Treating Opioid Withdrawal in the ED with Buprenorphine: A Bridge to Recovery
The Emergency Department (ED) is the frontline of the opioid crisis, treating patients with opioid-related infections, opioid withdrawal, and overdose. These encounters can be difficult or even downright confrontational. But that does not have to be the case! With the use of buprenorphine, we can “flip the script” for these encounters, encouraging patient-provider collaboration in the treatment of opioid addiction as medical disease.
A 25 year-old male presents to the ED complaining of left upper extremity pain, redness, and swelling. His cat bit him 2 days ago and his symptoms started today. On exam he has impressive induration, erythema, and warmth to the dorsum of the hand and forearm. He is neurovascularly intact and able to range his joints freely. In addition to IV antibiotics, you would like to keep his arm elevated while in the hospital. What is an easy and simple way help ensure that this patient keeps his arm elevated?
Emergency medicine (EM) is on the frontlines of climate change, which the Lancet Commission declared “the biggest global health threat of the 21st century” with “potentially catastrophic risk to human health.”
Ethanol withdrawal is a complex disease state. Two of the main players are GABA (an inhibitory neurotransmitter) and glutamate (an excitatory transmitter that can act on NMDA receptors). Simplistically, chronic ethanol use leads to a down-regulation of GABA receptors and an up-regulation in glutaminergic receptors, such as NMDA. When ethanol is abruptly discontinued, we are left with a largely excitatory state with less ability for GABA-mediated inhibition and more capacity for NMDA/glutamate-mediated excitation. While much of the treatment of severe ethanol withdrawal is focused on GABA, there are agents, such as phenobarbital and propofol, that can suppress the glutaminergic response. Ketamine seems like it should confer benefit, as well, due to its NMDA antagonist properties. Until recently there was only one clinical study using ketamine for severe ethanol withdrawal.
