Buprenorphine for High-dose Tramadol Dependence: A Case Report of Successful Outpatient Treatment

Introduction: During the coronavirus disease 2019 pandemic caused by the severe acute respiratory syndrome coronavirus 2, deaths from opiate drug overdoses reached their highest recorded annual levels in 2020. Medication-assisted treatment for opiate use disorder has demonstrated efficacy in reducing opiate overdoses and all-cause mortality and improving multiple other patient-centered outcomes. Treatment of tramadol dependence in particular poses unique challenges due to its combined action as opioid agonist and serotonin-norepinephrine reuptake inhibitor. Tramadol puts patients with dependence at risk for atypical withdrawal syndromes when attempting to reduce use. Little evidence is available to guide treatment of tramadol dependence.Case Report: We present a case of high-dose tramadol addiction that began with misuse of medically prescribed tramadol for treatment of musculoskeletal back pain. The patient’s use reached oral consumption of 5000-6000 milligrams of illicit tramadol daily. She complained of common complications of tramadol use disorder including memory impairment, excessive sedation, and tramadol-induced seizures. The patient was referred to the emergency department in a withdrawal crisis seeking treatment where she was successfully managed with buprenorphine and phenobarbital and then linked to ongoing outpatient treatment.Conclusion: Our report adds to the limited guidance currently available on the acute management of tramadol withdrawal and treatment of tramadol use disorder. Our case suggests the initiation of high-dose buprenorphine may be an effective and feasible option for emergency clinicians

Interobserver agreement between emergency clinicians and nurses for Clinical Opiate Withdrawal Scale.

ObjectivesThe Clinical Opiate Withdrawal Scale (COWS) is a validated, commonly used tool to objectively quantify withdrawal symptoms, often in anticipation of treatment with buprenorphine. Our primary aim was to determine the agreement between emergency department (ED) nurses compared with emergency physicians in determining this score in ED patients who presented for opioid withdrawal treatment. Secondarily, we wanted to investigate the safety of buprenorphine induction in the ED setting.MethodsScoring for opioid withdrawal using the COWS was performed by ED clinicians and ED nurses independently on 120 patients. In addition to overall concordance, agreement (weighted kappa) was calculated between the 2 scores by various cutoffs: overall severity, COWS ≥ 5, and the 11 different individual measures. Patient documents also were reviewed for complications that could be possibly linked to buprenorphine induction.ResultsOur study sample of 120 subjects was 77% Hispanic and 78.3% male. The clinicians assigned a median interquartile range overall COWS score of 6 (2-12), which categorizes as mild withdrawal. Seventy-eight (65%) subjects met the criteria of withdrawal (≥ 5 COWS) and 69 (58%) received an induction dose of buprenorphine (range 2 mg-24 mg) during the ED visit. No adverse effects or worsening withdrawal were reported. The overall observed concordance, based on severity withdrawal categorization, for all clinician pairs, was 67.5% (81/120) (95% confidence interval [CI], 58.7-75.2%). The weighted kappa for that concordance was 0.55 (95% CI, 0.43-0.67), giving a moderate strength of agreement. When data are dichotomized by COWS score ≥5, concordance was 82.5% (99/120) (95% CI, 74.7%-88.3%) and the weighted kappa was 0.65 (95% CI, 0.51-0.78), indicating substantial agreement. The breakdown by the 11 factors that constitute COWS showed only substantial agreement for pulse measurement.ConclusionThe agreement between ED clinicians and nurses for the overall COWS scoring in patients presenting for opioid withdrawal treatment was substantial. COWS scoring by ED nurses may help expedite treatment with buprenorphine on presentation