the emergency department for acute treatment of overdose and withdrawal. Case presentation: A 29-year-old male presented to the emergency room after intravenous heroin use followed by accidental ingestion of naltrexone. He was treated with buprenorphine with significant improvement in his Clinical Opioid Withdrawal Score, from moderately severe to mild withdrawal symptoms within a few hours. Conclusion: Buprenorphine and minimal supportive care can be used to treat acute withdrawal precipitated by oral naltrexone in patients with OUD. Keywords: Buprenorphine, Opioid use disorder, Overdose, Substance use treatment, Precipitated withdrawal, Naltrexone Background Opioid use disorder (OUD) is a public health emergency, with two out of three overdose deaths in 2018 involving an opioid [1]. In most cases, the Emergency Department (ED) is the primary location for acute treatment of these patients. If proper care is not provided to patients with OUD, they remain at a high risk for morbidity and mortality related to drug abuse. The increased usage of the opioid antagonist naloxone has played a vital role in treatment of opioid overdose, but its use can lead to precipitated withdrawal, which is a rapid and intense onset of withdrawal symptoms. Several case studies have recently addressed the issue of precipitated withdrawal by treatment with buprenorphine [2–4], a partial opioid agonist that is traditionally used to treat symptoms of long-term
withdrawal [5]. Patients in these studies were given buprenorphine after naloxone administration in order to alleviate acute symptoms, which resulted in a reduction in their Clinical Opioid Withdrawal Scores (COWS) [6]. Naltrexone is another opioid antagonist commonly used as abstinence in patients with opioid or alcohol dependence. Ingestion of naltrexone with measurable levels of opioids in the body can precipitate acute withdrawal, but withdrawal symptoms often appear more severe than usual [7]. One recent study found that elective naltrexone-induced withdrawal could be treated with buprenorphine in order to avoid methadone tapering and hasten treatment [8]. To the best of the authors’ knowledge, this is the first case of an accidental oral naltrexone ingestion after intravenous (IV) heroin use that was successfully treated by oral buprenorphine. Case presentation
*Correspondence: [email protected] 2 Department of Emergency Medicine, Upstate Medical University, 750 E Adams St, Syracuse, NY 13210, USA Full list of author information is available at the end of the article
A 29-year-old male with a history of IV drug use presented to the ED with severe abdominal pain and vomiting. He reported injecting heroin in the
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