What is the treatment for a patient with a Clinical Opiate Withdrawal Scale (COWS) score of 23, indicating moderate to severe opioid withdrawal symptoms?

Treatment for COWS Score of 23

For a patient with a COWS score of 23 (moderate to severe opioid withdrawal), administer buprenorphine 4-8 mg sublingually as the initial dose, reassess after 30-60 minutes, and provide additional 2-4 mg doses at 2-hour intervals as needed to achieve withdrawal relief. 1, 2

Initial Assessment and Timing Requirements

Before administering buprenorphine, verify the timing since last opioid use to prevent precipitated withdrawal: 3, 1

• Short-acting opioids (heroin, fentanyl): Wait >12 hours since last use 1, 2
• Extended-release opioid formulations: Wait >24 hours since last use 1, 2
• Methadone maintenance patients: Wait >72 hours since last dose 1, 2

The COWS score of 23 falls in the "moderate" range (13-24), confirming the patient is in active withdrawal and safe to receive buprenorphine. 3, 1

Buprenorphine Dosing Protocol

Day 1 Induction

• Initial dose: 4-8 mg sublingual buprenorphine based on withdrawal severity 1, 2
• Reassessment: Evaluate patient 30-60 minutes after initial dose 1
• Additional dosing: Give 2-4 mg every 2 hours if withdrawal symptoms persist 1
• Target Day 1 total: 8-16 mg total dose, with most patients requiring 8 mg 1, 4

The FDA label specifies that dosing on the initial day may be given in 2-4 mg increments if preferred, and that adequate treatment dose should be achieved as rapidly as possible to prevent dropout. 4

Day 2 and Maintenance

• Day 2 dose: 16 mg total dose 1
• Maintenance dose: 16 mg daily sublingual (range 4-24 mg) 1, 2, 4
• Transition: After induction, switch to buprenorphine/naloxone combination product for ongoing maintenance 4

Why Buprenorphine is First-Line

Buprenorphine demonstrates clear superiority over all alternatives with an 85% probability of being the most effective treatment for opioid withdrawal. 2 Compared to alpha-2 adrenergic agonists (clonidine/lofexidine), buprenorphine produces lower average withdrawal scores and significantly higher treatment completion rates, with a number needed to treat of 4. 3, 5 This means for every 4 patients treated with buprenorphine versus clonidine, one additional patient will complete treatment. 3, 5

Alternative and Adjunctive Medications

If Buprenorphine is Contraindicated or Unavailable

Use alpha-2 adrenergic agonists as second-line agents: 1, 6, 2

• Lofexidine: Preferred in outpatient settings due to lower hypotension risk; FDA-approved specifically for opioid withdrawal 6, 2
• Clonidine: Off-label use; start at low doses and titrate based on withdrawal symptoms and blood pressure monitoring 6

Symptom-Directed Adjunctive Medications

Regardless of primary agent, add medications targeting specific withdrawal symptoms: 1, 2

• Nausea/vomiting: Promethazine or ondansetron 1, 2
• Diarrhea: Loperamide 1, 2
• Anxiety/muscle cramps: Benzodiazepines (lorazepam), but monitor closely for respiratory depression 1, 2
• Autonomic symptoms: Clonidine for tachycardia, hypertension, sweating 1, 6

Critical Safety Considerations

Precipitated Withdrawal Risk

Buprenorphine's high binding affinity and partial agonist properties can displace full opioid agonists and precipitate severe withdrawal if administered too early. 3, 1 This risk is particularly elevated in methadone-maintained patients, who require waiting >72 hours since last dose. 1

If precipitated withdrawal occurs: Give more buprenorphine as the primary treatment, supported by case reports showing effectiveness. 1 Add symptomatic management with clonidine, antiemetics, benzodiazepines, and loperamide as needed. 1

Methadone as Alternative

Methadone has similar efficacy to buprenorphine for withdrawal management but is less commonly used in acute settings due to regulatory restrictions and potential interference with ongoing treatment programs. 3, 2 The 72-hour rule allows non-OTP providers to administer methadone for emergency withdrawal while arranging ongoing care. 7

Discharge Planning and Harm Reduction

Upon discharge, provide: 1, 2

• Prescription: Buprenorphine/naloxone 16 mg sublingual daily for 3-7 days or until follow-up (X-waiver requirement eliminated as of 2023) 1
• Naloxone kit: With overdose prevention education, as patients become more sensitive to opioid effects after withdrawal resolution 2
• Screening: Offer hepatitis C and HIV testing 1
• Follow-up: Arrange ongoing addiction treatment, as buprenorphine is not just for withdrawal but for long-term opioid use disorder treatment 1

Common Pitfalls to Avoid

• Do not administer buprenorphine before adequate withdrawal develops (COWS >8), as this precipitates withdrawal 3, 1
• Do not use gradual induction over several days, as this leads to high dropout rates; achieve adequate dose rapidly 4, 8
• Do not discontinue buprenorphine once started, as this precipitates withdrawal and dramatically increases relapse risk 1
• Do not taper buprenorphine prematurely; patients may require indefinite maintenance treatment 4