Psychotic Symptoms Following Buprenorphine Withdrawal

A 32-year-old man was referred to our department for buprenorphine withdrawal. He had been receiving buprenorphine, 6 mg/day, for 1 year. His medical and psychiatric history included past benzodiazepine and heroin abuse and buprenorphine misuse (12–24 mg/day by intranasal route) with concomitant crack use for 2 years. He reported having a psychotic disorder treated by aripiprazole (15 mg/day) for 12 months, which was discontinued last year by his psychiatrist while he was in jail. On admission, he presented no psychiatric symptoms and was receiving no treatment other than buprenorphine. His physical examination was normal, and a urinary drug screen was negative. We chose to gradually decrease the patient’s buprenorphine dose by 2 mg according to our standardized protocol. Three days after the first dose decrease, symptoms of opioid withdrawal occurred (anxiety, myalgia, sleep disturbance). Hydroxyzine, 150 mg/day, and loxapine, 100 mg/day, resulted in substantial symptom reduction, and buprenorphine was further decreased by 2 mg/day. Three days following this period, visual and auditory hallucinations, paranoid ideation, alternating phases of agitation, and prostration occurred. Loxapine was increased to 200 mg/day, and isolation partially improved the patient’s symptoms. We then decided to reintroduce buprenorphine at 6 mg/day, which is the same dose the patient had been receiving upon admission. The psychotic symptoms remitted in 24 hours. After a follow-up of 8 months, the patient was without psychotic symptoms but continued to receive buprenorphine (6 mg/day).