Management of Opioid Withdrawal

Assessment and Monitoring

The American College of Emergency Physicians recommends using a validated, standardized assessment tool, such as the Clinical Opiate Withdrawal Scale (COWS), to evaluate withdrawal symptoms in patients with opioid withdrawal, with a score of > 8 indicating active withdrawal 1, 2
Baseline symptoms and medication history, including duration of use and daily dose, should be documented for patients undergoing withdrawal management 2
The rationale for each dose of medication administered during withdrawal management should be documented, as recommended by the Society of Critical Care Medicine 3

The American College of Emergency Physicians recommends administering buprenorphine only when the patient shows active withdrawal symptoms (COWS > 8) to avoid precipitated withdrawal, with an initial dose of 4-8 mg sublingually 1, 4
The initial dose of buprenorphine should be based on the severity of withdrawal, with a maximum first-day total dose not exceeding 16 mg, as recommended by the American College of Emergency Physicians 1
Patients should be reassessed after 30-60 minutes, and additional doses may be provided if withdrawal symptoms persist, with a goal of reducing symptoms to a manageable level 1

The American College of Emergency Physicians recommends prescribing buprenorphine/naloxone 16 mg SL daily for 3-7 days or until follow-up appointment for patients being discharged with opioid withdrawal, along with overdose prevention education and a take-home naloxone kit 1
A sample discharge prescription is buprenorphine/naloxone 8 mg/2 mg SL tablet or film, take 2 tablets/films once daily in AM, dispense #6, no refills, as recommended by the American College of Emergency Physicians 1

The American College of Emergency Physicians recommends providing overdose prevention education and a take-home naloxone kit to patients being discharged with opioid withdrawal, as well as offering hepatitis C and HIV screening and reproductive health counseling 1

A standardized scoring system should be used to assess withdrawal symptoms in patients with benzodiazepine withdrawal, as recommended by the American Academy of Addiction Psychiatry 2
For breakthrough anxiety or agitation, the same benzodiazepine should be used at the lowest effective dose rather than adding different medications, as recommended by the American Academy of Addiction Psychiatry 2

Diazepam is preferred for moderate to severe alcohol withdrawal due to its rapid onset and long half-life, providing smoother withdrawal, as recommended by the Society of Critical Care Medicine 3
Bolus doses of diazepam should be titrated to symptoms, with no specified dose limit, and benzodiazepine-naïve patients should begin with 2 mg IV midazolam followed by an infusion of 1 mg/h if needed, as recommended by the Society of Critical Care Medicine 3

Buprenorphine should not be administered to patients not yet in withdrawal, as this can precipitate severe withdrawal symptoms due to its high binding affinity and partial agonist properties, as warned by the American College of Emergency Physicians 4
Particular caution should be used when transitioning from methadone to buprenorphine due to the risk of severe and prolonged precipitated withdrawal, as warned by the American College of Emergency Physicians 4
Patients on methadone maintenance should be considered for continued methadone rather than switching to buprenorphine, as recommended by the American College of Emergency Physicians 1
Individualized approaches are necessary for patients with complicating factors, such as pregnancy, chronic opioid therapy for pain, anticipated surgery, liver disease, or respiratory failure, as recommended by the American College of Emergency Physicians 1

A follow-up appointment should be arranged within 3-7 days for patients discharged on buprenorphine, as recommended by the American College of Emergency Physicians 1
Patients should be considered for referral to medication for addiction treatment programs for long-term management, as recommended by the American College of Emergency Physicians 1, 4
Resources for community support and counseling services should be provided to patients, as recommended by the Society of Critical Care Medicine 5