Management of Opioid Withdrawal Syndrome and Commencement of Opioid Dependence Treatment Following Chronic Use of a Vaping Product Containing Protonitazene: Case Report.

INTRODUCTION

Nitazenes, benzimidazole synthetic potent opioid μ-receptor agonists, have been implicated in increased risk for opioid toxicity. Subtypes of nitazenes, including protonitazene, have been recently detected in multiple overdose cases in Australia. We describe a case report of protonitazene dependence, inpatient withdrawal management and induction onto opioid dependence treatment.

CASE PRESENTATION: A 22-year-old man with no significant medical history presented to a metropolitan emergency department in opioid withdrawal after regular vaping of a product sold as cannabinoids. He required higher than expected buprenorphine doses and other standard treatment including diazepam and olanzapine to manage opioid withdrawal. Blood and urine samples taken in the emergency department later tested positive for protonitazene. Analysis of the vaping liquid was only positive for protonitazene. He was discharged for outpatient follow-up to later receive a 300 mg subcutaneous buprenorphine monthly injection.

DISCUSSION AND

CONCLUSIONS

This case describes the clinical presentation of dependence, withdrawal and buprenorphine induction for opioid dependence due to chronic protonitazene vaping. Future research may help guide optimal doses of buprenorphine to manage nitazene withdrawal. Vaping devices have increased in popularity, especially amongst youth, which poses public health risks to the community if adulterated with other substances. Detection of nitazenes currently requires specialised laboratories. Protonitazene withdrawal management was complex in this case report. Youth are at risk of harms in vaping products adulterated with other substances, including nitazenes. State-wide toxicosurveillance programs, such as the NSW PRISE program, are essential for coordinating detection, clinical management and community awareness of nitazenes.