This month JC will look at the use of buprenorphine (BUP) and phenobarbital in patients presenting with opioid and alcohol withdrawal respectively. Admittedly, and despite being X-waivered, reviewing the White Paper published by AAEM made me feel like a textbook description of a clinician with inherent biases that prevent me from effectively treating this patient population. I encourage everyone to read this informative paper. One common misconception regards the safety profile of buprenorphine at higher dosing which has been shown to be more effective in select ED patients with opioid withdrawal syndrome (OWS). We will review a recent RCT in JAMA that specifically addresses this issue. 

Patients with alcohol use disorder and those particularly interested in “detox” awaiting psychiatric assessment often develop withdrawal symptoms that are ineffectively treated because of inadequate nursing resources available for timely reassessments. Most of us have limited familiarity using phenobarbital to manage alcohol withdrawal syndrome (AWS) despite its longer half-life, predictable bioavailability, and narrower effective dose range when compared to benzodiazepines. So, what are the barriers to using phenobarbital as an effective adjunct in treating AWS? We include two articles for consideration.

Tidwell WP et al., Treatment of Alcohol Withdrawal Syndrome: Phenobarbital vs CIWA-Ar Protocol. Am J Crit Care. 2018 Nov;27(6):454-460. Appraisal

 Herring AA et al., Managing Opioid Withdrawal in the Emergency Department With Buprenorphine. Ann Emerg Med. 2019 May;73(5):481-487. Appraisal & Overview

 Herring AA et al., High-Dose Buprenorphine Induction in the Emergency Department for Treatment of Opioid Use Disorder. JAMA Netw Open. 2021 Jul 1;4(7) Appraisal

 Articles of Additional Interest

Rosenson J et al., Phenobarbital for acute alcohol withdrawal: a prospective randomized double-blind placebo-controlled study. J Emerg Med. 2013 Mar;44(3):592-598

Strayer RJ et al., Management of Opioid Use Disorder in the Emergency Department: A White Paper Prepared for the American Academy of Emergency Medicine. J Emerg Med. 2020 Mar;58(3):522-546.