What is the best approach to discharge a patient with withdrawal symptoms?

Best Approach to Discharge a Patient with Withdrawal Symptoms

For patients with opioid withdrawal, buprenorphine should be administered when the patient shows signs of withdrawal, with an initial dose of 4-8 mg sublingually, followed by prescription of 16 mg daily for 3-7 days until follow-up, along with overdose prevention education and naloxone kit. 1

Assessment and Monitoring

• Use a validated, standardized assessment tool to evaluate withdrawal symptoms, such as the Clinical Opiate Withdrawal Scale (COWS) for opioid withdrawal 1, 2
• Document baseline symptoms and medication history, including duration of use and daily dose 2
• Document the rationale for each dose of medication administered during withdrawal management 1

Medication Management for Opioid Withdrawal

Initial Dosing

• Administer buprenorphine only when patient shows active withdrawal symptoms (COWS > 8) to avoid precipitated withdrawal 1
• Initial dose: 4-8 mg sublingual buprenorphine based on severity of withdrawal 1
• Reassess after 30-60 minutes; additional doses may be provided if withdrawal symptoms persist 1
• Maximum first-day total dose should not exceed 16 mg 1

Discharge Planning

• Prescribe buprenorphine/naloxone 16 mg SL daily for 3-7 days or until follow-up appointment 1
• Sample discharge prescription: Buprenorphine/naloxone 8 mg/2 mg SL tablet or film, take 2 tablets/films once daily in AM, dispense #6, no refills 1
• For non-X-waivered providers, patients may return for up to 3 consecutive days for interim treatment 1

Preventative Health Measures

• Provide overdose prevention education and take-home naloxone kit 1
• Offer hepatitis C and HIV screening 1
• Provide reproductive health counseling 1

Alternative Approaches for Other Types of Withdrawal

Benzodiazepine Withdrawal

• Use a standardized scoring system to assess withdrawal symptoms 2
• Implement a slow tapering schedule over months rather than weeks to minimize withdrawal symptoms 3, 4
• Consider tapering to doses much lower than minimum therapeutic doses to reduce withdrawal severity 3
• For breakthrough anxiety or agitation, use the same benzodiazepine at the lowest effective dose rather than adding different medications 2, 4

Alcohol Withdrawal

• Diazepam is preferred for moderate to severe alcohol withdrawal due to its rapid onset and long half-life, providing smoother withdrawal 5
• Start with bolus doses of diazepam titrated to symptoms, with no specified dose limit 1
• For benzodiazepine-naïve patients, begin with 2 mg IV midazolam followed by an infusion of 1 mg/h if needed 1

Common Pitfalls and Caveats

• Avoid administering buprenorphine to patients not yet in withdrawal, as this can precipitate severe withdrawal symptoms due to its high binding affinity and partial agonist properties 1
• Use particular caution when transitioning from methadone to buprenorphine due to risk of severe and prolonged precipitated withdrawal 1
• For patients on methadone maintenance, withdrawal typically occurs >72 hours after last dose; consider continuing methadone rather than switching to buprenorphine 1
• For patients with complicating factors (pregnancy, chronic opioid therapy for pain, anticipated surgery, liver disease, respiratory failure), individualized approaches are necessary 1
• Recognize that withdrawal symptoms may be mistaken for recurrence of underlying disorder, potentially leading to unnecessary long-term medication 3

Follow-up Care

• Arrange follow-up appointment within 3-7 days for patients discharged on buprenorphine 1
• Consider referral to medication for addiction treatment programs for long-term management 1
• Educate patients about the high risk of relapse associated with discontinuation of maintenance treatment 6
• Provide resources for community support and counseling services 1