OPIOID WITHDRAWAL

Question 1

Clinical Features

Answer 1

Agitation
Anxiety
Sweating
Yawning
Muscle Aches
Mydriasis
Tachycardia
Goosebumps
Abdominal Cramps
Vomit
Diarrhea
Urine

Question 2

DDx

Answer 2

Alcohol(s) withdrawal
Benzo withdrawal
Baclofen withdrawal
Barbituate withdrawal
Clonidine withdrawal
Sympthomimetic toxicity

Sepsis
Influenza

Question 3

Approach

Answer 3

Assess Severity with COWS
Assess Indications for buprenorphine / naloxone
Assess Contraindications
Monitor with COWS
Pharmacologic management:
Clonidine
Ativan
Bupenorphine
OR
Naloxone

Question 4

Indications for buprenorphine / naloxone

Answer 4

At least 12 hrs since last short acting opioid (e.g. Heroin, crushed OxyContin®, Percocet®)

At least 24 hrs since last long acting opioid (e.g. PO OxyContin®, OxyNeo®)

At least 72 hrs since last methadone dose

Question 5

Contraindications for Buprenorphine / Naloxone

Answer 5

Allergy or hypersensitivity to buprenorphine or naloxone
Decreased level of consciousness
Prescribed methadone or buprenorphine/naloxone
Inability to provide informed consent
Severe liver dysfunction
Acute alcoholism or delirium tremens
Acute severe respiratory distress
Paralytic ileus

Question 6

Monitoring parameters

Answer 6

COWS score q 2 hrs
Doscontinue if COWS < 5

Question 7

Buprenorphine/naloxone dosing

Answer 7

Buprenorphine/naloxone 2/0.5 mg X 2 tabs sublingual q2h for COWS greater than 12, max 2 doses.

 Buprenorphine/naloxone 2/0.5 mg X 1 tabs sublingual q2h for COWS greater than 12, max 4 doses.

Question 8

Clonidine Dosing

Answer 8

0.1 mg PO q 60 min PRN

Monitor for HoTN

Question 9

Ativan Dosing

Answer 9

2-4 mg PO / IV q 4 hr prn for first day