Precipitous withdrawal? Research shows risk is low with buprenorphine for treating opioid use disorder

Buprenorphine can be used safely to treat opioid use disorder, according to work by a University of Ottawa research team.Many healthcare professionals are reluctant to use this drug because of the potential risk of “precipitous withdrawal,” a syndrome where the first dose causes sudden, intense pain and anxiety. Although available to the Canadian population, buprenorphine is prescribed to less than 1% of patients for this reason.Yet the systematic review, led by Dr. Barbara Eagles, associate professor in the department of emergency medicine at the University of Ottawa, shows that the incidence of precipitous withdrawal in adults with opioid use disorder is low at the first dose, and symptoms are mild. The findings were published by the medical journal Addiction.“It has been shown in many, many different studies that buprenorphine reduces overall opioid use and reduces opioid-related mortality,” said Dr. Caroline Gregory, an emergency medicine resident who participated in the review. “But the fear of this very severe reaction to the drug is enough to deter people from taking it, and even providers from prescribing it.”The team analyzed 26 studies of buprenorphine precipitated withdrawal, including five randomized trials, all conducted between 2002 and 2023 and involving a total sample of some 5,000 patients. Twenty-two of the 26 studies reported an incidence of precipitous withdrawal of 5% or less.While there is still room for improvement, say the researchers, including a standardized definition of precipitous withdrawal, the current highest-quality studies consistently show a low rate of precipitous withdrawal, even for fentanyl use.“Our study highlights that the risk of precipitous withdrawal appears low and should not be a barrier to initiating treatment,” the authors wrote. “When it does occur, it is usually mild and, in most cases, does not require hospitalization, although severity was often not described in the studies we reviewed.”Not dangerousHasty withdrawal is not dangerous in itself, said Dr. Gregory. However, it may be so uncomfortable that patients may abandon medication and even return to taking opioids for relief.While waiting for more rigorous studies, Dr. Gregory believes, doctors and patients should not hold back from using this “highly effective” treatment for opioid use disorder, since the data so far show that buprenorphine's benefits outweigh its potential risks.The opioid crisis sweeping several countries, including Canada, is responsible for countless emergency room visits, multiple hospital admissions and enormous expenses for the healthcare system, Dr. Gregory added.“It would therefore be very important to have drugs used more appropriately and more frequently in this patient population,” she said. “Our main goal is to try to increase the use of this drug, which has the potential to reduce opioid-related deaths and save healthcare dollars. We want to increase adoption of this drug, both by providers and patients.”This article has been translated from its original French.

Precipitous withdrawal? Research shows risk is low with buprenorphine for treating opioid use disorder

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