What can we learn from buprenorphine precipitated withdrawal in the ED/hospital? A 🧵 @AustinKilaru @JMPerroneMD @kit_delgadoMD @m_lowenstein @especially_APT @JACEPOpen @NIDAnews @PennMedicine #emergencymedicine #toxtwitter 
#1 Check those COWS Scores. 4 out of 13 cases of PW, got bupe for COWS scores of less than 8 (see below). Also important to check COWS scores shortly after getting bupe to make sure they are actually getting better. Great place for ordersets to improve care
#2 PW from traditional bupe inductions is real! Definitely a concern in the fentanyl era. We had patients develop PW after greater than 12 hours (sometimes even longer) since last opioid use. people who use fentanyl might be at higher risk
#3 There is still a lot we don't know about PW! Some got better with additional bupe, some didn't. Some of what treating clinicians called PW, didn't actually have worsening COWS scores and was probably protracted withdrawal (which still sucks for patients)
#4 we have to work with our patients going through PW. Many ended up having early patient directed discharges (AMA). Not great when many were also being admitted for other reasons than their PW. I believe this an area where adjunctive meds can help
#5 Finally EM, hospitalists, generalists of all sorts should not be afraid of rx'ing bupe, especially now that the #xwaiver is gone. despite all this 7/13 patients were discharged with buprenorphine, and it is truly a life-saving med in OUD.
Lots of questions remaining re: role of micro vs macro dose, optimal COWS cutoffs, how #xylazine plays into all this, how best to treat PW when it happens
Also want to include the Twitter-less Sophia Faude who did amazing work and made major contributions to this paper
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