2824 – Acute psychosis and buprenorphine withdrawal: abrupt vs. progressive could make a difference

Abstract

Buprenorphine, a partial μ-opioid agonist and κ-opioid antagonist, is frequently used in the treatment of heroin dependence, and to prevent complications arising from intravenous injection and social consequences of heroin use. Psychosis occurring after discontinuation of buprenorphine or other opioids has been described, but is uncommon. We report the case of a 37-year-old man, suffering from opiates dependence, presenting acute and intense psychotic symptoms beginning after an abrupt discontinuation of buprenorphine, which he was taking for two years as substitution therapy for heroin dependence. The initial medication by risperidone, up to a dose of 8 mg/day was inefficient to control psychotic symptoms. Four weeks later, buprenorphine was finally restarted at 8 mg/day, which allowed a complete remission of psychotic and anxiety-related symptoms. The antipsychotic medication was gradually discontinued two months later, allowing the patient to remain symptom-free eighteen months later. We discuss the potential role of abrupt withdrawal syndrome in the apparition of the psychotic symptoms and the presence of a latent psychotic disorder. An interesting issue in our case report is that a correctly conducted antipsychotic treatment did not succeed in stopping symptoms of delusions, even after four weeks, while reintroducing buprenorphine did, showing in this context an antipsychotic effect. This case report highlights the importance of taking opiate dependence into account in patients with recent onset of psychotic symptoms, even several weeks after withdrawal.