What is the recommended treatment for a patient with severe opioid withdrawal symptoms, as indicated by a Clinical Opiate Withdrawal Scale (COWS) score of 27, and would Suboxone (buprenorphine and naloxone) be an appropriate first-line treatment option?

Suboxone (Buprenorphine/Naloxone) for Severe Opioid Withdrawal (COWS 27)

Yes, Suboxone is the appropriate first-line treatment for this patient with a COWS score of 27, which indicates moderately severe withdrawal requiring immediate buprenorphine administration. 1, 2

Why Buprenorphine is the Correct Choice

Your patient's COWS score of 27 falls in the "moderately severe" range (25-36), which clearly exceeds the threshold of >8 required for safe buprenorphine initiation. 1 This score confirms active withdrawal and eliminates the risk of precipitated withdrawal, which is the primary concern when administering buprenorphine. 2

Buprenorphine demonstrates superior efficacy compared to all alternatives:

• Reduces withdrawal severity more effectively than clonidine or lofexidine (effect size: small to moderate) 1, 3
• Patients stay in treatment significantly longer (large effect size) 3
• Treatment completion rates are 1.6 times higher than alpha-2 agonists 1
• Number needed to treat is 4—meaning for every 4 patients treated with buprenorphine versus clonidine, one additional patient completes treatment 1
• Has an 85% probability of being the most effective treatment option 1, 2

Dosing Protocol for COWS 27

Initial dose: 8 mg sublingual buprenorphine/naloxone 1, 2

The guideline recommends 4-8 mg based on withdrawal severity; with a COWS of 27, start at the higher end (8 mg). 1, 2

Reassessment and titration:

• Reassess COWS after 30-60 minutes 1, 2
• If withdrawal persists (COWS remains >8), give additional 2-4 mg doses at 2-hour intervals 2
• Target Day 1 total dose: 8-12 mg for most patients 2
• Day 2 and maintenance: 16 mg daily (standard for most patients) 1, 2

Critical Timing Requirements Before Administration

You must confirm adequate time has passed since last opioid use to prevent precipitated withdrawal: 1, 2

• Short-acting opioids (heroin, morphine IR, oxycodone IR): >12 hours 1, 2
• Extended-release formulations (OxyContin, MS Contin): >24 hours 1, 2
• Methadone maintenance patients: >72 hours 1, 2

The high COWS score (27) provides additional reassurance that sufficient time has elapsed, but you must still verify the timing and type of last opioid used. 2

Discharge Planning

For X-waivered providers (note: X-waiver eliminated as of 2023): 2

• Prescribe buprenorphine/naloxone 16 mg sublingual daily
• Duration: 3-7 days or until follow-up appointment
• Sample prescription: "Buprenorphine/naloxone 8 mg/2 mg SL film, take 2 films once daily, dispense #6-14, no refills" 1

For non-waivered providers: 2

• Can administer (but not prescribe) buprenorphine for up to 72 hours
• Must arrange referral for ongoing treatment 2

Mandatory harm reduction measures at discharge: 1, 2

• Provide take-home naloxone kit with overdose prevention education
• Offer hepatitis C and HIV screening
• Consider reproductive health counseling 1, 2

Managing Precipitated Withdrawal (If It Occurs)

Despite the high COWS score making this unlikely, if precipitated withdrawal occurs:

Primary treatment: Give MORE buprenorphine 2, 4

• This is counterintuitive but pharmacologically sound and proven effective 2, 4
• Buprenorphine's high receptor affinity means increasing the dose will eventually saturate receptors and relieve symptoms 4

Adjunctive symptomatic management: 2, 5

• Clonidine or lofexidine for autonomic symptoms (tachycardia, hypertension, sweating)
• Promethazine or ondansetron for nausea/vomiting
• Benzodiazepines for anxiety and muscle cramps
• Loperamide for diarrhea 2

Why Not Alternative Treatments?

Methadone: 1

• Similar efficacy to buprenorphine for withdrawal management
• Less practical in ED settings due to regulatory restrictions
• Cannot be prescribed for take-home use without special licensure
• May interfere with ongoing treatment programs 1

Clonidine/Lofexidine: 1, 5

• Significantly less effective than buprenorphine
• Lower treatment completion rates
• More severe withdrawal symptoms persist
• Appropriate only when buprenorphine is contraindicated or unavailable 1, 5

Common Pitfalls to Avoid

Never administer buprenorphine if: 1, 2

• Patient is not in active withdrawal (COWS <8)
• Insufficient time has passed since last opioid use (see timing requirements above)
• Patient is intoxicated with alcohol, benzodiazepines, or other sedatives
• Patient is a methadone maintenance patient who used methadone <72 hours ago 1, 2

Do not discontinue buprenorphine once started: 2

• Discontinuation precipitates withdrawal and dramatically increases relapse risk to more dangerous opioids
• Buprenorphine for opioid use disorder is long-term treatment, not just for acute withdrawal 2