What is the recommended protocol for managing withdrawal from morphine in a patient?

Management of Morphine Withdrawal

For patients withdrawing from morphine, use buprenorphine as the primary treatment when the Clinical Opiate Withdrawal Scale (COWS) score exceeds 8, starting with 4-8 mg sublingually and titrating up to a maximum of 16 mg on day one. 1

Initial Assessment and Risk Stratification

Use the Clinical Opiate Withdrawal Scale (COWS) to evaluate withdrawal severity before initiating treatment. 1

• Active withdrawal is defined as COWS score >8, which is the threshold for safe buprenorphine administration 1
• Document baseline symptoms including duration of morphine use, daily dose, and last time of use 1
• Assess for polysubstance use and psychiatric comorbidities that may complicate withdrawal 2

Critical pitfall: Never administer buprenorphine to patients not yet showing active withdrawal symptoms (COWS ≤8), as this will precipitate severe withdrawal 1

Primary Treatment Protocol: Buprenorphine

Administer buprenorphine only after confirming COWS >8 to avoid precipitated withdrawal. 1

Initial Dosing Algorithm:

• First dose: 4-8 mg buprenorphine sublingually based on withdrawal severity 1
• Reassessment: Evaluate patient 30-60 minutes after initial dose 1
• Additional dosing: Provide supplemental doses if withdrawal symptoms persist 1
• Maximum day 1 dose: Do not exceed 16 mg total on the first day 1

Subsequent Days:

• Continue buprenorphine/naloxone 16 mg sublingual daily 1
• Provide 3-7 days of medication or until follow-up appointment 1
• Arrange follow-up within 3-7 days for ongoing management 1

Alternative Approach: Morphine Continuation for Stable Patients

If the patient is already comfortable on a stable dose of morphine, continue that morphine at the same dose rather than switching medications. 3

This approach is particularly relevant in:

• Patients on morphine maintenance who are not seeking complete abstinence 3
• Situations where withdrawal is being managed during concurrent medical treatment 4

Symptom-Directed Management

Use standardized scoring systems to assess and document pain, agitation, and respiratory distress throughout withdrawal. 3

For Breakthrough Symptoms:

If using morphine for symptom control:

• Patients on continuous morphine infusion can receive bolus doses of 2× the hourly infusion rate every 15 minutes as needed 3
• If patient requires 2 bolus doses within one hour, double the infusion rate 3
• Titrate opioids to symptoms with no dose limit 3

For agitation after pain is controlled:

• Only add sedatives once pain and dyspnea are adequately treated with opioids 3
• Benzodiazepine-naïve patients: start with 2 mg IV midazolam bolus, followed by 1 mg/h infusion 3, 1
• Titrate sedatives to symptoms with no specified dose limit 3

Documentation Requirements

Document the rationale for every dose of medication administered during withdrawal management. 3, 1

• Record withdrawal assessment scores using validated tools 1
• Note specific symptoms being treated (e.g., "for tachypnea," "for agitation") 3
• Track medication history including duration and daily dose 1

Discharge Planning

Provide comprehensive discharge support to prevent relapse and overdose. 1

• Prescribe buprenorphine/naloxone 16 mg sublingual daily for 3-7 days 1
• Provide overdose prevention education and take-home naloxone kit 1
• Arrange follow-up appointment within 3-7 days 1
• Refer to medication for addiction treatment programs for long-term management 1

Special Considerations

For patients transitioning from methadone maintenance, exercise extreme caution when switching to buprenorphine due to risk of severe and prolonged precipitated withdrawal. 1

For hospitalized patients with concurrent medical conditions:

• Implement standardized withdrawal protocols using buprenorphine and COWS 4
• Coordinate care between medical teams, nursing, pharmacy, and case management 4
• Ensure seamless medication administration through electronic order sets 4

Common Pitfalls to Avoid

• Never give buprenorphine before COWS >8 - this causes precipitated withdrawal that is more severe than natural withdrawal 1
• Do not abruptly discontinue morphine in physically dependent patients - this leads to serious withdrawal symptoms, uncontrolled pain, and increased suicide risk 5
• Avoid fixed-dose schedules - use symptom-triggered regimens to prevent drug accumulation 1
• Do not neglect polysubstance use assessment - patients may require inpatient admission for complex withdrawal 2