Buprenorphine/Naloxone Toxicity Follow-up

Updated: Dec 29, 2015
  • Author: Timothy J Wiegand, MD; Chief Editor: Asim Tarabar, MD  more...
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Follow-up

Further Outpatient Care

The prescribing physician (OBOT provider) should be notified in all cases of exposure to Suboxone.

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Further Inpatient Care

Any symptomatic patient with Suboxone exposure will need prolonged monitoring until symptoms have been absent for at least 8 hours to avoid recurrence, particularly after naloxone administration.* Patients' respiratory and cardiovascular status should be monitored throughout.

An asymptomatic patient, in particular, a pediatric exposure, should be monitored for 6-8 hours.* If no signs of respiratory depression, nausea, or vomiting or decreased level of consciousness is manifest, the patient may be safely discharged to caregivers.

*Subtle signs and symptoms from Suboxone exposure may be difficult to detect in pediatric patients and some experts recommend even longer periods of observation, up to 24 hours, to ensure patient safety.

Patients with an overdose must be evaluated from a psychiatric point of view.

All pediatric exposures should be referred for assessment by the Department of Health and Human Services (DHHS).

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Transfer

If unable to provide adequate monitored settings, transfer the patient to the institution with the higher level of care. Patients with intentional exposure have to be evaluated by psychiatric service prior to discharge.

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Deterrence/Prevention

Parents who are enrolled in buprenorphine treatment should be educated how to store medication safely and how to prevent drug exposure to children at home.

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Complications

Intravenous abuse of Suboxone preparation

Intravenous drug abuse (IVDA) carries an additional list of complications. Cellulitis and abscesses are frequent complications of intravenous drug abuse (IVDA), and staphylococcal or streptococcal bacteria are typical organisms cultured from infections; however, anaerobic bacteria may be seen.

  • Hematogenous dissemination of bacteria, commonly to the epidural space, can cause spinal epidural abscess. This also may occur from spread of vertebral osteomyelitis, and Staphylococcus aureus is the most common organism causing this type of infection. Gram-negative bacilli may be observed as well.
  • Osteomyelitis in IVDA is well known; if a patient with long-term IVDA presents with back pain, this diagnosis should be added to the differential.
  • Site-specific sequelae, such as Horner syndrome from patients injecting into the neck region, may be observed.
  • Particulate matter poses a threat because of embolic phenomena. Pulmonary emboli and peripheral emboli are two common complications. Thrombi initiated by vessel intimal damage from the needle may lead to similar syndromes. Inadvertent intra-arterial injection is another potential complication, possibly resulting in necrosis of the affected extremity. Intraneural injection may cause transient or permanent neuropathy.
  • Endocarditis is one of the most serious complications of IVDA. The diagnosis is difficult to make in the ED and requires a high index of suspicion. Although either side of the heart may be affected, the right side, particularly the tricuspid valve, is involved more commonly than the left. Murmurs may be heard. Repeated septic pulmonary emboli may be the only presenting signs. S aureus is commonly the etiologic agent. Left-sided endocarditis can result from a variety of bacterial pathogens, including Escherichia coli or Streptococcus, Klebsiella, or Pseudomonas species. Physical examination findings consistent with endocarditis are observed more frequently in left-sided disease than in right-sided disease.
  • Necrotizing fasciitis is a life-threatening infection that is characterized by septic necrosis. A dusky, erythematous, tender, confluent rash that spreads rapidly and is associated with fever, chills, tachycardia, tachypnea, and leukocytosis should prompt aggressive resuscitation, aggressive therapy, and surgical consultation.
  • Pneumonia is common in IVDU. Normal pathogens should be considered, but aspiration should be added in patients who have been unconscious. Tuberculosis should be added to the differential diagnosis early to avoid unnecessary exposure to health care workers and other patients and to ensure timely and adequate treatment.
  • HIV and HCV should be considered in all patients who have a history of IVDU. [23]

Complications related to general opioid effects

See the list below:

  • Rhabdomyolysis, with or without a compartment syndrome, may occur in patients who have experienced a potentially long period of unconsciousness.
  • Acute lung injury or noncardiogenic pulmonary edema may be seen in patients who present with an opioid overdose, although it is likely less common in regard to a Suboxone overdose. The etiology of this injury is unclear and may be related to hypoxia, the opioid overdose in and of itself, the catecholamine surge precipitated by use of naloxone, or it may be multifactorial. In any event, care is supportive, and the condition typically improves within 24-48 hours. Diuretics or mannitol are not useful and may cause intravascular volume depletion or worsen hypotension.

Withdrawal syndrome

See the list below:

  • Typical signs and symptoms of the opioid withdrawal syndrome include diarrhea, yawning, hypersensitivity to any pain, cramps and aches, pupillary dilation, and sweating. A withdrawal syndrome may be experienced upon discontinuation of buprenorphine preparations; however, it is significantly less severe and of shorter duration than withdrawal associated with other full opioid receptor agonists.
  • Administration of buprenorphine may precipitate a withdrawal syndrome in individuals dependent on full opioid agonists such as methadone, morphine, or heroin.
  • Significant withdrawal symptoms more likely may occur in patients treated with higher doses of methadone (>30 mg) and after administration of the first buprenorphine dose in proximity to the last methadone dose.
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