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Alprazolam/buprenorphine/naloxone Various toxicities: case report

A 26-year-old man developed drug dependence during treatment with buprenorphine/naloxone. Additionally, he developed withdrawal symptoms following withdrawal of buprenorphine/naloxone. He also developed sedation and dilated pupils following misuse and overdose alprazolam in a suicide attempt [outcomes not stated]. The man in India, who had a history of heroin and tobacco dependence, started receiving buprenorphine/naloxone [buprenorphine-naloxone] 4mg in November 2019. For the initial 2 months, he was not adherent to the treatment. In February 2020, buprenorphine/naloxone dose was increased from 4mg to 6mg, which resulted in better control of craving (dependence) and improved adherence. On 18 March 2020, at a follow-up, his abstinence was confirmed by negative urine test for morphine. At that time, he was prescribed take-away buprenorphine/naloxone for a week. However, from 24 March 2020, a nationwide lockdown was started, which led to immediate suspension of public conveyance, sealing of state borders and suspension of his daily income. Therefore, he was not able to attend for follow-up on a scheduled date. As he was not able to procure buprenorphine/naloxone, he experienced intense craving and withdrawal symptoms including pain. On day 3, while experiencing unbearable pain, he attempted suicide by drinking Phenyl (a disinfectant). However, he could not drink more disinfectant due to local irritation and nausea. Subsequently, he was taken to the health centre and received supportive care. He was discharged after a few hours. On next day, from a known drug‑peddler, he obtained heroin. He received heroin injection; however, he experienced guilt for restarting heroin. Thereafter, to relieve withdrawal-related pain and insomnia, he managed to acquire 10 tablets of alprazolam 0.5mg from a health care worker (misuse). On next day, he attempted suicide by consuming all ten tablets of alprazolam together (overdose). However, he revealed the same to his family and therefore, he was brought to the emergency department. Subsequent examination showed sedation and dilated pupils. He responded to verbal commands and he had vitals within normal limits. He was kept under overnight observation. On next day, he was consulted in addiction psychiatry clinic. At that time, he admitted to attempt suicide due to unbearable withdrawal pain and inability to procure medication. Therefore, he underwent re-induction of buprenorphine/naloxone. Ghosh A, et al. Multiple suicide attempts in an individual with opioid dependence: Unintended harm of lockdown during the COVID-19 outbreak?. Indian Journal of Psychiatry 62: 604-606, No. 5, Oct 2020. Available from: URL: http://doi.org/10.4103/psychiatry.IndianJPsychiatry_447_20

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Reactions 21 Nov 2020 No. 1831