Precipitated Withdrawal following Emergency Department-initiated Buprenorphine: A Retrospective Study

Buprenorphine may be offered less frequently than indicated for treatment of opioid withdrawal in the emergency department (ED) due to patient and clinician concerns regarding precipitated withdrawal (PW). Our objective is to determine an accurate estimate of the incidence of PW following buprenorphine initiation in the ED.

We performed a retrospective study of adults seen in one of the 15 EDs within the University of Maryland Medical System who received ED-initiated buprenorphine between January 1, 2019 and December 31, 2023. Patients were excluded if they were given buprenorphine to continue an established treatment regimen, had buprenorphine ordered by an inpatient clinician, or did not have a Clinical Opiate Withdrawal Scale (COWS) score recorded before treatment. PW was defined as either a ≥5-point increase in COWS score within 4 hours of buprenorphine administration or any increase in the COWS score associated with additional opioid administration within 4 hours of the first buprenorphine dose.

A total of 1229 patients received buprenorphine in the ED during the study period; 990 were excluded. We identified 16 cases of PW [6.7% (95% CI: 3.5%-9.9%)]. No association was found between the development of PW and initial COWS, buprenorphine formulation, fentanyl use, or buprenorphine dose.

PW was uncommon following ED-initiated buprenorphine in this cohort. However, the rate of PW was higher than reported in some prior studies. Patients should be counseled regarding the possibility of PW before treatment, and clinicians should be prepared to address symptoms of PW when they occur.