Emergency Department Management of Precipitated Opioid Withdrawal after Intravenous Buprenorphine/Naloxone Use: A Case Report

Abstract

The opioid epidemic in the United States continues to grow at staggering rates. More than 760,000 people have died of drug overdose since 1999, with the annual death toll increasing exponentially. In response, the use of medication assisted treatment (MAT) for opioid use disorder has grown considerably. Abuse of MAT is common, with studies showing rates as high as 28% of patients on MAT abusing the medications. There are case reports detailing precipitated withdrawal following intravenous buprenorphine/naloxone (Suboxone) misuse, but little literature exists regarding management of these cases. The current recommendation per other case reports is to treat with additional doses of Suboxone. We present the case of a 44-year-old male presenting to the emergency department in precipitated withdrawal after injecting Suboxone intravenously. In this case, the patient had eloped from inpatient rehabilitation about 36 hours after his last dose of Fentanyl. He then injected Suboxone to combat symptoms of opioid withdrawal. He felt markedly worse following the injection, prompting him to seek treatment. On arrival he was visibly uncomfortable and irritable during the exam. He was treated with additional Suboxone at the suggestion of other case reports, but this significantly worsened his symptoms. He was additionally treated with diazepam, resulting in improvement. He was discharged with resources for opioid use disorder and was successfully contacted six months after his initial presentation, at which time he reported continued opioid use as well as suboxone misuse.