What is the appropriate treatment for a patient with a COWS (Clinical Opiate Withdrawal Scale) score of 27, indicating severe opioid withdrawal symptoms?

Treatment for COWS Score of 27 (Moderately Severe Opioid Withdrawal)

Administer buprenorphine 8 mg sublingual immediately, reassess after 30-60 minutes, and give additional 2-4 mg doses every 2 hours as needed to target a total Day 1 dose of 8-16 mg, as this patient is in moderately severe withdrawal requiring urgent treatment. 1, 2, 3

Understanding the COWS Score

• A COWS score of 27 falls in the "moderately severe" range (25-36), indicating significant opioid withdrawal that requires immediate pharmacological intervention 4, 5
• This score is well above the threshold of COWS >8 required to safely initiate buprenorphine without risk of precipitating withdrawal 1, 2, 3

First-Line Treatment: Buprenorphine Dosing Protocol

Initial Dose Administration

• Start with 8 mg sublingual buprenorphine as the initial dose for this severity of withdrawal 1, 2, 3
• The American College of Emergency Physicians recommends 4-8 mg initial dosing based on withdrawal severity, with higher doses (8 mg) appropriate for moderately severe withdrawal 2, 3
• Reassess the patient 30-60 minutes after the initial dose 3

Subsequent Dosing on Day 1

• If withdrawal symptoms persist after initial assessment, administer additional 2-4 mg doses at 2-hour intervals 3
• Target a total Day 1 dose of 8-16 mg based on symptom response, with most patients in moderately severe withdrawal requiring doses toward the higher end of this range 1, 2, 3
• The FDA label supports Day 1 dosing given in 2-4 mg increments if preferred, with rapid titration to clinical effectiveness 6

Day 2 and Maintenance Dosing

• On Day 2, administer 16 mg buprenorphine, which becomes the standard maintenance dose for most patients 2, 3, 6
• The recommended target maintenance dosage is 16 mg as a single daily dose, with a typical range of 4-24 mg depending on individual response 3, 6
• After Day 2, transition to buprenorphine/naloxone combination products for ongoing maintenance treatment to reduce diversion risk 1, 6

Critical Timing Considerations Before Buprenorphine

Before administering buprenorphine, verify the following waiting periods have been met to avoid precipitated withdrawal:

• >12 hours since last short-acting opioid use (heroin, oxycodone, hydrocodone) 1, 2, 3
• >24 hours since last extended-release opioid formulation 1, 2, 3
• >72 hours since last methadone dose for patients on methadone maintenance 1, 2, 3

The American College of Emergency Physicians emphasizes that buprenorphine's high binding affinity and partial agonist properties can displace full opioid agonists and precipitate severe withdrawal if administered too early, particularly in methadone-maintained patients 3

Adjunctive Symptomatic Management

Regardless of buprenorphine administration, add symptom-specific medications to improve comfort:

• Antiemetics (promethazine or ondansetron) for nausea and vomiting 1, 2, 3
• Loperamide for diarrhea 1, 2, 3
• Benzodiazepines (lorazepam) for anxiety and muscle cramps, but monitor closely for respiratory depression when combined with opioids 1, 2, 3
• Clonidine or lofexidine can be added for autonomic symptoms (tachycardia, hypertension, sweating) if needed 1, 3

Evidence Supporting Buprenorphine as First-Line

• Buprenorphine has an 85% probability of being the most effective treatment for opioid withdrawal, compared to 12.1% for methadone, 2.6% for lofexidine, and 0.01% for clonidine 2
• The American College of Emergency Physicians guidelines demonstrate that buprenorphine is superior to alpha-2 adrenergic agonists (clonidine/lofexidine) with lower average withdrawal scores and significantly higher treatment completion rates 4, 7
• The number needed to treat is 4, meaning for every 4 patients treated with buprenorphine versus clonidine/lofexidine, one additional person will complete treatment 4, 7

Discharge Planning and Harm Reduction

Upon discharge or stabilization:

• Prescribe buprenorphine/naloxone 16 mg sublingual daily for 3-7 days or until follow-up appointment 2, 3
• Provide naloxone kits and overdose prevention education, as patients become more sensitive to opioid effects after withdrawal resolution, dramatically increasing overdose risk if they resume opioid use 1, 2
• Arrange immediate follow-up for ongoing medication for opioid use disorder (MOUD) treatment 1, 2
• Consider hepatitis C and HIV screening 2

Critical Safety Considerations

• Do not discontinue buprenorphine once started, as discontinuation precipitates withdrawal and dramatically increases relapse risk to more dangerous illicit opioids 3, 6
• Buprenorphine is not just for withdrawal management but for long-term treatment of opioid use disorder—there is no maximum recommended duration of maintenance treatment 2, 3, 6
• The American Society of Addiction Medicine recommends that patients may require treatment indefinitely and should continue as long as they are benefiting 3, 6

Common Pitfalls to Avoid

• Underdosing on Day 1: With a COWS of 27, err toward the higher end of dosing (8 mg initial, targeting 12-16 mg total Day 1) rather than being overly conservative 1, 2, 3
• Administering buprenorphine too early: Always confirm adequate time has passed since last opioid use and that objective withdrawal signs are present 2, 3, 6
• Treating this as short-term detoxification only: The goal is transition to long-term MOUD, not just symptom relief 2, 3, 6
• Failing to provide naloxone at discharge: This is a critical harm reduction measure given increased overdose sensitivity post-withdrawal 1, 2