How to manage a young to middle-aged adult patient with a history of intravenous (IV) drug use, severe opioid use disorder, and endocarditis, who is experiencing opioid withdrawal and requesting to leave the hospital against medical advice (AMA) to use heroin?

Managing Opioid Withdrawal and Preventing AMA Discharge in a Patient with Endocarditis

Immediately initiate buprenorphine treatment for opioid withdrawal in the emergency department or on the inpatient unit, as this is the most effective intervention to manage withdrawal symptoms, retain the patient in the hospital for life-saving endocarditis treatment, and establish long-term medication for opioid use disorder. 1, 2

Immediate Assessment and Intervention

Confirm Active Withdrawal Status

• Use the Clinical Opiate Withdrawal Scale (COWS) to objectively assess withdrawal severity through evaluation of 11 clinical signs: pulse rate, sweating, restlessness, pupil size, bone/joint aches, runny nose/tearing, GI upset, tremor, yawning, anxiety, and piloerection 3, 2
• Administer buprenorphine only when COWS score is >8 (moderate to severe withdrawal) to avoid precipitating more severe withdrawal 2
• Verify timing since last opioid use: >12 hours for short-acting opioids like heroin, >24 hours for extended-release formulations, or >72 hours for methadone maintenance patients 2

Initiate Buprenorphine Treatment

• Administer initial dose of 4-8 mg sublingual buprenorphine based on withdrawal severity 2
• Reassess after 30-60 minutes and provide additional 2-4 mg doses at 2-hour intervals if withdrawal symptoms persist 2
• Target Day 1 total dose of 8 mg, with Day 2 dosing of 16 mg total, which becomes the standard maintenance dose for most patients 2
• Buprenorphine demonstrates clear superiority over alternative treatments (clonidine/lofexidine) with lower average withdrawal scores and significantly higher treatment completion rates, with a number needed to treat of 4 2

Critical Rationale: Why This Approach Saves Lives

Impact on Endocarditis Treatment Outcomes

• Patients who receive buprenorphine during hospitalization for endocarditis have, on average, 5.7 additional days of gold-standard intravenous antibiotic treatment compared to those who do not receive medication for opioid use disorder 4
• Initiation of buprenorphine addresses the underlying cause of the infection (injection drug use) while simultaneously treating the acute medical condition 5, 6
• Early addiction treatment and intensive outpatient care are associated with periods without rehospitalization, while leaving outpatient care and return to drug use directly precede rehospitalization 7

Mortality Without Treatment

• Among persons who inject drugs undergoing surgery for endocarditis, the conditional probability of relapse is 32% at 1 year and 79% at 5 years without adequate addiction treatment 8
• Mortality reaches 21% at 1 year and 68% at 5 years, demonstrating that addiction is far more lethal than the surgical intervention itself 8
• Discontinuing or failing to initiate buprenorphine precipitates withdrawal and dramatically increases relapse risk to more dangerous opioids 2

Adjunctive Symptom Management

Address Specific Withdrawal Symptoms

While buprenorphine is being initiated, provide targeted symptomatic relief:

• Antiemetics (promethazine or ondansetron) for nausea and vomiting 2
• Benzodiazepines for anxiety and muscle cramps 2
• Loperamide for diarrhea 2
• Clonidine or lofexidine for autonomic symptoms (tachycardia, hypertension, sweating) if buprenorphine alone is insufficient 9

Alternative if Buprenorphine Unavailable

• If buprenorphine cannot be administered immediately, methadone has similar effectiveness for withdrawal management and can be used for up to 72 hours while arranging referral 1, 2
• Alpha-2 adrenergic agonists (clonidine or lofexidine) are second-line options but are significantly less effective than buprenorphine, with only a 12.1% probability of being most effective compared to buprenorphine's 85% 2, 9

Critical Safety Considerations

Preventing Precipitated Withdrawal

• Exercise extreme caution with timing of buprenorphine administration - buprenorphine's high binding affinity and partial agonist properties can displace full opioid agonists and precipitate severe withdrawal if given too early 2, 10
• For methadone-maintained patients specifically, wait at least 72 hours since last methadone dose before administering buprenorphine to avoid precipitating more severe withdrawal 2
• If precipitated withdrawal occurs, give more buprenorphine as the primary treatment, with adjunctive symptomatic management 2

Managing Concurrent Pain from Endocarditis

• Buprenorphine can effectively manage both opioid use disorder and acute pain simultaneously 6
• Do not withhold buprenorphine due to concerns about pain management - it provides analgesic effects while preventing withdrawal 6

Discharge Planning and Long-Term Management

Prescribe Continuation Therapy

• Prescribe buprenorphine/naloxone 16 mg sublingual daily for 3-7 days or until follow-up (as of 2023, the X-waiver requirement has been eliminated, expanding prescribing access) 2
• Buprenorphine should not be discontinued once started, as discontinuation precipitates withdrawal and dramatically increases relapse risk 2
• There is no maximum recommended duration of maintenance treatment - patients may require treatment indefinitely 2

Harm Reduction and Follow-up

• Provide take-home naloxone kit and overdose prevention education 2
• Offer hepatitis C and HIV screening 2
• Arrange immediate outpatient addiction treatment follow-up, as the intensity of support and observation determines success more than the absolute opioid dose 9
• Consider outpatient parenteral antimicrobial therapy (OPAT) with concurrent addiction treatment, as OPAT use among people who inject drugs yields similar outcomes to non-PWID when paired with comprehensive opioid use disorder treatment 5

Common Pitfalls to Avoid

Do Not Use Naloxone Inappropriately

• Caution should be exercised in administering naloxone to patients with a history of chronic opioid or drug use because of the risk of inducing acute narcotic withdrawal 1
• Naloxone is for opioid overdose with respiratory depression, not for managing withdrawal or preventing AMA discharge 1

Do Not Delay Treatment

• Standard resuscitative measures for endocarditis should not delay buprenorphine administration for withdrawal - both can and should occur simultaneously 1
• Waiting for formal addiction consultation before initiating buprenorphine may result in the patient leaving AMA before treatment begins 1, 2

Do Not Rely on Non-Evidence-Based Treatments

• Dopamine agonists like ropinirole are not appropriate for opioid withdrawal management 2
• Symptomatic management alone (without buprenorphine or methadone) is significantly less effective and associated with higher rates of treatment discontinuation 1, 2