Rates of Precipitated Withdrawal in a Trial of ED–Initiated Buprenorphine for Opioid Use Disorder—Reply

Abstract

In Reply We appreciate the opportunity to respond to comments by Drs Morris and Adams related to the low rate of precipitated withdrawal (<1%) in our recently published article, noting that 40% of the study patients had baseline urine toxicology positive for buprenorphine. We agree with Morris and Adams that even if all participants with buprenorphine-positive urine were excluded, the rate of precipitated withdrawal would remain very low. Of note, 1 of the 14 patients with precipitated withdrawal had buprenorphine in their urine. We appreciate the reference by Morris and Adams to their local population, few of whom report recent use of diverted buprenorphine, and we note the importance of knowing local phenomena and considering urine testing when initiating buprenorphine. However, the prospective nature of our study and the use of an a priori operational definition for precipitated withdrawal, with adjudication, improve rigor over anecdotal reports and retrospective case series. To our knowledge, there are no other large prospective trials that have reported precipitated withdrawal rates in the setting of fentanyl use. We observed that regardless of the presence of buprenorphine, people who used daily fentanyl who were carefully evaluated and met the described clinical criteria, including objective signs of withdrawal, could have buprenorphine initiated safely with low rates of precipitated withdrawal. Additional buprenorphine doses and ancillary medications were readily available (Supplement 2 of the article), and this may not be true in other, non-ED settings.