NUBE 2024

Precipitated opioid withdrawal is an abrupt onset of severe withdrawal symptoms after administration of full or partial mu antagonists.  This clinical case series and skill building workshop will elucidate options for management of precipitated opioid withdrawal in the emergency department.  Precipitated withdrawal can lead to symptoms from piloerection, nausea, vomiting and diarrhea to delirium and critical illness.  This series will look at 3 different patient scenarios to help guide clinicians in providing critical care for patients in acute precipitated withdrawal.  The fear of this complication and challenges managing precipitated withdrawal can be a barrier for some providers in starting buprenorphine.  Education around how to manage precipitated withdrawal can assist clinicians in increasing their comfort with buprenorphine initiation.

The patient scenarios involve precipitated opioid withdrawal with naloxone and buprenorphine administration in the ED and in the community. Clinicians will have increasing comfort in assessing patients Clinical Opioid Withdrawal Score (COWS) as well as immediate management of withdrawal symptoms.

Patient #1 has initiated buprenorphine through a home start and is presenting to the ED with worsening symptoms of withdrawal.

Patient #2 received naloxone by EMS in the field after unintentional opioid overdose and presents to ED with signs of precipitated withdrawal.

Patient #3 was started on buprenorphine in the ED and has rising COWS despite maximizing buprenorphine dosing.

This presentation will discuss using multimodal agents including buprenorphine (IV, SL and patches), benzodiazepines, ketamine, anti-dopaminergic agents and full agonist opioids for management of opioid withdrawal symptoms. The clinical scenarios, patient characteristics, risk factors for precipitated withdrawal and patient outcomes as well as follow up care will be discussed. Clinicians can utilize these skills to improve care for patients and gain confidence in starting medication assisted treatment in the emergency department.

Learning Objectives:

Recognizing precipitated opioid withdrawal.

Treating precipitated opioid withdrawal with multimodal agents.

Increasing confidence to initiate buprenorphine treatment for opioid withdrawal safely in the ED.