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

opioid withdrawal

Care of Life in the Fast Lane

Clinical Opioid Withdrawal Scale (COWS) to assess candidacy for suboxone

COWS pdf

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:

  • 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

2. Assess for contraindications:

  • 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


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

Discharge orders:

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