Incidence of Precipitated Withdrawal During a Multisite Emergency Department–Initiated Buprenorphine Clinical Trial in the Era of Fentanyl

Source:

D’Onofrio G, Hawk KF, Perrone J, et al. Incidence of Precipitated Withdrawal During a Multisite Emergency Department–Initiated Buprenorphine Clinical Trial in the Era of Fentanyl. JAMA Netw Open. 2023;6(3):e236108. doi:10.1001/jamanetworkopen.2023.6108

Discussion

This cohort study used data from the first, to our knowledge, prospective trial4 using uniform surveillance, operational definitions, and adjudicated outcomes to document buprenorphine-induced PW in persons using fentanyl. Despite high fentanyl prevalence, the incidence of PW in this multisite trial4 of ED-initiated buprenorphine was less than 1%, similar to reported rates among persons using heroin or prescription opioids.6 All 9 patients with PW used fentanyl, most without PW also used fentanyl, and no factors suggest a specific phenotype for PW. The discordance between our findings and those of retrospective studies is striking.

Limitations include possible undetected fentanyl analogues or nitazenes leading to PW. We may have missed PW after discharge, although follow-up rates at 7 days after the ED visit were 86% and likely would be captured as adverse events.

In this geographically diverse observational cohort, buprenorphine induction in the ED remained safe and effective, even with fentanyl present. Continued access to buprenorphine for opioid use disorder treatment is essential given the ongoing overdose crisis.