Precipitated Withdrawal 2.0: Outpatient Tips and Tricks

Following on last year’s successful presentation “Precipitated Withdrawal: When, Where, and What to do Next” at the 2021 ASAM Annual Scientific Conference, management of precipitated withdrawal in both acute care and outpatient settings remains not only relevant but also increasingly important for the safe and appropriate treatment of patients with opioid use disorder. During the previous presentation at ASAM, presenters discussed the basics of precipitated withdrawal including the pathophysiology, reviewed the existing medical evidence for various induction protocols, and management of precipitated withdrawal in the acute care setting. This session will expand upon the previous year topics into applying various induction protocols to the outpatient setting and will address management of precipitated withdrawal in the outpatient setting including use of telemedicine support and indications for referral to higher levels of care. As the current opioid epidemic grows, the number of patients presenting for management of opioid use disorder has increased. While access to buprenorphine in the emergency department and other acute care settings has increased, the need for outpatient management has grown in parallel. Since it is not always feasible for acute care settings to absorb the majority of medication induction needs, it is important to encourage medication initiation in the outpatient setting and for outpatient providers to have access to resources, understanding of various induction strategies for buprenorphine, as well as the techniques used to mitigate precipitated withdrawal. As fentanyl adulteration of heroin has become increasingly widespread questions remain for assessing the medical threshold for management of patients in various medical settings given the increasing risk for precipitated withdrawal when initiating buprenorphine in the era of widespread illicit fentanyl availability. Can we predict which patients are more likely to develop precipitated withdrawal? How does fentanyl use affect the timing and dose of buprenorphine initiation? How do the various buprenorphine induction protocols (including microdosing with sublingual formulations, strategies aimed at changing bioavailability, transdermal patch use, macrodosing, or subcutaneous buprenorphine) compare with the likelihood of precipitating significant withdrawal and to what degree? If precipitated withdrawal does occur, what patient characteristics or aspects of an outpatient setting could lead to successful outpatient management of precipitated withdrawal? For example, does precipitated withdrawal from fentanyl indicate the need for a different management setting or adjunctive mitigation strategies?Workshop attendees will be able to observe and participate in an engaging panel discussion of medical toxicology and addiction medicine experts on the risk, prevention, and management of precipitated opioid withdrawal in the outpatient setting. Participants will review several cases illustrating the complex decision-making surrounding this process and develop their practice management skills for the above questions. The expert panel will discuss cases and allow time for audience questions. Cases will involve complex scenarios ranging from precipitated withdrawal in patients using fentanyl versus heroin versus methadone to management of precipitated withdrawal in patients who self-administer buprenorphine. The panel will discuss which patients require transfer to a higher level of care and what ancillary staff or resources are needed for management in the outpatient setting.