Buprenorphine precipitated opioid withdrawal: Prevention and management in the ED setting

Buprenorphine precipitated opioid withdrawal (BPOW) is an uncommon complication of buprenorphine initiation in the emergency department (ED), but it can produce significant discomfort and be distressing to patients. As EDs continue to care for those with opioid use disorder (OUD), clinicians should be aware of how to prevent and treat BPOW.

This narrative review provides an evidence-based update of the epidemiology, prevention strategies, and management of BPOW for the emergency clinician.

BPOW is a rapid worsening of opioid withdrawal symptoms upon initiating buprenorphine. BPOW can be prevented by waiting for the onset of moderate Clinical Opioid Withdrawal Scale (COWS) > 13 opioid withdrawal symptoms and a sufficient amount of time since last full opioid agonist use before buprenorphine administration. Risk factors for BPOW include chronic fentanyl use, methadone use, and concurrent benzodiazepine use. Alternative dosing strategies such as low-dose or "microdosing" and high-dose or "macrodosing" are options for buprenorphine that may impact the development of BPOW. The strategy of treating BPOW with more buprenorphine has a pharmacological basis and has been effective in case reports. Additional management is symptom-based and supportive. Although most cases have a benign course, patients may be significantly less likely to use buprenorphine for OUD in the future or seek care for substance use disorder.

Appropriate initiation of buprenorphine is important to prevent BPOW. Dosing buprenorphine should be based on the patient's patterns of opioid use and response to therapy. Management of BPOW should be symptom-based but include additional buprenorphine and adjunctive medications.