This is EM Cases Best Case Ever 76 – Opioid Withdrawal
In anticipation of EM Cases Episode 116 on Opioid Misuse, Overdose and Withdrawal, Dr. Michelle Klaiman, Addictions and Emergency Medicine specialist, tells her Best Case Ever exemplifying how we can positively impact the lives of ED patients for years to come – even when they present with simple, run-of-the-mill diagnoses – by thinking outside the box and doing brief screening and interventions for patients with opioid use disorder. She discusses alternative pain control options as well as the use of suboxone to treat opioid withdrawal and opioid addiction.
Published by Anton Helman, October 2018
Features of Opioid Withdrawal
Clinical Opioid Withdrawal Scale (COWS) to assess candidacy for suboxone
Example protocol/order set for ED opioid withdrawal
Opioid(s) last used: _________________ Time opioid(s) last used: ____________
1. Assess indications for buprenorphine/naloxone:
Clinical Opioid Withdrawal Scale (COWS) > 12 and one of the following:
2. Assess for contraindications:
COWS score at presentation and q2h
Discontinue COWS when COWS less than 5
Notify MD to reassess patient when COWS less than 5 or when maximum buprenorphine/naloxone given
Use low dose buprenorphine/naloxone if elderly or risk of central nervous system or respiratory depression
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.
Observe patient until buprenorphine/naloxone is fully dissolved under the tongue
Acetaminophen 500-1000 mg PO q6h PRN for pain, max 4g in 24 hours
Ibuprofen 200-400 mg PO q6h PRN for pain
Ondansetron 4-8mg PO/IV q4h PRN for nausea
Provide patient with prescription, completed by MD.
Provide patient with information handout “Acute Opioid Withdrawal”
Fax referral to addiction medicine clinic if completed by MD