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Treating Opioid Withdrawal in the ED with Buprenorphine: A Bridge to Recovery

The next time you have a patient in opioid withdrawal, you can use the Clinical Opiate Withdrawal Score (COWS) tool to quantify the level of severity. If the patient has a COWS of ≥8 with an objective sign of withdrawal, give 8 mg of sublingual buprenorphine. No labs are needed. In 30-60 minutes, if they are feeling better, give a second dose. Severe withdrawal is actually the easiest to treat, as the patient has usually gone at least 24 hours since their last use, and thus all opioids have washed out of their system. This patient can be rapidly titrated to a therapeutic level (16-32 mg) without concern for precipitated withdrawal. Before discharge, refer to a local clinic that offers buprenorphine.

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 Managing Opioid Withdrawal in the Emergency Department With Buprenorphine

Emergency departments (EDs) provide acute treatment for patients with opioid use disorder, including opioid overdose and opioid withdrawal, and serve as access portals for the initiation of medication-assisted therapy (also called medication for addiction treatment, or medication for opioid use disorder).

 Treatment of Opioid Withdrawal with Buprenorphine in the Emergency Department

A 2015 study showed that when patients with opioid use disorder were started on buprenorphine with a behavioral intervention in the ED, they were 80% more likely to remain in treatment at 30 days.

Previously Featured

Monthly buprenorphine injections effective for opioid use disorders

Daily dose buprenorphine was approved by the Food and Drug Administration (FDA) in 2002 and has proven to be effective in the treatment of opioid use disorders (OUD). However, daily doses require patients to recommit to taking medication every day and can result in cravings near the end of the 24-hour cycle. Although the National Institute on Drug Abuse (NIDA) did not fund this current study, it did support the development of buprenorphine as a treatment for OUD. NIDA’s support also contributed to the development and approval of another long-acting buprenorphine formulation -- a six-month subcutaneous implant for some patients who have stabilized on daily dosing (Probuphine®).

Nearly all doctors can freely prescribe opioids. Now a new movement aims to vastly deregulate an addiction treatment

Deregulating buprenorphine would make it far easier for Americans to get addiction care from their own doctors instead of being pushed through bureaucratic hoops and into treatment programs of varying quality, said Dr. Andrew Kolodny, the co-director of the Brandeis University Opioid Policy Research Collaborative. Currently, just 1 in 20 doctors have obtained the license necessary to prescribe it.

This Drug Could Help End Opioid Addiction

So why are only 3 percent of doctors prescribing it?

America’s Health-Care System Is Making the Opioid Crisis Worse

Arcane rules and outdated beliefs about addiction are keeping many people from getting treatment.

Buprenorphine Precipitated Opioid Withdrawal: Tips for Prevention and Management for the Emergency Clinician

Buprenorphine is highly effective for the treatment of OUD but can occasionally cause precipitated opioid withdrawal in some patients. Longer acting opioid use such as methadone and chronic fentanyl use may increase the risk of POW. Microdosing or Macrodosing are alternative dosing options for preventing POW.

Despite an opioid crisis, most ERs don’t offer addiction treatment. California is changing that

The moment that helped him survive came in October 2017, when he went to an emergency room not due to an overdose or an injection-related infection but to seek treatment for addiction. Unlike most hospitals in the US, Marshall Medical Center, an hour’s drive east of Sacramento, provided him with real treatment — particularly, buprenorphine, a highly effective medication that treats opioid addiction by mitigating withdrawal and cravings for the drugs.

ED Buprenorphine Guide

3. You DO NOT need an X waiver to treat opioid withdrawal while the patient is in the ED, but you do need an X-waiver to prescribe buprenorphine to the patient for opioid use disorder.

ED-Initiated Buprenorphine

Assess for opioid type and last use. Patients taking methadone may have withdrawal reactions to buprenorphine up to 72 hours after last use. Consider consultation before starting buprenorphine in these patients.

France had a big heroin epidemic in the 1980s and ’90s. Here’s how the country fixed it

In 1995, France made it so any doctor could prescribe buprenorphine without any special licensing or training. Buprenorphine, a first-line treatment for opioid addiction, is a medication that reduces cravings for opioids without becoming addictive itself. With the change in policy, the majority of buprenorphine prescribers in France became primary-care doctors, rather than addiction specialists or psychiatrists. Suddenly, about 10 times as many addicted patients began receiving medication-assisted treatment, and half the country’s heroin users were being treated. Within four years, overdose deaths had declined by 79 percent.

How Buprenorphine Implants Help People Fight Opioid Addiction

Even though buprenorphine can be used to treat opioid addiction, its efficacy is limited by the potential lack of adherence to daily, sublingual doses. To help increase medication compliance among patients undergoing buprenorphine treatment in the country, the FDA approved the first buprenorphine implant for the treatment of opioid dependence in May 2016. Called Probuphine...

How France Cut Heroin Overdoses by 79 Percent in 4 Years

And the United States could, too.

How to Treat an Opioid Epidemic

As an opioid drug itself, bupe is a pharmacological replacement therapy, like methadone, the classic anti-addiction opioid medication. It prevents withdrawal symptoms and suppresses drug craving, and usually comes as a filmstrip that dissolves under the tongue. Bupe has some clear advantages over methadone. Its chemical properties make it less risky if taken in excess. And unlike methadone, which must be dispensed in clinics tightly regulated by the DEA, bupe can be prescribed by any qualified physician, who can refill a month’s worth of the drug from his or her office.

Methadone and Buprenorphine 101: A Guide for Law Enforcement

Methadone and Suboxone can be abused and diverted, but are far less likely to be than street opioids or prescription pain medications.

Opioid Treatment Is Used Vastly More in States That Expanded Medicaid

The states with the highest Medicaid prescribing rates for the anti-craving drug buprenorphine — Vermont, West Virginia, Kentucky, Montana and Ohio — all expanded the program.

Strayerisms – Opioid Abuse and Buprenorphine

Move willing opioid misusers into treatment with ED initiated buprenorphine.

We Know How to Treat Opioid Addiction

But our antiquated conceptions of addicts prevent us from doing so.

What Is the Difference Between Buprenorphine, Subutex and Suboxone?

The generic drug buprenorphine, which is marketed under the brand names Subutex and Suboxone, can help you face the challenge of withdrawal and increase your chances of long-term recovery.

When an Iowa Family Doctor Takes On the Opioid Epidemic

Few primary care doctors are willing to do what Nicole Gastala has: endure the challenges of prescribing buprenorphine, a medication for opioid addiction.

Why it’s easier to be prescribed an opioid painkiller than the treatment for opioid addiction

While little training is required for doctors to prescribe opioids for pain, onerous restrictions are placed on physicians who wish to and currently do prescribe oral buprenorphine. These restrictions exist because buprenorphine does have the potential to be misused. Yet the restrictions placed on it far exceed those on prescription opioid painkillers, for which the potential for abuse is high.

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Subutex vs Suboxone

If you are concerned about relapsing and abusing the medication or have experienced relapses in the past, Suboxone may be a better choice for you due to the abuse-deterrent features of naloxone. Because Subutex contains only buprenorphine as its active ingredient, it is simpler to make and therefore less expensive than Suboxone, and is also available as a generic prescription.