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Registration date : 2008-11-09
 | | Subject: Buprenorphine Withdrawal in a Toddler Sun 30 Aug 2009, 1:38 am | |
| Buprenorphine Withdrawal in a Toddler
To the Editor:
A 2 year old, 13.4 kg female was transferred to our service
for opioid withdrawal. The patient was previously healthy
and met all of her developmental milestones. Her mother
had been surreptitiously administering two-thirds of a tablet
of 2 mg of buprenorphine daily since birth. Two days before
admission, the patient’s mother attempted suicide. In the
suicide note, she described giving the buprenorphine and
instructed the patient’s father to continue administering
the buprenorphine so the patient would not undergo
withdrawal.
The patient last ingested buprenorphine approximately 48
hours before admission. The father reported the patient had not
slept in the previous 24 hours, and had become increasingly
irritable and inconsolable for 12 hours before admission.
Despite measures to calm the patient, she became increasingly
irritable and agitated. She was taken to an emergency
department at an outside hospital. Her blood pressure was 89/
43 with a pulse rate of 118. She was afebrile. Her exam was
notable for crying, yawning, and piloerection. Her pupils were 4
mm. Her exam was otherwise normal. She was given 1 mg of
intravenous morphine, and all of her symptoms resolved. She
was transferred to our hospital.
Upon arrival in the pediatric intensive care unit, the
patient was again crying and agitated. Her blood pressure at
this time was 113/66, with a pulse rate of 154. The exam
again was notable for rhinorrhea, yawning, and piloerection.
Approximately 2.5 hours after the first dose of morphine was
given, an additional 1 mg of intravenous morphine was
administered, and her symptoms resolved. The patient was
started on 1 mg of oral methadone. Blood work, including a
complete blood count and a comprehensive metabolic
profile, were normal. A basic drug of abuse screen (enzyme
multiplied immunoassay technique [EMIT]) was negative
except for opiates and acetone. The opiates had been
administered at the outside hospital. The only additional
drug detected on a comprehensive urine drug screen, which
screens urine via thin layer chromatography with subsequent
gas chromatography/mass spectroscopy (GC-MS) for
confirmation, was methadone. This comprehensive drug
screen was obtained after methadone was administered.
The patient was initially maintained on 1 mg of methadone
daily. She was discharged on the third hospital day. The
methadone was successfully tapered over 5 weeks. The patient
tolerated the outpatient taper fairly well.
Acute withdrawal, including neonatal abstinence syndrome is
well-described in neonatal patients born to mothers using
buprenorphine.
1 However, to our knowledge, buprenorphine
withdrawal has never been described in children who themselves
were consuming buprenorphine.
In summary, we report a case of withdrawal from
buprenorphine in a young child, who presented to the
emergency department with irritability. The history provided
made the diagnosis easy in our case. However, we would like to
remind emergency physicians to consider the diagnosis of
opioid withdrawal in pediatric patients presenting to the
emergency department with irritability, with no other clear
etiology for their symptoms.
Volume
, . : September Annals of Emergency Medicine 477
Michael Levine, MD
Anne-Michelle Ruha, MD
Department of Medical Toxicology
Banner Good Samaritan Medical Center
Phoenix, AZ
Department of Medical Toxicology
Phoenix Children’s Hospital
Phoenix, AZ
doi:10.1016/j.annemergmed.2009.03.032
Funding and support:
By Annals policy, all authors are required to
disclose any and all commercial, financial, and other relationships
in any way related to the subject of this article that might create
any potential conflict of interest. The authors have stated that no
such relationships exist. See the Manuscript Submission Agreement
in this issue for examples of specific conflicts covered by this
statement.
1. Marquet P, Chevrel J, Lavignasse P, et al. Buprenorphine
withdrawal syndrome in a newborn.
Clin Pharmacol Ther.1997;62:569-571
Aris K. Exadaktylos, MD
University Department of Emergency Medicine
Inselspital Bern
University Hospital
Bern, Switzerland
doi:10.1016/j.annemergmed.2008.06.475
Funding and support:
By Annals policy, all authors are required to
disclose any and all commercial, financial, and other relationships
in any way related to the subject of this article that might create
any potential conflict of interest. The author has stated that no
such relationships exist. See the Manuscript Submission Agreement
in this issue for examples of specific conflicts covered by this
statement.
1. Green S.Trauma surgery: discipline in crisis.
Ann Emerg Med.
2009:53:198-207.
2. Exadaktylos A, Velmahos GC. Emergency medicine and acute care
surgery: a modern “Hansel and Gretel” fairytale?
Emerg Med J.
Posted by:Dee | |
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