Case Review: Suboxone Overdose and Treatment

[Catticus11]

23-year-old male with history of polysubstance abuse, particularly benzodiazepines, heroin and cocaine. Mother brought patient into the ED and patient collapsed in ED waiting room. He was administered 2mg IVP Narcan x2 which made him arouse. Patient was in ED room where he was being monitored by security, he asked to use the commode where the security gave him privacy. During this moment of privacy, he pulled out a balloon from his rectum which he admitted to being "2 bundles of suboxone" which he snorted and then proceeded to get back into bed (after stealing a bunch of IV start kits from the nearby cart). Patient was found nonresponsive again and hypoxic with an O2 saturation in the 70s. He was manually bagged, given IVP Narcan x2, before being started on a Narcan gtt. Patient was then placed on a NRB before I came down to bring him up to ICU. His VSS on NRB, but only responsive to painful stimuli.

Labs:

Urine positive for Cocaine and benzodiazepines.

Urine negative for opiods

BAC 0.03

Lactate 1.7

ABG (after being on NRB for 30 minutes): pH 7.37, PCO2: 57, PO2 >500, HCO3 27

On arrival to the ICU, he remained only responsive to painful stimuli for 6hours. He remained on the Narcan gtt with NS at 125mL/hr. The Narcan gtt is titratable but it had already been titrated up so high that I clarified with the MD if he wanted me to continue to titrate up. MD declined, said to keep the Narcan gtt at its current rate, and that he did not want to pursue any further action or administer anything. I verified that he aware of patient urine being positive for cocaine and benzos, and that MD acknowledged and clarified that he wanted no further action for this patient.

After reviewing ABG, patient was changed over to 3 L via NC, and VS remained stable for the rest of the night. Patient placed on CIWA protocol (though nothing ordered PRN) for which patient didn't score.

When patient aroused, he was drowsy but could recall the events of the night. He started that the previous day he took "benzos, 2 tabs of acid, suboxone" and then "2 bundles of suboxone" when he was left alone with the commode. He began stating that he needed subozone and benzodiazepines to function due to his history of anxiety disorder and agoraphobia, and he takes it everyday. He began trying to take out his IVs and wanted to go home, however he made him aware that he couldn't leave for the sake of his safety for which the patient reluctantly agreed. MD discontinued Narcan gtt and wanted to order no further action.

My question: Was this handled correctly? I'm normally in the CCU, so this whole thing is new to me.

[MunoRN, RN]

My understanding of suboxone, which is admittedly limited, is that overdose symptoms are not typically due to the suboxone, but usually due to another substance in combination with the suboxone, often benzos. Narcan usually isn't of much use in a patient who's taken both suboxone and benzos, keep in mind that suboxone contains narcan, and the purpose of it is to generally occupy opiate receptors without causing the euphoria and CNS depression that comes with full opiate agonists. This is why it can be difficult to treat acute pain in hospitalized patients who take suboxone (ie a suboxone patient who's now a trauma patient).

In my experience the first step would be to reverse the benzos, not the suboxone.

[Catticus11]

I have a very limited knowledge on Suboxone and it's effect. But with the positive urine That's what I was thinking too, but the MD got annoyed with me when I suggested it because of his history of benzo addiction. Again, this whole thing was very new to me.

[offlabel]

Reversing benzodiazepines in an addict is pretty dangerous. If the kid was breathing OK, better just to let him sleep it off, which he apparently did.

[nrsang97, BSN, RN]

I agree with Off Label. Treating with romazican to reverse benzos is rsiky. Better to let him sleep it off.