Precipitated Withdrawal, Delirium, and Cerebellar Stroke: The Pharmacology of Buprenorphine Induction in Non-pharmaceutical Fentanyl and the Neuropsychiatric Manifestations of Cerebellar Stroke

K.I. is a 61-year-old, intermittently homeless Caucasian male with a history of alcohol use disorder, opioid use disorder (OUD), peripheral arterial disease status post aortofemoral bypass graft complicated by persistent hernia, hypertension, and hepatitis C status post treatment with ledipasvir/sofosbuvir who initially self-presented to an inpatient psychiatric unit for voluntary admission for a medically supervised withdrawal from both opioids and alcohol on hospital day (HD) 1. K.I. stated he had last used alcohol 48 hours prior to admission and noted using intravenous (IV) heroin and fentanyl right before presenting to the facility. A urine toxicology screen was positive for both opioids and fentanyl with a positive fentanyl confirmation test, and although urine alcohol level was negative, he had a positive ethyl glucuronide test. While admitted for withdrawal management, K.I. was monitored with clinical opioid withdrawal scale (COWS) and clinical institute withdrawal assessment of alcohol scale (CIWA). On HDs 1 4, his CIWA scores ranged from 0 to 3, and the patient received only one dose of oxazepam 15 mg as part of the facilities protocol but did not require any additional benzodiazepines for suspected GABAergic withdrawal. His COWS scores on HDs 1 4 ranged from 0 to 6, for which he received doses of ibuprofen 600 mg and clonidine 0.1 mg, with subsequent reduction in his COWS. The treatment team had made a plan for induction of buprenorphine/naloxone (hereinafter buprenorphine) on HD 4. K.I. stated he had been on buprenorphine a few months prior but had fallen out of treatment andwas interested in restarting as he had been able tomaintain sobriety for several yearswhile on it.On the day of induction, HD4, K.I. scored onCOWS5 atmidnight, 6 at 6:40 am, and 4 at 8:37 am, primarily scoring for sweating, tremor, and anxiety. His last use of fentanyl and heroinwere right before presenting atmidnight onHD1, and his induction wasHD4 at 10:53 am(approximately 59 hours later). During his admission, there was no overt evidence of opioid misuse while at the facility (he was on a locked unit), no concern for his obtaining outside opioid medications from other patients, and no appearance of being intoxicated to explain why his COWS scores remained low.