Eduovisual
Behavioral Health
Opioid withdrawal: COWS and management
— Encountered across ED, inpatient medicine, surgical wards, OB triage, and primary care — especially when home opioids (prescribed or illicit) are interrupted by hospitalization.
— With rising fentanyl prevalence in the US illicit supply, withdrawal onset is faster and more severe than classic heroin pictures.
— A frequent cause of AMA discharge if untreated, with direct mortality consequences (overdose post-discharge).
— Hospitalized patient on chronic opioids whose home dose was held.
— Patient with known OUD (opioid use disorder), recent incarceration, post-detox, or recent naloxone administration.
— Pregnant patient with restlessness, cramping, vomiting → suspect withdrawal before labeling as hyperemesis.
— Neonate ≥24–72 h of life with hypertonia, high-pitched cry → neonatal opioid withdrawal syndrome (NOWS).
— Post-op patient on tolerance-level home opioids now getting only short-acting PRN dosing.
— Short-acting (heroin, oxycodone, fentanyl): onset 6–12 h, peak 36–72 h, resolves 5–7 d.
— Methadone: onset 24–48 h, peak 3–5 d, lingers 2–3 weeks.
— Buprenorphine: onset 24–48 h, milder, 7–14 d.
Board pearl: A patient who "left AMA" after starting withdrawal in the ED has a markedly elevated 30-day overdose death risk — treat withdrawal aggressively and link to MOUD before discharge, not after.
— Autonomic: yawning, lacrimation, rhinorrhea, sweating, piloerection ("cold turkey"), mydriasis.
— GI: nausea, vomiting, diarrhea, abdominal cramping, anorexia.
— Musculoskeletal: myalgias, arthralgias, restless legs, low back pain, "bone pain."
— Neuropsychiatric: anxiety, dysphoria, irritability, insomnia, drug craving.
— Sensory: hyperalgesia — minor stimuli feel severely painful.
— Last use: drug, route (IV, intranasal, smoked, oral), dose, time of last dose. Fentanyl smoked from foil is now the dominant pattern in many regions.
— Tolerance markers: daily morphine milligram equivalents (MME), use of multiple agents, prior overdoses, prior naloxone reversals.
— Treatment history: prior methadone, buprenorphine, or naltrexone trials; reasons for discontinuation; last dose date.
— Co-use: benzodiazepines, alcohol, stimulants (cocaine, methamphetamine), xylazine ("tranq") — affects withdrawal picture and risk.
— Psychosocial: housing, pregnancy status, custody issues, incarceration history, prior AMA, infectious risks (HIV, HCV, endocarditis).
— Day 2 hospitalized patient on chronic oxycodone develops anxiety, diarrhea, dilated pupils → iatrogenic withdrawal from held home opioids.
— Post-naloxone ED patient who was just revived is suddenly diaphoretic, vomiting, combative → precipitated withdrawal, manage symptomatically; do NOT re-sedate with more opioids reflexively.
— Patient on buprenorphine who used fentanyl 4 h ago now feels worse after a clinic dose → precipitated withdrawal from partial agonist displacing full agonist.
Key distinction: Opioid withdrawal has mydriasis, rhinorrhea, lacrimation, piloerection, hyperactive bowel sounds. Opioid intoxication has miosis, hypopnea, hypoactive bowel sounds, sedation. Pupils are the fastest bedside discriminator — but fentanyl-era patients may have intermediate pupils due to mixed states.
— Mild–moderate tachycardia (HR 90–110), mild hypertension, low-grade temperature elevation, tachypnea.
— Red flags suggesting alternate or comorbid diagnosis: HR >120 sustained, T >38.5°C, SBP >180, AMS, neck stiffness, focal neuro deficits, hypoxia.
— Mydriasis (often 5–7 mm, reactive), lacrimation, rhinorrhea, frequent yawning.
— Dental decay, oral abscesses in chronic users.
— Piloerection ("gooseflesh"), diaphoresis, track marks, abscesses, cellulitis, xylazine-associated necrotic ulcers (often on extensor surfaces, can occur at non-injection sites).
— Examine for endocarditis stigmata: Janeway lesions, Osler nodes, splinter hemorrhages, new murmur.
— Tachycardia regular; new murmur → think tricuspid endocarditis in IVDU.
— Clear lungs unless aspiration from vomiting or septic pulmonary emboli.
— Hyperactive bowel sounds, diffuse cramping tenderness without peritoneal signs. Frank peritonitis demands alternate workup.
— Tremor, restless legs, hyperreflexia possible. Clonus and rigidity suggest serotonin syndrome rather than pure withdrawal — important if patient is on tramadol, fentanyl + SSRI, or linezolid.
— Anxious, dysphoric, but alert and oriented. AMS is NOT typical of uncomplicated opioid withdrawal — search for sepsis, intoxication, hypoglycemia, Wernicke's.
Step 3 management: When hemodynamics exceed "mild surge" or AMS appears, broaden workup. Don't anchor on withdrawal — comorbid sepsis, endocarditis, intracranial bleed (after fall), or alcohol/benzo withdrawal can hide inside the picture. Order CBC, BMP, lactate, blood cultures, and consider CT head if any trauma history or focal findings.
— Resting HR (0–4), sweating (0–4), restlessness (0–5), pupil size (0–5), bone/joint aches (0–4), runny nose/tearing (0–4), GI upset (0–5), tremor (0–4), yawning (0–4), anxiety/irritability (0–4), gooseflesh skin (0–5).
— 5–12: mild — supportive care, consider symptomatic meds, monitor.
— 13–24: moderate — initiate buprenorphine induction safely; methadone an alternative in inpatient/OTP setting.
— 25–36: moderately severe — buprenorphine appropriate; aggressive symptom control.
— >36: severe — rare; reassess for comorbid illness.
— Reassess COWS every 1–2 hours during active management; document trend.
— Score reflects objective + subjective components; restlessness and anxiety dominate scoring in mild cases.
— For buprenorphine induction, traditional teaching requires COWS ≥ 8–12 to avoid precipitated withdrawal — increasingly modified in fentanyl era (see chunk 7).
— CBC — leukocytosis suggests infection, not withdrawal.
— BMP — hypokalemia, hyponatremia, AKI from vomiting/diarrhea.
— LFTs — baseline for naltrexone candidacy and to screen HCV-associated injury.
— Magnesium, phosphorus — replete; low Mg worsens cramping and arrhythmia risk.
— Lactate if vital sign abnormal or ill-appearing.
— β-hCG in all reproductive-age women — changes management (methadone or buprenorphine indicated; avoid clonidine monotherapy).
— UDS with fentanyl and methadone-specific assays (standard opiate immunoassay misses both); also screen benzo, cocaine, methamphetamine, xylazine if available.
— ECG if methadone planned or if tachycardia warrants — baseline QTc.
Board pearl: A standard "opiates" immunoassay screens for morphine/codeine and may be negative in fentanyl, methadone, oxycodone, and buprenorphine users. Always order the expanded panel or specific assays when OUD is suspected.
— GC/MS or LC-MS/MS confirms specific opioids and metabolites. Useful in custody, pain contract, OB, or pediatric exposure contexts.
— Fentanyl analog panels (acetylfentanyl, carfentanil) increasingly relevant — fentanyl can persist in urine 5–7+ days in chronic users due to lipophilic redistribution, complicating buprenorphine induction timing.
— Methadone metabolite EDDP distinguishes therapeutic adherence from spiking.
— HIV (4th gen Ag/Ab), HCV Ab with reflex RNA, HBV serologies (sAg, sAb, cAb).
— Syphilis RPR/treponemal.
— TB screening (IGRA) — especially if homeless, incarcerated.
— Pregnancy testing + STI panel as indicated.
— Blood cultures × 2 and TTE if fever, new murmur, or septic emboli concern → rule out endocarditis.
— Methadone: baseline QTc, repeat at 30 days and annually; more often if dose >100 mg/d or QT-risk meds (azoles, ondansetron, fluoroquinolones, methadone + cocaine).
— Concern for TdP if QTc >500 ms.
— CXR if cough, hypoxia, or aspiration concern.
— CT head if any AMS, trauma, or focal deficit.
— Echo if endocarditis suspicion in IVDU.
Key distinction: A negative urine "opiate" screen does not rule out OUD or withdrawal. Diagnosis is clinical (history + COWS); labs corroborate and risk-stratify.
— Treat acute withdrawal so the patient doesn't suffer or leave AMS/AMA.
— Initiate medication for OUD (MOUD) — buprenorphine or methadone — during the same encounter whenever possible.
— Engage and link to longitudinal care before discharge.
— Outpatient/clinic: mild–moderate COWS, stable vitals, no comorbid acute illness → buprenorphine induction in office or home-induction protocol with clinician support.
— ED: moderate–severe COWS → start buprenorphine in ED ("ED-initiated bup"), now standard of care; gives 30-day retention benefit. Bridge prescription + warm handoff to clinic within 72 hours.
— Inpatient (admitted for unrelated medical reason): address withdrawal proactively; consult addiction medicine if available; this is a "reachable moment" with strong evidence for MOUD initiation.
— Incarcerated/jail intake: mandatory continuation of MOUD per emerging legal precedent in many states.
— Buprenorphine: office-based, partial agonist, ceiling on respiratory depression, safer in overdose; preferred for most. No X-waiver required (eliminated 2023).
— Methadone: for severe tolerance, fentanyl users struggling with bup induction, pregnancy preference per patient, or prior bup failure; can be initiated inpatient for any indication, but maintenance requires a federally licensed Opioid Treatment Program (OTP).
— Naltrexone (XR-injectable): only after 7–10 days opioid-free; not for acute withdrawal; risk of precipitated withdrawal and overdose if relapse.
Step 3 management: Every OUD encounter should end with (1) MOUD started or prescribed, (2) take-home naloxone, (3) follow-up appointment, (4) harm reduction counseling — these are the four discharge "vitals."
— Mechanism: high-affinity partial mu-agonist + kappa antagonist. High affinity displaces full agonists → precipitated withdrawal if given too early.
— Traditional induction: wait until COWS ≥ 8–12 and last short-acting opioid use ≥ 12–16 h (or ≥ 24–48 h for methadone). Start 2–4 mg SL, reassess in 1–2 h, redose 2–8 mg as needed. Day 1 target 8–16 mg; maintenance typically 16–24 mg/d (max 32 mg/d).
— Low-dose ("micro") induction: for fentanyl users or those who can't tolerate withdrawal — start 0.5 mg daily, uptitrate over 5–7 days while continuing full agonist; avoids precipitation. Increasingly favored.
— High-dose ED induction: 16–32 mg loading in ED has emerging evidence for fentanyl-tolerant patients.
— Formulations: SL film/tab (Suboxone = bup/naloxone), monthly extended-release SC injection (Sublocade) after ≥7 days of stable SL dosing.
— Mechanism: full mu-agonist, long half-life (15–60 h), also NMDA antagonist.
— Inpatient withdrawal protocol: start 10–20 mg PO, reassess q2–4 h, additional 5–10 mg PRN. Day 1 max typically 30–40 mg; titrate up over days.
— Maintenance dose usually 60–120 mg/d via OTP.
— Cautions: QT prolongation, drug interactions (CYP3A4), accumulation risk in first 2 weeks — most methadone deaths occur during induction.
— Clonidine 0.1–0.2 mg q4–6 h PRN (hold for SBP <90) — autonomic symptoms. Lofexidine is an FDA-approved alternative.
— Ondansetron for nausea, loperamide for diarrhea (watch dose — high-dose causes QT/arrhythmia and is itself abused), dicyclospasmolytic for cramps, NSAIDs/acetaminophen for myalgias, trazodone or hydroxyzine for sleep, gabapentin cautiously for restlessness.
— Avoid benzodiazepines unless treating concurrent alcohol/benzo withdrawal — overdose risk.
Board pearl: Naloxone in Suboxone is poorly bioavailable sublingually; it deters IV misuse but does not blunt the buprenorphine effect when taken correctly.
— Occurs when buprenorphine or naloxone/naltrexone displaces a full agonist → abrupt severe withdrawal within 30–90 min.
— Counterintuitive but evidence-supported: give MORE buprenorphine, not less. Dose 8–16 mg SL rapidly, repeat q1–2 h up to 32 mg/day. Saturating receptors with the partial agonist resolves symptoms.
— Add clonidine, ondansetron, IV fluids, ketorolac as adjuncts.
— Avoid giving a full agonist on top of buprenorphine — won't bind effectively and risks delayed respiratory depression once bup wanes.
— Short-lived (30–90 min as naloxone wears off); supportive care, observe for re-sedation as opioid outlasts naloxone — especially fentanyl, methadone, sustained-release oxycodone.
— Don't re-narcotize; offer buprenorphine induction once COWS rises.
— Pure mu-antagonist. Requires 7–10 days opioid-free (10–14 for methadone) before initiation.
— Naloxone challenge can confirm opioid-free state before XR injection.
— Good for highly motivated patients, those in monitored programs, or post-incarceration.
— Key risk: overdose if relapse due to lost tolerance. Counsel and provide take-home naloxone.
— Continue buprenorphine through surgery in most cases; multimodal analgesia + short-acting full agonists for acute pain on top.
— Continue methadone at home dose; add separate analgesics for surgical pain — never count methadone toward analgesia.
— Coordinate with anesthesia and pain service preoperatively.
— Methadone + QT-prolonging agents → TdP.
— Buprenorphine + benzodiazepines → respiratory depression (use with caution but don't withhold MOUD solely for benzo co-use — risk of untreated OUD is higher).
— CYP3A4 inducers (rifampin, phenytoin) → withdrawal on stable methadone.
Step 3 management: Post-naloxone ED patient who is now in withdrawal — induce buprenorphine in the ED, give naloxone kit, schedule clinic in 72 h. Do not discharge to "follow up with PCP next week."
— Often iatrogenic OUD from chronic pain prescriptions; underdiagnosed.
— Lower tolerance, more comorbidities (CAD, CKD, falls); withdrawal may unmask angina, CHF decompensation, or arrhythmia due to sympathetic surge.
— Use lower starting doses of buprenorphine (2 mg increments) and titrate slowly.
— Avoid clonidine if orthostasis or symptomatic bradycardia; if used, monitor BP closely and counsel on rebound HTN with abrupt stop.
— Screen for cognitive impairment affecting consent and adherence; consider involving caregiver/PCP.
— Polypharmacy: review for QT-prolonging, sedating, anticholinergic agents.
— Buprenorphine is metabolized hepatically with minimal renal excretion → no dose adjustment in CKD or ESRD. Preferred MOUD in renal failure.
— Methadone is also predominantly hepatic; safe in renal failure, no dose adjustment, not removed by hemodialysis — useful pearl.
— Morphine and codeine metabolites (M6G, M3G) accumulate in renal failure → toxicity; avoid in chronic pain in CKD.
— Naloxone: short half-life, generally safe; may need redosing.
— Adjust gabapentin, pregabalin for renal function if used adjunctively (high overdose-co-substance risk — counsel).
— Both buprenorphine and methadone are hepatically metabolized; mild–moderate cirrhosis generally tolerates standard doses, but severe hepatic impairment (Child-Pugh C) warrants dose reduction and addiction-medicine input.
— Monitor LFTs at baseline and periodically — buprenorphine-associated transaminitis is mild and usually doesn't require discontinuation.
— Naltrexone is hepatotoxic at high doses — avoid in acute hepatitis or hepatic failure; relative contraindication, not absolute, at standard doses.
— Comorbid HCV is the norm — treat with DAAs; coordinate with hepatology. SUD is not a contraindication to HCV treatment.
Key distinction: In ESRD on hemodialysis, buprenorphine and methadone need no dose adjustment, but morphine, codeine, and meperidine should be avoided due to active metabolite accumulation causing prolonged sedation and seizures (meperidine → normeperidine).
— MOUD is standard of care. Untreated OUD → preterm birth, IUGR, abruption, fetal demise, overdose. Detoxification is NOT recommended during pregnancy — high relapse and overdose risk.
— Methadone and buprenorphine are both first-line; counsel on tradeoffs:
— Methadone: more data, daily OTP visits provide structure; higher NOWS severity.
— Buprenorphine: less severe NOWS, fewer treatment days for neonate; office-based access.
— Buprenorphine monoproduct (Subutex) vs combo (Suboxone): historically monoproduct preferred in pregnancy, but current ACOG/SAMHSA endorse either; combo is fine.
— Dose increases often needed in 3rd trimester due to increased clearance and volume; do not under-dose out of fetal concern.
— Naltrexone: limited data; can be continued if patient was stable on it pre-pregnancy after shared decision.
— Coordinate MFM, addiction medicine, pediatrics, social work prenatally.
— Onset 24–72 h (later for methadone, up to 5–7 d).
— Signs: high-pitched cry, hypertonia, tremor, poor feeding, sneezing, loose stools, fever.
— Scoring: Finnegan or ESC (Eat-Sleep-Console) — ESC reduces pharmacotherapy and LOS.
— First-line pharmacotherapy when needed: morphine or methadone; clonidine adjunct. Breastfeeding is encouraged on stable bup/methadone (helps NOWS, transfers minimal drug).
— Rising fentanyl exposures; treat with buprenorphine (FDA-approved ≥16 yr).
— Confidentiality and consent rules vary by state; family engagement when feasible.
— Screen mental health comorbidities — depression, ADHD, trauma.
Board pearl: In a pregnant patient presenting with COWS 14 and rhinorrhea, start buprenorphine or methadone in the hospital; do NOT taper to abstinence and do NOT give naltrexone — fetal stress from withdrawal and relapse overdose are the real dangers.
— Dehydration, hypokalemia, hypomagnesemia, metabolic acidosis from vomiting/diarrhea.
— Aspiration pneumonia in severe vomiting, especially with altered mental status from comorbid intoxication.
— Acute kidney injury (prerenal) from volume loss.
— Cardiac events: demand ischemia and arrhythmia from sympathetic surge in those with CAD; uncommon but reported.
— Esophageal Mallory-Weiss tear from retching.
— Withdrawal in pregnancy → uteroplacental insufficiency, preterm labor, fetal demise in severe cases. Treat aggressively.
— Precipitated withdrawal from bup or naltrexone.
— Respiratory depression: methadone induction (especially with benzo, alcohol); buprenorphine alone is ceilinged but still risky with other CNS depressants.
— QT prolongation/TdP with methadone, especially > 100 mg/day or with QT-cosegments.
— Constipation once stabilized on MOUD — treat preemptively.
— Hypogonadism, adrenal suppression with long-term opioids (including methadone).
— AMA discharge is itself a complication — drives post-discharge overdose.
— Relapse during/after taper with markedly lost tolerance → fatal overdose risk especially after hospitalization, incarceration, or detox — a guideline-emphasized hazard.
— Loss of housing, employment, custody — address with social work.
— Endocarditis (often tricuspid, S. aureus), epidural abscess, septic arthritis, osteomyelitis, soft-tissue infections, xylazine wounds, HIV, HCV, HBV.
Step 3 management: A patient discharged after inpatient stay who used opioids prior to admission has post-discharge overdose risk peaking in the first 2 weeks. Mitigate by: (1) starting/continuing MOUD inhospital, (2) dispensing take-home naloxone, (3) scheduling follow-up within 72 h, (4) educating household contacts.
— Hemodynamic instability unexplained by volume status (shock, persistent HR >130, SBP <90 after fluids) → suspect sepsis, GI bleed, endocarditis, adrenal insufficiency.
— Severe electrolyte derangements: K <3, Mg <1.2, severe AKI with arrhythmia risk.
— Methadone overdose during induction with respiratory depression — monitored bed minimum; ICU if intubated or on naloxone infusion (long t½ methadone may require prolonged naloxone drip, 24–48 h).
— TdP / sustained ventricular arrhythmia from methadone → telemetry/CCU.
— Severe co-withdrawal (alcohol or benzo) → CIWA-driven benzo dosing; ICU if delirium tremens or seizures.
— Need for parenteral fluids, antiemetics, electrolyte repletion.
— Failed outpatient induction.
— Acute medical/surgical comorbidity (endocarditis, abscess, pneumonia, OB issue).
— Pregnancy with significant withdrawal.
— Social factors precluding safe outpatient management.
— Addiction medicine / psychiatry — for MOUD initiation if unfamiliar, complex polysubstance, treatment-resistant patterns.
— OB/MFM — every pregnant patient with OUD.
— Cardiology — endocarditis, QTc concerns on methadone.
— Infectious disease — endocarditis, HIV/HCV management, OPAT planning.
— Pain management — chronic pain on chronic opioids; perioperative coordination.
— Social work / case management — every patient, every time.
— Inpatient → outpatient: ensure MOUD prescription, bridge dose, follow-up within 72 hours, naloxone, peer recovery specialist warm handoff.
— Inter-facility transfers: communicate MOUD doses explicitly to receiving team to prevent dose interruption.
CCS pearl: Orders that move the clock and the score in CCS-style opioid withdrawal cases: IV NS bolus, ondansetron IV, COWS reassessment q2h, buprenorphine SL 4 mg, social work consult, addiction medicine consult, naloxone kit on discharge, follow-up clinic appointment.
— Onset 6–24 h after last drink; tremor, hallucinations (12–24 h), seizures (24–48 h), delirium tremens (48–96 h).
— Hemodynamic surge more dangerous, can be fatal; high fever, severe HTN, true delirium.
— CIWA-Ar scoring; treat with benzodiazepines (lorazepam, diazepam) — not symptomatic-only.
— Key distinction from opioid: AMS, seizures, hallucinations are alcohol; pupil findings, GI, myalgia point to opioid.
— Onset depends on half-life (1–2 d short-acting, up to 7+ d for diazepam); seizure and death risk; treat with gradual benzo taper, not abrupt stop. Often co-occurs with opioid withdrawal.
— "Crash" picture: hypersomnia, hyperphagia, depression, anhedonia, vivid dreams; no autonomic surge, no pupillary findings consistent with opioid withdrawal. Often comorbid.
— Irritability, sleep disturbance, decreased appetite, mild GI upset; mild and self-limited; no autonomic storm.
— Irritability, craving, increased appetite, low mood; common confounder in hospitalized OUD patients — offer nicotine replacement.
— Mimics withdrawal autonomic surge: HTN, tachycardia, mydriasis, sweating. Key differentiators: stimulant intox has euphoria/agitation/psychosis, hyperthermia, hyperreflexia without GI/lacrimation/yawning, and no piloerection.
— Triad: mental status changes, autonomic instability, neuromuscular hyperactivity (clonus, hyperreflexia); rapid onset after serotonergic med change. Overlap with withdrawal in fentanyl + SSRI patients.
Key distinction: A patient on methadone who starts linezolid for an IV-drug-use-related infection and develops clonus, agitation, fever — think serotonin syndrome, not breakthrough withdrawal. Stop linezolid, supportive care, consider cyproheptadine.
— Tachycardia, fever, diaphoresis, AMS overlap with withdrawal. IVDU population is high-risk for endocarditis, soft-tissue infection, spinal abscess.
— Lactate, blood cultures, source workup before anchoring on withdrawal — especially if T >38.5, leukocytosis, hypotension, or AMS.
— Tachycardia, tremor, anxiety, diarrhea, sweating; may have AF, fever, AMS. Check TSH, free T4. Treat with beta-blockade, thionamide, iodine, steroids if storm.
— Episodic HTN, tachycardia, diaphoresis, headache. Rare but classic boards differential of autonomic surge; plasma/urinary metanephrines.
— Lacks pupillary, GI, and piloerection findings; psych history; no opioid use history.
— Sympathetic surge can be misread; in opioid users, ACS may present atypically with diaphoresis and anxiety. ECG and troponin if any chest symptoms or risk factors — especially older patients in withdrawal.
— Nausea, vomiting, abdominal pain, tachycardia, dehydration; check glucose, anion gap, ketones in any unwell-appearing patient.
— Cramping pain in withdrawal can mask bowel obstruction, perforation, pancreatitis, appendicitis. Peritoneal signs, severe localized tenderness, vomiting blood, no bowel sounds → image (CT) before assuming withdrawal.
— Fever, rigidity, autonomic instability, AMS after antipsychotic exposure. Lead-pipe rigidity, not clonus.
— Hot, dry skin, mydriasis, urinary retention, AMS, absent bowel sounds — opposite of opioid withdrawal's wet, hyperactive picture.
Board pearl: In a febrile (≥38.5°C) opioid-withdrawal-appearing patient with new murmur or back pain, rule out endocarditis and epidural abscess before attributing fever to withdrawal. Low-grade temperature elevation is acceptable in pure withdrawal; frank fever is not.
— Buprenorphine SL film/tab at therapeutic dose (commonly 16–24 mg/d); prescription bridge to first outpatient visit (typically 7–14 day supply with refill plan).
— Or methadone linkage to OTP — patient needs an OTP appointment in hand; otherwise, ED/inpatient bup induction is the smoother path.
— Or XR-naltrexone if patient has been opioid-free 7–10 d (uncommon at acute discharge).
— Take-home naloxone for every patient with OUD or any opioid prescription; nasal spray easiest. Now available OTC in the US.
— Train household contacts on use.
— Never use alone; use fentanyl test strips when available; avoid mixing with benzos/alcohol; tester doses; clean injection supplies; safe injection sites where legal.
— HCV — refer for DAA therapy; OUD is not a barrier.
— HIV — link to ART; PrEP for HIV-negative IV-drug users.
— HBV vaccination if non-immune; HAV vaccine in outbreaks/risk; pneumococcal, influenza, COVID, tetanus, HPV per ACIP.
— Contraception counseling and offer LARC; all methods are compatible with MOUD.
— Mental health referrals — depression, PTSD, anxiety screen.
— Multimodal: acetaminophen, NSAIDs, topical agents, gabapentinoids (cautious), PT, CBT.
— For acute severe pain on bup, increase bup divided dosing (TID/QID) or add short-acting full agonist on top with coordination.
Step 3 management: The discharge checklist is "MOUD + Narcan + Hep/HIV + 72-h follow-up + warm handoff" — these five items repeatedly drive Step 3 answer choices.
— Week 1: in-person or telehealth follow-up within 72 hours of induction or discharge; reassess withdrawal, cravings, side effects, dose.
— Weeks 2–4: weekly visits, dose stabilization, urine drug screening.
— Months 2–3: every 2 weeks as stable.
— Maintenance: monthly visits once stable; some transition to XR-buprenorphine SC monthly.
— Urine drug screens — patient-centered, non-punitive; positive results trigger conversation and dose adjustment, not discharge.
— LFTs at baseline and periodically (every 6–12 months).
— PDMP (state prescription drug monitoring) check at each visit — required in most states.
— ECG baseline, at 30 days, then annually; sooner if dose escalations or QT-cosegments.
— Daily observed dosing at OTP; take-homes earned with time and stability.
— LFTs every 3–6 months.
— Monthly injections for XR-naltrexone.
— Cognitive behavioral therapy, contingency management, motivational interviewing improve outcomes.
— Mutual-help groups — NA, SMART Recovery — voluntary, complementary.
— Peer recovery specialists during transitions of care reduce relapse.
— Couples/family therapy when appropriate.
— Lapses are common and not failures; stay engaged, adjust dose, intensify support.
— Retention at 6 months on buprenorphine ~ 40–60%; mortality benefit persists.
CCS pearl: Order "follow-up in 72 hours" and "PDMP check" as part of every CCS opioid withdrawal scenario — both are graded items in modern board-style management cases.
— 42 CFR Part 2 governs SUD treatment records — stricter than HIPAA for OTP and federally-funded SUD programs. Disclosure requires patient consent in most cases; recent rule changes have aligned more with HIPAA but baseline protections remain. Do not broadcast OUD status in handoffs to non-treating staff.
— Patient in active withdrawal may have impaired decisional capacity (anxiety, dysphoria) but most retain capacity for medical decisions. Treat the withdrawal, then re-engage on complex decisions.
— AMA discharges: assess capacity, treat reversible factors (withdrawal), document discussion, provide MOUD bridge and naloxone even if leaving AMA — harm reduction principle.
— Pregnant patients with SUD: state laws vary — some mandate CPS reporting, some prohibit punitive responses, some require it only after delivery. Know your jurisdiction; ACOG opposes criminalization and supports treatment-first approach. Reassure patients that prenatal MOUD is protective, not incriminating.
— Suspected child abuse/neglect related to parental SUD: report per state law.
— Impaired colleagues (physician/nurse with OUD): report to state professional health program — supports treatment, often non-punitive.
— Use person-first, non-stigmatizing language: "person with OUD" not "addict"; "positive/negative UDS" not "clean/dirty."
— Implicit bias affects pain control and MOUD access — particularly for Black and Hispanic patients, who are less likely to be offered buprenorphine despite equal need.
— Medication reconciliation errors are the #1 transition risk — verify methadone dose with OTP directly; missed methadone doses ≥ 3 days require re-induction at lower dose to prevent overdose.
— Surgical/anesthesia teams must be informed of MOUD; sudden discontinuation perioperatively is unsafe.
— Stable MOUD does not impair driving; counsel that intoxication and withdrawal both do.
— DEA Schedule III (buprenorphine), II (methadone, oxycodone, fentanyl). X-waiver requirement eliminated 2023 — any DEA-licensed prescriber can write buprenorphine.
— Good Samaritan laws protect bystanders calling for overdose help; share this with patients and families.
Board pearl: Refusing to continue a patient's home buprenorphine or methadone during an inpatient stay — without an emergent clinical contraindication — is both substandard care and an ethical breach; precipitating withdrawal endangers the patient.
Key distinction: Opioid withdrawal alone is rarely fatal; alcohol and benzo withdrawal can be. But the post-withdrawal relapse overdose is the silent killer in opioid patients.
— Patient with known OUD presents with restlessness, rhinorrhea, mydriasis, hyperactive bowel sounds, COWS 14. Best next step? → Buprenorphine 4 mg SL induction. Distractors: methadone (needs OTP), naltrexone (precipitates withdrawal), clonidine alone (suboptimal, no MOUD).
— Patient revived in ED, now in florid withdrawal at COWS 22. Best management? → Buprenorphine induction now; don't re-narcotize; observe for re-sedation as naloxone wears off.
— 26-week G2P1 with daily heroin use, COWS 10. Management? → Admit, initiate methadone or buprenorphine, MFM consult, social work, NOT detoxification, NOT naltrexone.
— Day 2 post-op, restless, sweating, tearful; home oxycodone held. Diagnosis and step? → Iatrogenic withdrawal; resume home opioid equivalent or initiate buprenorphine; coordinate post-op pain plan.
— Patient started methadone 30 mg/d 5 days ago, now somnolent and hypoxic. Cause? → Methadone accumulation due to long half-life; reduce dose, monitor with telemetry; consider naloxone if respiratory depression.
— Patient who used fentanyl 8 h ago gets first bup dose, develops worse symptoms. Next step? → More buprenorphine (8–16 mg), adjuncts; do not give full agonist on top.
— Patient stabilized on bup 16 mg/d in hospital, ready for discharge. Plan? → Bridge prescription, naloxone kit, follow-up clinic in 72 hours, harm reduction counseling, social work referral, HCV/HIV testing.
— Patient on home methadone 80 mg/d admitted for cellulitis. Best step? → Confirm dose with OTP, continue methadone; do not halve or hold "to be safe" — risks withdrawal and AMA.
— Patient on methadone 120 mg/d starts ciprofloxacin, then develops syncope; ECG QTc 540. Cause and step? → Drug-induced QT prolongation, TdP risk; stop cipro, alternative antibiotic, reduce methadone, magnesium repletion, telemetry.
— Patient in withdrawal demanding to leave. Best response? → Treat withdrawal aggressively (bup), assess capacity, provide naloxone and bridge MOUD prescription, document discussion — harm reduction even at AMA.
Board pearl: When the stem mentions rhinorrhea + yawning + mydriasis → opioid withdrawal. When it adds "last fentanyl use 6 hours ago" → think micro-induction or wait + symptomatic to avoid precipitated withdrawal.
Opioid withdrawal is a noradrenergic syndrome diagnosed clinically with COWS, treated definitively by starting medication for OUD — buprenorphine or methadone — at the index encounter, plus take-home naloxone, harm reduction counseling, and 72-hour follow-up, because MOUD halves mortality and AMA without treatment markedly raises overdose death.
High-yield recap bullets:
— Buprenorphine SL — start 2–4 mg, titrate to 16–24 mg/d; no X-waiver needed since 2023; safer overdose profile.
— Methadone — inpatient withdrawal control any time; maintenance only through OTP; watch QTc and accumulation in first 2 weeks.
— Naltrexone XR — only after 7–10 days opioid-free; high relapse-overdose risk if not adherent.
— Use clonidine, ondansetron, loperamide, NSAIDs, trazodone as adjuncts — never as a substitute for MOUD.
— Pregnancy: bup or methadone first-line; never detox; coordinate MFM and pediatrics; NOWS managed with ESC scoring.
— Renal/hepatic disease: bup and methadone need no renal adjustment; avoid morphine/codeine/meperidine in CKD.
— Post-incarceration, post-discharge, post-detox: overdose risk peaks at 2 weeks — start MOUD before transition.
— MOUD prescription/bridge.
— Take-home naloxone.
— HIV/HCV/HBV testing, vaccinations, contraception.
— Follow-up within 72 hours + PDMP, warm handoff to clinic.
— Harm reduction counseling + non-stigmatizing language.
Board pearl: If a Step 3 stem ends with "what is the most appropriate next step?" in an opioid withdrawal scenario, the answer is almost always start buprenorphine — the rest of the management cascade follows.