Emergency Severity Index (ESI) Guidelines for Managing Substance Withdrawals

Introduction to Substance Withdrawal Management

The Emergency Severity Index (ESI) triage system should incorporate standardized assessment tools for substance withdrawals, with validated scales like the Clinical Opiate Withdrawal Scale (COWS) for opioid withdrawal (score >8 indicating active withdrawal) and the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) for alcohol withdrawal (score >8 indicating moderate withdrawal, ≥15 indicating severe withdrawal) 1

Benzodiazepines are the gold standard treatment for alcohol withdrawal syndrome (AWS), with symptom-triggered regimens preferred over fixed-dose schedules to prevent drug accumulation 2
For benzodiazepine-naïve patients, start with 2 mg IV midazolam followed by an infusion of 1 mg/h if needed 2
Bolus doses should be titrated to symptoms with no specified dose limit; if a patient receives 2 bolus doses in an hour, consider doubling the infusion rate 2
For severe withdrawal refractory to benzodiazepines, consider barbiturates or propofol as second-line agents 3

Use the Clinical Opiate Withdrawal Scale (COWS) to evaluate withdrawal symptoms, with a score >8 indicating active withdrawal 1
Administer buprenorphine only when the patient shows active withdrawal symptoms (COWS >8) to avoid precipitated withdrawal 1
Initial buprenorphine dose should be 4-8 mg sublingually based on withdrawal severity, with maximum first-day total dose not exceeding 16 mg 1
Reassess after 30-60 minutes; provide additional doses if withdrawal symptoms persist 1
For discharge, prescribe buprenorphine/naloxone 16 mg SL daily for 3-7 days or until follow-up appointment 1
For patients on methadone maintenance, consider continuing methadone rather than switching to buprenorphine 1

Use a standardized scoring system to assess withdrawal symptoms 1, 4
For breakthrough anxiety or agitation, use the same benzodiazepine at the lowest effective dose rather than adding different medications 1, 4
Consider gradual tapering schedule with careful symptom monitoring, typically reducing the dose by 25% weekly for short-term users, or more gradually over several weeks to months for long-term users 4
Consider adjunctive treatments including carbamazepine, pregabalin, or paroxetine to facilitate tapering, though evidence is limited 4

Document baseline symptoms and medication history, including duration of use and daily dose 1
Record the rationale for each dose of medication administered during withdrawal management 1
Document withdrawal assessment scores using validated tools 1

Provide overdose prevention education and take-home naloxone kit to patients being discharged with opioid withdrawal 1
Arrange follow-up appointment within 3-7 days for patients discharged on buprenorphine 1
Refer patients to medication for addiction treatment programs for long-term management 1
Provide resources for community support and counseling services 1

Avoid administering buprenorphine to patients not yet in withdrawal, as this can precipitate severe withdrawal symptoms 1
Use caution when transitioning from methadone to buprenorphine due to risk of severe and prolonged precipitated withdrawal 1
Avoid fixed-dose benzodiazepine schedules, as symptom-triggered regimens prevent drug accumulation 2