What is the management of acute detoxification in the Emergency Department (ED)?

From the Guidelines

Buprenorphine is the most effective treatment for opioid withdrawal in the emergency department, as it has been shown to reduce the severity of withdrawal symptoms and improve treatment retention compared to other medications, such as clonidine and methadone 1. When managing acute detoxification in the emergency department, it is essential to consider the specific substance involved and tailor the treatment approach accordingly. For opioid withdrawal, the use of buprenorphine-naloxone (Suboxone) is recommended, with an initial dose of 4-8mg sublingually, followed by additional doses as needed, based on the patient's symptoms and COWS score 1. Some key points to consider when managing opioid withdrawal in the emergency department include:

• Buprenorphine has been shown to be effective in reducing the severity of withdrawal symptoms and improving treatment retention compared to other medications, such as clonidine and methadone 1
• The use of buprenorphine-naloxone (Suboxone) is recommended, with an initial dose of 4-8mg sublingually, followed by additional doses as needed, based on the patient's symptoms and COWS score 1
• Clonidine 0.1-0.2mg orally every 4-6 hours can help manage autonomic symptoms, but it is not as effective as buprenorphine in reducing the severity of withdrawal symptoms 1
• Patients should be connected to appropriate follow-up care and substance use disorder treatment before discharge to improve long-term outcomes 1 It is also important to note that the management of opioid withdrawal in the emergency department should be part of a comprehensive approach to addressing the opioid epidemic, which includes reducing the prescribing of opioids for acute pain and increasing access to evidence-based treatment for opioid use disorder 1.

From the FDA Drug Label

Particular vigilance is necessary during treatment initiation, during conversion from one opioid to another, and during dose titration. For detoxification and maintenance of opiate dependence methadone should be administered in accordance with the treatment standards cited in 42 CFR Section 8. 12, including limitations on unsupervised administration. The initial methadone dose should be administered, under supervision, when there are no signs of sedation or intoxication, and the patient shows symptoms of withdrawal. For Short-term Detoxification For patients preferring a brief course of stabilization followed by a period of medically supervised withdrawal, it is generally recommended that the patient be titrated to a total daily dose of about 40 mg in divided doses to achieve an adequate stabilizing level

Management of Acute Detox in ED:

• The initial dose of methadone should not exceed 30 mg and should be administered under supervision when the patient shows symptoms of withdrawal.
• The total daily dose of methadone on the first day of treatment should not ordinarily exceed 40 mg.
• Dose adjustments should be cautious and made based on control of withdrawal symptoms at the time of expected peak activity.
• For short-term detoxification, the patient should be titrated to a total daily dose of about 40 mg in divided doses to achieve an adequate stabilizing level, followed by a gradual decrease in dose 2.

From the Research

Management of Acute Detox in the ED

• The management of acute detox in the ED involves various medical interventions, including medications, diagnostic testing, and procedures 3.
• A study found that 56% of patients with alcohol or illicit substance intoxication received at least one intervention that could not be provided by a local detoxification or sobering facility 3.
• The use of phenobarbital has been shown to be an effective adjunctive therapy for severe alcohol withdrawal syndrome (AWS), reducing benzodiazepine use in the ED and ICU 4.

Treatment Options for Alcohol Withdrawal

• Symptom-triggered benzodiazepine administration remains the most commonly provided treatment for AWS, but may not be appropriate for patients with significant medical or psychiatric comorbidity or pending discharge 5.
• Phenobarbital may be a reasonable alternative to lorazepam in the management of AWS patients admitted to general medical units 4.
• The SAEM GRACE-4 Writing Team suggests using phenobarbital in addition to benzodiazepines for adult ED patients with moderate to severe AWS who are being admitted to hospital 6.

Management of Co-occurring Opioid and Alcohol Withdrawal

• The safety of combining buprenorphine with a benzodiazepine or barbiturate in the treatment of concurrent alcohol and opioid withdrawal has not been well established 7.
• A retrospective cohort study found no serious adverse events related to the medications used to treat opioid or alcohol withdrawal in a cohort of ED patients 7.
• Further work is needed to assess optimal use of medical therapy for opioid and alcohol withdrawal and the transition to maintenance treatment for substance use disorders 7.