What are the guidelines for inpatient management of opioid withdrawal?

Inpatient Management of Opioid Withdrawal

Buprenorphine is the most effective first-line medication for managing opioid withdrawal in the inpatient setting, demonstrating superior outcomes in terms of withdrawal symptom control, treatment retention, and completion rates compared to other pharmacologic options. 1, 2

Assessment and Diagnosis

Confirm Opioid Withdrawal Status

• Assess using the Clinical Opiate Withdrawal Scale (COWS)
• Determine time since last opioid use:
  • Short-acting opioids (heroin, immediate-release morphine): >12 hours
  • Extended-release formulations (OxyContin): >24 hours
  • Methadone maintenance: >72 hours 1

Severity Assessment

• Mild withdrawal: COWS <8
• Moderate to severe withdrawal: COWS >8 1

Pharmacologic Management

First-Line Treatment: Buprenorphine

Dosing Protocol

• For moderate to severe withdrawal (COWS >8):
  • Initial dose: 4-8 mg sublingual based on withdrawal severity
  • Reassess after 30-60 minutes
  • Target dose: 16 mg daily for most patients 1
  • May continue for duration of inpatient stay with transition to outpatient treatment

Advantages of Buprenorphine

• More effective than clonidine/lofexidine in reducing withdrawal severity
• Higher treatment completion rates (59% higher likelihood of completing withdrawal treatment)
• Longer treatment retention
• Fewer adverse effects 2
• May resolve withdrawal symptoms more quickly than methadone 2

Cautions

• Must be administered only when patient is in active withdrawal to avoid precipitated withdrawal
• For patients transitioning from methadone, particular care is required due to risk of severe and prolonged precipitated withdrawal 1
• If precipitated withdrawal occurs, it can be managed with additional buprenorphine doses 3

Second-Line Treatment: Methadone

• Equally effective as buprenorphine for managing withdrawal symptoms
• Can be legally initiated during hospitalization for opioid withdrawal management 4
• Particularly useful for patients already on methadone maintenance
• Initial dosing: individualized based on withdrawal severity
• May be preferred for patients who cannot tolerate buprenorphine 1

Third-Line Treatment: Alpha-2 Adrenergic Agonists

• Options: clonidine or lofexidine
• Lofexidine FDA-approved specifically for opioid withdrawal management 1, 5
• Lofexidine dosing: up to 2.88 mg/day (0.72 mg four times daily) 5
• Less effective than buprenorphine or methadone for withdrawal management 2
• Consider when opioid agonists are contraindicated or unavailable

Adjunctive Medications for Symptom Management

• Nausea/vomiting: promethazine or other antiemetics
• Anxiety/muscle cramps: benzodiazepines (also help reduce catecholamine release)
• Diarrhea: loperamide
• Insomnia: zolpidem (if needed)
• Pain: acetaminophen 1, 5

Monitoring and Follow-up

• For buprenorphine: reassess 30-60 minutes after initial dose for moderate-severe withdrawal
• For mild withdrawal: reassess in 1-2 hours
• Monitor vital signs regularly, particularly with alpha-2 agonists (risk of hypotension)
• Assess COWS score daily to track withdrawal progression
• Evaluate for adverse effects of medications 1

Discharge Planning

• Arrange follow-up with outpatient addiction treatment program
• Provide prescription for continued medication (buprenorphine/naloxone or referral to methadone program)
• Offer overdose prevention education and naloxone kit
• Screen for hepatitis C and HIV
• Provide reproductive health counseling if applicable 1

Common Pitfalls to Avoid

1. Inadequate assessment of withdrawal: Failure to use validated tools like COWS can lead to inappropriate timing of medication administration.

2. Precipitated withdrawal: Administering buprenorphine too early before patient is in sufficient withdrawal can worsen symptoms dramatically.

3. Detoxification without maintenance planning: Opioid detoxification alone without transition to maintenance treatment is associated with high relapse rates and poor outcomes 6.

4. Undertreatment due to regulatory confusion: Many providers incorrectly believe they cannot legally prescribe methadone for inpatient withdrawal management 4.

5. Inadequate symptom management: Failing to address all withdrawal symptoms can lead to patient discomfort and premature discharge.

Inpatient management of opioid withdrawal represents a critical opportunity to engage patients in long-term treatment for opioid use disorder, potentially reducing morbidity and mortality associated with ongoing opioid use.