From the Guidelines
The patient should be provided with a short-term bridge prescription of buprenorphine at their usual dose to prevent withdrawal symptoms until they can establish care with a pain management clinic. The ED physician should prescribe buprenorphine at the patient's usual dose (typically 8-24 mg daily) for 3-4 days to prevent withdrawal symptoms, as recommended by the study published in the Annals of Internal Medicine 1. If the patient's exact dose is known, it should be matched; otherwise, the physician should start with 8 mg sublingual daily or twice daily based on their reported previous dosing.
Key Considerations
- The prescription should be limited to the exact number of days until their pain management appointment, plus perhaps one extra day as a buffer.
- The ED provider should consider prescribing supportive medications for breakthrough withdrawal symptoms, including clonidine 0.1-0.2 mg every 6 hours as needed for autonomic symptoms, ondansetron 4 mg every 6 hours as needed for nausea, loperamide 2 mg as needed for diarrhea, and acetaminophen/NSAIDs for pain and discomfort.
- The patient should be educated about the importance of keeping their pain management appointment and the risks of abrupt discontinuation of buprenorphine, which can lead to severe withdrawal lasting 2-4 weeks due to its long half-life.
Preventing Withdrawal
The approach of providing a short-term bridge prescription of buprenorphine bridges the gap in care while preventing the medical and psychological distress of opioid withdrawal, reducing the risk that the patient might seek illicit opioids to self-manage withdrawal symptoms, as supported by the guidelines for managing patients on opioid agonist therapy 1.
Additional Support
It is essential to note that the study published in the Annals of Emergency Medicine 1 provides recommendations for managing agitation in adult psychiatric patients, which may not be directly applicable to this patient's situation. However, the primary concern in this case is preventing opioid withdrawal, and the recommended approach focuses on providing a bridge prescription of buprenorphine and supportive medications as needed.
From the Research
Management of Buprenorphine Withdrawal
The patient presenting to the ED with a history of 7 years of buprenorphine use is at risk of withdrawal due to lack of access to buprenorphine or methadone. The following plan of care can be considered:
- Assess the patient's withdrawal symptoms and medical history to determine the best course of treatment.
- Consider using clonidine to manage withdrawal symptoms, as it has been shown to be effective in reducing symptoms of opiate withdrawal 2, 3, 4.
- Clonidine can be used as a transitional treatment between opiate dependence and induction onto the opiate antagonist naltrexone 3.
- Dosage regimens of clonidine must be individualized according to symptoms and side effects and closely supervised due to varying sensitivity to clonidine's sedative, hypotensive, and withdrawal-suppressing effects 3.
Clonidine Dosage and Administration
- The dosage of clonidine may vary depending on the patient's symptoms and medical history.
- A peak mean dose of 16 microg/kg/day has been used in previous studies to manage methadone withdrawal 2.
- Clonidine can be administered orally or via infusion, and the dosage should be slowly tapered down to prevent withdrawal symptoms 5.
Monitoring and Follow-up
- The patient should be closely monitored for signs and symptoms of withdrawal, as well as any potential side effects of clonidine.
- Regular follow-up appointments should be scheduled to assess the patient's progress and adjust the treatment plan as needed.
- The patient should be educated on the importance of follow-up care and the potential risks of relapse if treatment is not continued.