Leah Steckler, MD
November 20th, 2017
According to the Centers for Disease Control, opioids were involved in 33,091 deaths in 2015 and overdoses have increased four-fold since 1999, including both illicit and prescribed opioid medications (1). This dramatic increase in mortality has persisted despite prescribers writing fewer prescriptions for opioids in the past few years (2). It is possible that fewer opioid prescriptions may lead to more patients experiencing withdrawal. Current practice approaches in the emergency department (ED) tend to focus more on symptomatic treatment with anti-emetic and anti-diarrheal agents, and referral to rehabilitation services (3). The standard of care does not currently include opioid agonist-antagonists, like buprenorphine, in the acute period for the management of these patients. The unpleasant effects of withdrawal undoubtedly contribute to opioid addiction. As such, improving pharmacologic methods to control withdrawal symptoms may provide another means of fighting this epidemic.
An article in Annals of Emergency Medicine by Love et al. (4) presents an emergency medicine-focused snapshot of a recent Cochrane Review assessing our current opioid withdrawal treatments (5). This Cochrane Review analyzed data from 27 studies comparing buprenorphine to tapered methadone, and studies comparing buprenorphine with clonidine (an alpha-2 adrenergic agonist used commonly to treat withdrawal symptoms).
Love and colleagues suggest that buprenorphine administration in the ED may be an appropriate intervention for opioid withdrawal. Fourteen of the studies compared buprenorphine and alpha-2 adrenergic agonists as pharmacologic withdrawal management. Using data extraction, subgroups were analyzed and the results showed that patients treated with buprenorphine had significantly lower withdrawal scores and greater number of days in treatment than patients treated with alpha 2-adrenergic medications. The authors concluded that the number of patients needed to treat with buprenorphine was four in order for one additional patient to reach withdrawal treatment (4) (Figure 1).
Figure 1: Buprenorphine versus alpha2-adrenergic agonists for acute opioid withdrawal (4)
Upon reviewing the above information, it is clear that limitations still exist with the use of buprenorphine to treat opioid withdrawal. Buprenorphine is not without risk and may cause dangerous adverse effects including hypotension, derangements in liver function, and respiratory depression (6). It is important that prescribers are comfortable with the evidence behind a medication, that they understand appropriate dosing regimens, and that the medications are safe for patients. Further, a provider cannot prescribe buprenorphine without taking an 8-hour course and receiving a certificate from the Drug Enforcement Agency (7). Additionally, this topic has not been well studied in the ED population, and there is always the risk of patients becoming addicted to the treatment for their addiction (8). Starting withdrawal treatment in the ED may help to bridge opioid users to outpatient treatment and contribute to our country’s mission to stave off future opioid abuse. Continued research on buprenorphine use in the ED is certainly worthwhile.
Resources:
- Drug Overdose Death Data. 2014-2015 Death Increases. CDC. Available from: https://www.cdc.gov/drugoverdose/data/statedeaths.html
- S. Prescribing Rate Maps. Total number and rate of opioid prescriptions dispensed, United States, 2006-2016. CDC. Available from: https://www.cdc.gov/drugoverdose/maps/rxrate-maps.html
- Tintinalli Burillo-Putze G, Miro O. Opioids. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e New York, NY: McGraw-Hill; 2016. http://accessmedicine.mhmedical.com.proxygw.wrlc.org/content.aspx?bookid=1658§ionid=109414267. Accessed November 10, 2017.
- Love, J, Perrone, J, Nelson, L. Should Buprenorphine Be Administered to Patients with Opioid Withdrawal in the Emergency Department? Ann Emerg Med. Published online November
- Gowing L, Ali R, White JM, et al. Buprenorphine for managing opioid withdrawal. Cochrane Database Syst Rev. 2017;2:CD002025.
- Epocrates. Available from: https://online.epocrates.com/drugs/7468/Belbuca
- Buprenorphine Waiver Management. Available from: https://www.samhsa.gov/medication-assisted-treatment/buprenorphine-waiver-management
- Addicted to a Treatment for Addiction. New York Times. 2016. https://www.nytimes.com/2016/05/29/opinion/sunday/addicted-to-a-treatment-for-addiction.html
Leah Steckler, MD is an Emergency Medicine Resident at The George Washington University Hospital
