Review Question - QID 218375

This patient presenting with early signs of alcohol withdrawal (tremulousness, anxiety) and mild opiate withdrawal (diarrhea) is given lorazepam for alcohol withdrawal and buprenorphine for opiate withdrawal. Buprenorphine administration can induce opiate withdrawal, presenting as lacrimation, piloerection, and vomiting.

Buprenorphine is a partial agonist at the mu opioid receptor with a strong affinity for the receptor. Therefore, buprenorphine will bind to and displace other opioids from the receptor. Because of its partial agonist effect, it will activate the opioid receptor below the effect seen with full agonists such as methadone. As such, buprenorphine can induce opioid withdrawal in patients after its administration. Opioid withdrawal presents with lacrimation, rhinorrhea, piloerection, myalgias, diarrhea, nausea, vomiting, mydriasis, and yawning. Buprenorphine is often used in the treatment of opioid dependence because it activates the mu opioid receptor with a lower likelihood of causing fatal respiratory depression. Other treatments for opioid dependence include methadone, a full mu opioid receptor agonist, and naltrexone, an antagonist of the mu opioid receptor.

Fareed et al. studied the effect of buprenorphine dosing on treatment outcomes for opioid dependence. The authors found that higher buprenorphine doses (16-32 mg/day) resulted in greater efficacy than lower doses (<16 mg/day). The authors recommended that higher buprenorphine doses be used in maintenance treatment for opioid dependence to improve efficacy.

Incorrect Answers:
Answer 1: Alcohol withdrawal presents with anxiety, restlessness, diaphoresis, and tremulousness. Moderate or severe withdrawal may present with hallucinations or seizures. Alcohol withdrawal can be life-threatening and should be treated with benzodiazepines. Thiamine supplementation should be initiated prior to glucose administration to prevent Wernicke encephalopathy. In contrast, yawning is specific for opiate withdrawal.

Answer 2: Anticholinergic toxicity presents with hyperthermia, altered mental status, tachycardia, flushing, dry mouth, constipation, urinary retention, and dry eyes. Common medications with anticholinergic side effects include antipsychotics, tricyclic antidepressants, and diphenhydramine. Neither lorazepam nor buprenorphine have anticholinergic effects.

Answer 3: Benzodiazepine overdose presents with somnolence, amnesia, and respiratory depression. Benzodiazepine overdose is treated conservatively, as the effects will wear off. Benzodiazepine overdose is unlikely in the setting of supervised administration for alcohol withdrawal, as medication administration and dosage is protocolized.

Answer 5: Delirium tremens is a severe form of alcohol withdrawal characterized by altered mental status, agitation, tachycardia, hypertension, fever, and diaphoresis. Delirium tremens occurs 48-96 hours after last alcohol intake and is life-threatening. Treatment is with benzodiazepines.

Bullet Summary:
Buprenorphine is a partial mu opioid receptor agonist with strong affinity for the receptor and can displace full opioid agonists, leading to opiate withdrawal.