Opioid use disorder - Revision history

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← Older revision		Revision as of 16:17, 19 March 2026
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	<languages/>		==Background==
			*<languages/>
	<translate>		<translate>

	~~==Background==~~

	*Opioid use disorder (OUD) is a chronic, relapsing medical condition defined as a problematic pattern of opioid use leading to clinically significant impairment or distress<ref name="DSM5">American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Washington, DC: APA; 2013.</ref>		*Opioid use disorder (OUD) is a chronic, relapsing medical condition defined as a problematic pattern of opioid use leading to clinically significant impairment or distress<ref name="DSM5">American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Washington, DC: APA; 2013.</ref>
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	*Medications for opioid use disorder (MOUD) — [[Special:MyLanguage/buprenorphine\|buprenorphine]], [[Special:MyLanguage/methadone\|methadone]], and [[Special:MyLanguage/naltrexone\|naltrexone]] — reduce all-cause mortality by '''50-80%'''<ref name="Sordo2017">Sordo L, Barrio G, Bravo MJ, et al. Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies. BMJ. 2017;357:j1550.</ref>		*Medications for opioid use disorder (MOUD) — [[Special:MyLanguage/buprenorphine\|buprenorphine]], [[Special:MyLanguage/methadone\|methadone]], and [[Special:MyLanguage/naltrexone\|naltrexone]] — reduce all-cause mortality by '''50-80%'''<ref name="Sordo2017">Sordo L, Barrio G, Bravo MJ, et al. Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies. BMJ. 2017;357:j1550.</ref>
	*ED-initiated buprenorphine '''increases 30-day treatment engagement ~5-fold''' compared to referral alone (D'Onofrio 2015 landmark RCT)<ref name="DOnofrio2015">D'Onofrio G, O'Connor PG, Pantalon MV, et al. Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial. JAMA. 2015;313(16):1636-1644.</ref>		*ED-initiated buprenorphine '''increases 30-day treatment engagement ~5-fold''' compared to referral alone (D'Onofrio 2015 landmark RCT)<ref name="DOnofrio2015">D'Onofrio G, O'Connor PG, Pantalon MV, et al. Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial. JAMA. 2015;313(16):1636-1644.</ref>
	*~~'''~~No X-waiver or special certification is required~~'''~~ to prescribe buprenorphine (eliminated January 2023 by the Consolidated Appropriations Act)<ref name="CAA2023">Consolidated Appropriations Act, 2023, Pub. L. No. 117-328, § 1262.</ref>		*No X-waiver or special certification is required to prescribe buprenorphine (eliminated January 2023 by the Consolidated Appropriations Act)<ref name="CAA2023">Consolidated Appropriations Act, 2023, Pub. L. No. 117-328, § 1262.</ref>
	*The ED is often the '''only point of healthcare contact''' for patients with OUD — every visit is an opportunity to initiate lifesaving treatment<ref name="ACEP2021">Hawk K, Hoppe J, Ketcham E, et al. Consensus Recommendations on the Treatment of Opioid Use Disorder in the Emergency Department. Ann Emerg Med. 2021;78(3):434-442.</ref>		*The ED is often the '''only point of healthcare contact''' for patients with OUD — every visit is an opportunity to initiate lifesaving treatment<ref name="ACEP2021">Hawk K, Hoppe J, Ketcham E, et al. Consensus Recommendations on the Treatment of Opioid Use Disorder in the Emergency Department. Ann Emerg Med. 2021;78(3):434-442.</ref>

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	*[[Special:MyLanguage/Rhabdomyolysis\|Rhabdomyolysis]] (prolonged immobilization during intoxication)		*[[Special:MyLanguage/Rhabdomyolysis\|Rhabdomyolysis]] (prolonged immobilization during intoxication)
	*Non-cardiogenic [[Special:MyLanguage/pulmonary edema\|pulmonary edema]] (post-overdose)		*Non-cardiogenic [[Special:MyLanguage/pulmonary edema\|pulmonary edema]] (post-overdose)
	*~~'''~~Xylazine ("tranq")~~'''~~-associated skin wounds: necrotic, non-healing ulcers at sites distant from injection; not reversed by [[Special:MyLanguage/naloxone\|naloxone]]<ref name="Friedman2022">Friedman J, Montero F, Bourgois P, et al. Xylazine spreads across the US: A growing component of the increasingly synthetic and polysubstance overdose crisis. Drug Alcohol Depend. 2022;233:109380.</ref>		*Xylazine ("tranq")-associated skin wounds: necrotic, non-healing ulcers at sites distant from injection; not reversed by [[Special:MyLanguage/naloxone\|naloxone]]<ref name="Friedman2022">Friedman J, Montero F, Bourgois P, et al. Xylazine spreads across the US: A growing component of the increasingly synthetic and polysubstance overdose crisis. Drug Alcohol Depend. 2022;233:109380.</ref>


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	===Workup===		===Workup===

	*~~'''~~No labs are required before initiating buprenorphine~~'''~~ — do not delay treatment for test results<ref name="ACEP2021"/><ref name="Hughes2024">Hughes T, Nasser N, Mitra A. Overview of best practices for buprenorphine initiation in the emergency department. Int J Emerg Med. 2024;17:23.</ref>		*No labs are required before initiating buprenorphine — do not delay treatment for test results<ref name="ACEP2021"/><ref name="Hughes2024">Hughes T, Nasser N, Mitra A. Overview of best practices for buprenorphine initiation in the emergency department. Int J Emerg Med. 2024;17:23.</ref>
	*Focused evaluation for common complications:		*Focused evaluation for common complications:
	**Point-of-care [[Special:MyLanguage/glucose\|glucose]] (rule out [[Special:MyLanguage/hypoglycemia\|hypoglycemia]])		**Point-of-care [[Special:MyLanguage/glucose\|glucose]] (rule out [[Special:MyLanguage/hypoglycemia\|hypoglycemia]])
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	===Diagnosis===		===Diagnosis===

	*~~'''~~DSM-5 criteria:~~'''~~ ≥2 of 11 criteria within a 12-month period (see below)<ref name="DSM5"/>		*DSM-5 criteria: ≥2 of 11 criteria within a 12-month period (see below)<ref name="DSM5"/>
	**Mild: 2-3 criteria; Moderate: 4-5 criteria; Severe: ≥6 criteria		**Mild: 2-3 criteria; Moderate: 4-5 criteria; Severe: ≥6 criteria
	*In the ED, a formal 11-criterion assessment is not necessary — '''a clinical diagnosis based on history is sufficient to initiate treatment'''<ref name="ACEP2021"/>		*In the ED, a formal 11-criterion assessment is not necessary — '''a clinical diagnosis based on history is sufficient to initiate treatment'''<ref name="ACEP2021"/>
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	**25-36: Moderately severe withdrawal		**25-36: Moderately severe withdrawal
	**>36: Severe withdrawal		**>36: Severe withdrawal
	*~~'''~~COWS ≥8~~'''~~ is the traditional threshold for buprenorphine induction, though emerging protocols allow initiation at lower scores or without formal COWS scoring<ref name="ASAM2023">Weimer MB, Herring AA, Kawasaki SS, et al. ASAM Clinical Considerations: Buprenorphine Treatment of OUD for Individuals Using High-potency Synthetic Opioids. J Addict Med. 2023;17(6):632-639.</ref>		*COWS ≥8 is the traditional threshold for buprenorphine induction, though emerging protocols allow initiation at lower scores or without formal COWS scoring<ref name="ASAM2023">Weimer MB, Herring AA, Kawasaki SS, et al. ASAM Clinical Considerations: Buprenorphine Treatment of OUD for Individuals Using High-potency Synthetic Opioids. J Addict Med. 2023;17(6):632-639.</ref>


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	*See [[Special:MyLanguage/Opioid overdose\|Opioid overdose]] for complete management		*See [[Special:MyLanguage/Opioid overdose\|Opioid overdose]] for complete management
	*~~'''~~[[Special:MyLanguage/Naloxone\|Naloxone]]~~'''~~ 0.04-0.4 mg IV (titrate to respiratory effort, not consciousness) — higher doses (2-4 mg) may be needed for fentanyl		*[[Special:MyLanguage/Naloxone\|Naloxone]] 0.04-0.4 mg IV (titrate to respiratory effort, not consciousness) — higher doses (2-4 mg) may be needed for fentanyl
	*Bag-valve mask ventilation is the primary intervention; naloxone is an adjunct		*Bag-valve mask ventilation is the primary intervention; naloxone is an adjunct
	*Post-reversal: observe for re-sedation (fentanyl's duration may exceed naloxone's half-life of 30-90 min)		*Post-reversal: observe for re-sedation (fentanyl's duration may exceed naloxone's half-life of 30-90 min)
	*~~'''~~Post-overdose is an ideal time to initiate buprenorphine~~'''~~ — see below		*Post-overdose is an ideal time to initiate buprenorphine — see below

	===Opioid Withdrawal Symptom Management===		===Opioid Withdrawal Symptom Management===

	*~~'''~~Buprenorphine is the treatment of choice~~'''~~ — treats withdrawal AND initiates OUD treatment simultaneously<ref name="ACEP2021"/>		*Buprenorphine is the treatment of choice — treats withdrawal AND initiates OUD treatment simultaneously<ref name="ACEP2021"/>
	*See {{Suboxone protocol}} for induction strategies		*See {{Suboxone protocol}} for induction strategies

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	*[[Special:MyLanguage/Hydroxyzine\|Hydroxyzine]] 25-50 mg PO for anxiety/insomnia (avoid benzodiazepines if possible)		*[[Special:MyLanguage/Hydroxyzine\|Hydroxyzine]] 25-50 mg PO for anxiety/insomnia (avoid benzodiazepines if possible)
	*IV fluids for dehydration		*IV fluids for dehydration
	*~~'''~~Avoid:~~'''~~ phenothiazines (lower seizure threshold), chronic benzodiazepine prescriptions		*Avoid: phenothiazines (lower seizure threshold), chronic benzodiazepine prescriptions

	===ED-Initiated Buprenorphine for OUD===		===ED-Initiated Buprenorphine for OUD===
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	*Precipitated withdrawal is managed with '''more buprenorphine''' (not less), plus adjunctive medications<ref name="Hughes2024"/>		*Precipitated withdrawal is managed with '''more buprenorphine''' (not less), plus adjunctive medications<ref name="Hughes2024"/>
	*Discharge with buprenorphine/naloxone prescription (16 mg/day × 7-14 day bridge supply)		*Discharge with buprenorphine/naloxone prescription (16 mg/day × 7-14 day bridge supply)
	*~~'''~~No X-waiver required~~'''~~<ref name="CAA2023"/>		*No X-waiver required<ref name="CAA2023"/>

	===Methadone in the ED===		===Methadone in the ED===
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	*ED physicians may administer (not prescribe) methadone for up to 72 hours for acute withdrawal under the '''72-hour rule''' (21 CFR §1306.07(b)) while arranging referral to an OTP<ref name="72hour">21 CFR §1306.07(b). Administering or dispensing of narcotic drugs.</ref>		*ED physicians may administer (not prescribe) methadone for up to 72 hours for acute withdrawal under the '''72-hour rule''' (21 CFR §1306.07(b)) while arranging referral to an OTP<ref name="72hour">21 CFR §1306.07(b). Administering or dispensing of narcotic drugs.</ref>
	*Starting dose: 20-30 mg PO; may give additional 5-10 mg after 2-4 hours if withdrawal persists (max 40 mg day 1)		*Starting dose: 20-30 mg PO; may give additional 5-10 mg after 2-4 hours if withdrawal persists (max 40 mg day 1)
	*~~'''~~Caution:~~'''~~ QTc prolongation risk, full agonist (no ceiling effect for respiratory depression), unpredictable half-life (8-59 hours)		*Caution: QTc prolongation risk, full agonist (no ceiling effect for respiratory depression), unpredictable half-life (8-59 hours)

	===Naltrexone===		===Naltrexone===
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	===Harm Reduction===		===Harm Reduction===

	*~~'''~~Naloxone kit~~'''~~ — prescribe or provide to every patient with OUD at discharge (and to household contacts)<ref name="ACEP2021"/>		*Naloxone kit — prescribe or provide to every patient with OUD at discharge (and to household contacts)<ref name="ACEP2021"/>
	*~~'''~~Fentanyl test strips~~'''~~ — where legal, offer to patients who use illicit substances		*Fentanyl test strips — where legal, offer to patients who use illicit substances
	*Counsel on safer use practices (never use alone, carry naloxone, avoid mixing with benzodiazepines/alcohol)		*Counsel on safer use practices (never use alone, carry naloxone, avoid mixing with benzodiazepines/alcohol)
	*Provide information on syringe services programs and supervised consumption sites where available		*Provide information on syringe services programs and supervised consumption sites where available
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	*Most patients with uncomplicated OUD or opioid withdrawal can be discharged from the ED		*Most patients with uncomplicated OUD or opioid withdrawal can be discharged from the ED
	*~~'''~~Discharge with:~~'''~~		*Discharge with:
	**Buprenorphine/naloxone prescription (7-14 day supply, typically 16 mg/day)		**Buprenorphine/naloxone prescription (7-14 day supply, typically 16 mg/day)
	**Naloxone kit (or prescription for naloxone)		**Naloxone kit (or prescription for naloxone)
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	===Follow-Up Resources===		===Follow-Up Resources===

	*~~'''~~SAMHSA National Helpline:~~'''~~ 1-800-662-4357 (referral and information, 24/7)		*SAMHSA National Helpline: 1-800-662-4357 (referral and information, 24/7)
	*~~'''~~PEPline (buprenorphine clinical questions):~~'''~~ 1-888-448-4911		*PEPline (buprenorphine clinical questions): 1-888-448-4911
	*~~'''~~SAMHSA Buprenorphine Practitioner Locator:~~'''~~ https://www.samhsa.gov/medications-substance-use-disorders/find-help		*SAMHSA Buprenorphine Practitioner Locator: https://www.samhsa.gov/medications-substance-use-disorders/find-help

Ostermayer: Created page with " ==Background== Opioid use disorder (OUD) is a chronic, relapsing medical condition defined as a problematic pattern of opioid use leading to clinically significant impairment or distressAmerican Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Washington, DC: APA; 2013. ~87,000 opioid-related overdose deaths in the US annually (2023-2024 data); fentanyl is now the dominant illicit..."

2026-03-10T17:53:28Z

Created page with "<languages/> <translate> ==Background== *Opioid use disorder (OUD) is a chronic, relapsing medical condition defined as a problematic pattern of opioid use leading to clinically significant impairment or distress<ref name="DSM5">American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Washington, DC: APA; 2013.</ref> *~87,000 opioid-related overdose deaths in the US annually (2023-2024 data); fentanyl is now the dominant illicit..."

New page

<languages/>
<translate>

==Background==

*Opioid use disorder (OUD) is a chronic, relapsing medical condition defined as a problematic pattern of opioid use leading to clinically significant impairment or distress<ref name="DSM5">American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Washington, DC: APA; 2013.</ref>
*~87,000 opioid-related overdose deaths in the US annually (2023-2024 data); fentanyl is now the dominant illicit opioid<ref name="CDC2024">CDC. Overdose Prevention: Drug Overdose Deaths. https://www.cdc.gov/overdose-prevention/</ref>
*Medications for opioid use disorder (MOUD) — [[Special:MyLanguage/buprenorphine|buprenorphine]], [[Special:MyLanguage/methadone|methadone]], and [[Special:MyLanguage/naltrexone|naltrexone]] — reduce all-cause mortality by '''50-80%'''<ref name="Sordo2017">Sordo L, Barrio G, Bravo MJ, et al. Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies. BMJ. 2017;357:j1550.</ref>
*ED-initiated buprenorphine '''increases 30-day treatment engagement ~5-fold''' compared to referral alone (D'Onofrio 2015 landmark RCT)<ref name="DOnofrio2015">D'Onofrio G, O'Connor PG, Pantalon MV, et al. Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial. JAMA. 2015;313(16):1636-1644.</ref>
*'''No X-waiver or special certification is required''' to prescribe buprenorphine (eliminated January 2023 by the Consolidated Appropriations Act)<ref name="CAA2023">Consolidated Appropriations Act, 2023, Pub. L. No. 117-328, § 1262.</ref>
*The ED is often the '''only point of healthcare contact''' for patients with OUD — every visit is an opportunity to initiate lifesaving treatment<ref name="ACEP2021">Hawk K, Hoppe J, Ketcham E, et al. Consensus Recommendations on the Treatment of Opioid Use Disorder in the Emergency Department. Ann Emerg Med. 2021;78(3):434-442.</ref>

==Clinical Features==

===Opioid Intoxication===

*[[Special:MyLanguage/Miosis|Miosis]] (pinpoint pupils — most reliable sign)
*[[Special:MyLanguage/Respiratory depression|Respiratory depression]] / bradypnea
*[[Special:MyLanguage/Altered mental status|Altered mental status]] / sedation / [[Special:MyLanguage/coma|coma]]
*[[Special:MyLanguage/Hypotension|Hypotension]], [[Special:MyLanguage/bradycardia|bradycardia]]
*Hypothermia
*Decreased bowel sounds
*Needle marks / track marks (may be absent with intranasal or smoked use)

===[[Special:MyLanguage/Opioid withdrawal|Opioid Withdrawal]]===

*Onset varies by substance: heroin 6-12 hrs, prescription opioids 8-24 hrs, fentanyl variable (lipophilic depot may delay onset), methadone 24-72 hrs
*Pupils: '''mydriasis''' (opposite of intoxication)
*GI: nausea, vomiting, diarrhea, abdominal cramping
*Musculoskeletal: myalgias, arthralgias
*Autonomic: diaphoresis, piloerection ("goose flesh"), rhinorrhea, lacrimation, yawning
*Neuropsychiatric: restlessness, insomnia, anxiety, irritability, cravings
*Vital signs: tachycardia, hypertension (mild)
*'''Opioid withdrawal is extremely uncomfortable but NOT life-threatening''' in otherwise healthy adults (unlike [[Special:MyLanguage/alcohol withdrawal|alcohol]] or [[Special:MyLanguage/benzodiazepine withdrawal|benzodiazepine]] withdrawal)
**Exception: neonatal abstinence syndrome, medically frail/pregnant patients — withdrawal may be dangerous in these populations

===Complications of Chronic OUD===

*[[Special:MyLanguage/Endocarditis|Infective endocarditis]] (right-sided > left-sided in IVDU; ''Staphylococcus aureus'' most common)
*[[Special:MyLanguage/Abscess|Soft tissue abscess]], [[Special:MyLanguage/cellulitis|cellulitis]], [[Special:MyLanguage/necrotizing fasciitis|necrotizing fasciitis]]
*[[Special:MyLanguage/Sepsis|Sepsis]] / bacteremia
*[[Special:MyLanguage/Deep vein thrombosis|DVT]], [[Special:MyLanguage/septic thrombophlebitis|septic thrombophlebitis]]
*[[Special:MyLanguage/Hepatitis B|Hepatitis B]], [[Special:MyLanguage/Hepatitis C|hepatitis C]], [[Special:MyLanguage/HIV|HIV]]
*[[Special:MyLanguage/Pulmonary embolism|Septic pulmonary emboli]], lung abscess
*Wound botulism (especially skin-popping black tar heroin)
*[[Special:MyLanguage/Rhabdomyolysis|Rhabdomyolysis]] (prolonged immobilization during intoxication)
*Non-cardiogenic [[Special:MyLanguage/pulmonary edema|pulmonary edema]] (post-overdose)
*'''Xylazine ("tranq")'''-associated skin wounds: necrotic, non-healing ulcers at sites distant from injection; not reversed by [[Special:MyLanguage/naloxone|naloxone]]<ref name="Friedman2022">Friedman J, Montero F, Bourgois P, et al. Xylazine spreads across the US: A growing component of the increasingly synthetic and polysubstance overdose crisis. Drug Alcohol Depend. 2022;233:109380.</ref>

==Differential Diagnosis==

===For Opioid Intoxication/Overdose===

*Other [[Special:MyLanguage/Toxidromes|toxidrome]]: [[Special:MyLanguage/sedative-hypnotic toxicity|sedative-hypnotics]], [[Special:MyLanguage/clonidine|clonidine]] / centrally-acting alpha-2 agonists, [[Special:MyLanguage/organophosphate toxicity|organophosphate poisoning]] (miosis + altered mental status)
*[[Special:MyLanguage/Hypoglycemia|Hypoglycemia]]
*[[Special:MyLanguage/Stroke|Stroke]], intracranial hemorrhage
*[[Special:MyLanguage/Sepsis|Sepsis]] / [[Special:MyLanguage/meningitis|meningitis]]
*[[Special:MyLanguage/Hypothermia|Hypothermia]]
*[[Special:MyLanguage/Carbon monoxide poisoning|Carbon monoxide poisoning]]
*Polysubstance ingestion (fentanyl commonly mixed with xylazine, benzodiazepines, stimulants)

===For Opioid Withdrawal===

*[[Special:MyLanguage/Gastroenteritis|Gastroenteritis]]
*[[Special:MyLanguage/Sepsis|Sepsis]] / infection
*[[Special:MyLanguage/Thyrotoxicosis|Thyrotoxicosis]]
*Stimulant intoxication ([[Special:MyLanguage/cocaine|cocaine]], [[Special:MyLanguage/amphetamine|amphetamine]])
*Other withdrawal syndromes ([[Special:MyLanguage/alcohol withdrawal|alcohol]], [[Special:MyLanguage/benzodiazepine withdrawal|benzodiazepines]])
*[[Special:MyLanguage/Anxiety|Anxiety]] / [[Special:MyLanguage/panic disorder|panic disorder]]

==Evaluation==

===Workup===

*'''No labs are required before initiating buprenorphine''' — do not delay treatment for test results<ref name="ACEP2021"/><ref name="Hughes2024">Hughes T, Nasser N, Mitra A. Overview of best practices for buprenorphine initiation in the emergency department. Int J Emerg Med. 2024;17:23.</ref>
*Focused evaluation for common complications:
**Point-of-care [[Special:MyLanguage/glucose|glucose]] (rule out [[Special:MyLanguage/hypoglycemia|hypoglycemia]])
**ECG (if concern for QTc prolongation from methadone, co-ingestions, or [[Special:MyLanguage/endocarditis|endocarditis]])
**CBC, BMP (if febrile, ill-appearing, or significant comorbidities)
**[[Special:MyLanguage/Lactate|Lactate]], [[Special:MyLanguage/blood cultures|blood cultures]] (if sepsis concern)
**[[Special:MyLanguage/Hepatic function panel|LFTs]] (not required prior to buprenorphine initiation but may be helpful for outpatient follow-up)
**Urine drug screen: may inform clinical picture but '''should not be used as a prerequisite''' for treatment; note that standard immunoassays do NOT detect fentanyl (requires specific fentanyl assay)<ref name="ACEP2021"/>
**Pregnancy test (informs formulation choice: buprenorphine monoproduct preferred in pregnancy)
*Screening for associated infections in IVDU patients when clinically indicated: [[Special:MyLanguage/Hepatitis C|hepatitis C]], [[Special:MyLanguage/HIV|HIV]], [[Special:MyLanguage/Hepatitis B|hepatitis B]] (can be performed as outpatient if not acutely relevant)

===Diagnosis===

*'''DSM-5 criteria:''' ≥2 of 11 criteria within a 12-month period (see below)<ref name="DSM5"/>
**Mild: 2-3 criteria; Moderate: 4-5 criteria; Severe: ≥6 criteria
*In the ED, a formal 11-criterion assessment is not necessary — '''a clinical diagnosis based on history is sufficient to initiate treatment'''<ref name="ACEP2021"/>
*Key ED diagnostic clues: recurrent overdoses, needle marks, withdrawal symptoms, requests for OUD treatment, opioid-positive UDS in clinical context
*[https://www.mdcalc.com/cows-score-opiate-withdrawal '''Clinical Opioid Withdrawal Scale (COWS)'''] — 11-item scoring tool to quantify withdrawal severity and guide induction timing:
**0-4: No withdrawal
**5-12: Mild withdrawal
**13-24: Moderate withdrawal
**25-36: Moderately severe withdrawal
**>36: Severe withdrawal
*'''COWS ≥8''' is the traditional threshold for buprenorphine induction, though emerging protocols allow initiation at lower scores or without formal COWS scoring<ref name="ASAM2023">Weimer MB, Herring AA, Kawasaki SS, et al. ASAM Clinical Considerations: Buprenorphine Treatment of OUD for Individuals Using High-potency Synthetic Opioids. J Addict Med. 2023;17(6):632-639.</ref>

==Management==

===Acute Opioid Overdose===

*See [[Special:MyLanguage/Opioid overdose|Opioid overdose]] for complete management
*'''[[Special:MyLanguage/Naloxone|Naloxone]]''' 0.04-0.4 mg IV (titrate to respiratory effort, not consciousness) — higher doses (2-4 mg) may be needed for fentanyl
*Bag-valve mask ventilation is the primary intervention; naloxone is an adjunct
*Post-reversal: observe for re-sedation (fentanyl's duration may exceed naloxone's half-life of 30-90 min)
*'''Post-overdose is an ideal time to initiate buprenorphine''' — see below

===Opioid Withdrawal Symptom Management===

*'''Buprenorphine is the treatment of choice''' — treats withdrawal AND initiates OUD treatment simultaneously<ref name="ACEP2021"/>
*See {{Suboxone protocol}} for induction strategies

'''Adjunctive symptom management (if buprenorphine not initiated or as supplemental therapy):'''
*[[Special:MyLanguage/Clonidine|Clonidine]] 0.1-0.2 mg PO/SL q4-6h for autonomic symptoms (max 0.8 mg/day; monitor for [[Special:MyLanguage/hypotension|hypotension]])
*[[Special:MyLanguage/Ondansetron|Ondansetron]] 4 mg IV/PO for nausea/vomiting
*[[Special:MyLanguage/Loperamide|Loperamide]] 4 mg PO initially, then 2 mg after each loose stool (max 16 mg/day)
*[[Special:MyLanguage/Ibuprofen|NSAIDs]] or [[Special:MyLanguage/Acetaminophen|acetaminophen]] for myalgias
*[[Special:MyLanguage/Dicyclomine|Dicyclomine]] 10-20 mg PO for abdominal cramping
*[[Special:MyLanguage/Hydroxyzine|Hydroxyzine]] 25-50 mg PO for anxiety/insomnia (avoid benzodiazepines if possible)
*IV fluids for dehydration
*'''Avoid:''' phenothiazines (lower seizure threshold), chronic benzodiazepine prescriptions

===ED-Initiated Buprenorphine for OUD===

'''This is the cornerstone of ED OUD management.'''<ref name="DOnofrio2015"/><ref name="ACEP2021"/><ref name="Hughes2024"/>

*Three induction strategies exist depending on withdrawal status — standard, high-dose (macro), and low-dose (micro)
*See [[Special:MyLanguage/Buprenorphine|Buprenorphine]] page and {{Suboxone protocol}} for detailed induction protocols

'''Key principles:'''
*Any patient with OUD who is willing to accept treatment should be offered buprenorphine
*'''Do not delay initiation for lab results, urine drug screen, or social work evaluation'''
*COWS ≥8 is traditional threshold; post-overdose patients can be inducted earlier while naloxone is still active
*Precipitated withdrawal is managed with '''more buprenorphine''' (not less), plus adjunctive medications<ref name="Hughes2024"/>
*Discharge with buprenorphine/naloxone prescription (16 mg/day × 7-14 day bridge supply)
*'''No X-waiver required'''<ref name="CAA2023"/>

===Methadone in the ED===

*Full mu-opioid agonist; available for OUD only through registered opioid treatment programs (OTPs)
*ED physicians may administer (not prescribe) methadone for up to 72 hours for acute withdrawal under the '''72-hour rule''' (21 CFR §1306.07(b)) while arranging referral to an OTP<ref name="72hour">21 CFR §1306.07(b). Administering or dispensing of narcotic drugs.</ref>
*Starting dose: 20-30 mg PO; may give additional 5-10 mg after 2-4 hours if withdrawal persists (max 40 mg day 1)
*'''Caution:''' QTc prolongation risk, full agonist (no ceiling effect for respiratory depression), unpredictable half-life (8-59 hours)

===Naltrexone===

*Long-acting mu-opioid antagonist; blocks opioid effects
*Must be opioid-free for '''7-10 days''' before initiation (risk of precipitated withdrawal)
*Not practical for ED initiation but may be referenced in follow-up planning
*Available as oral (50 mg daily) or IM depot (Vivitrol 380 mg monthly)

===Harm Reduction===

*'''Naloxone kit''' — prescribe or provide to every patient with OUD at discharge (and to household contacts)<ref name="ACEP2021"/>
*'''Fentanyl test strips''' — where legal, offer to patients who use illicit substances
*Counsel on safer use practices (never use alone, carry naloxone, avoid mixing with benzodiazepines/alcohol)
*Provide information on syringe services programs and supervised consumption sites where available
*Offer [[Special:MyLanguage/Hepatitis C|hepatitis C]] and [[Special:MyLanguage/HIV|HIV]] testing or referral

==Disposition==

===Discharge===

*Most patients with uncomplicated OUD or opioid withdrawal can be discharged from the ED
*'''Discharge with:'''
**Buprenorphine/naloxone prescription (7-14 day supply, typically 16 mg/day)
**Naloxone kit (or prescription for naloxone)
**Outpatient follow-up appointment with addiction medicine, primary care, or federally qualified health center that provides MOUD
**Written withdrawal management instructions (if home induction planned)
**Harm reduction resources
*Ensure patient has had resolution or improvement of withdrawal symptoms before discharge

===Admit===

*Medically complicated withdrawal (significant dehydration, electrolyte abnormalities, comorbid medical illness)
*OUD-related complications requiring inpatient management: [[Special:MyLanguage/endocarditis|endocarditis]], [[Special:MyLanguage/abscess|epidural or deep abscess]], [[Special:MyLanguage/osteomyelitis|osteomyelitis]], [[Special:MyLanguage/sepsis|sepsis]], [[Special:MyLanguage/necrotizing fasciitis|necrotizing fasciitis]]
*Post-overdose with persistent respiratory depression, [[Special:MyLanguage/pulmonary edema|non-cardiogenic pulmonary edema]], or [[Special:MyLanguage/aspiration pneumonitis|aspiration]]
*Concurrent alcohol or benzodiazepine withdrawal requiring monitored detoxification
*Pregnancy with uncontrolled withdrawal (risk to fetus)
*Suicidal ideation or acute psychiatric emergency co-occurring with OUD
*Failed outpatient management or patient without safe discharge plan

===Post-Overdose Observation===

*Patients reversed with naloxone should be observed for '''at least 1 hour''' after last naloxone dose (longer if sustained-release opioid or fentanyl suspected, where re-sedation risk is higher)<ref name="ACEP2021"/>
*Use the observation period to engage patient in OUD treatment discussion and buprenorphine initiation

===Follow-Up Resources===

*'''SAMHSA National Helpline:''' 1-800-662-4357 (referral and information, 24/7)
*'''PEPline (buprenorphine clinical questions):''' 1-888-448-4911
*'''SAMHSA Buprenorphine Practitioner Locator:''' https://www.samhsa.gov/medications-substance-use-disorders/find-help

==See Also==

*[[Special:MyLanguage/Opioid overdose|Opioid overdose]]
*[[Special:MyLanguage/Opioid withdrawal|Opioid withdrawal]]
*[[Special:MyLanguage/Buprenorphine|Buprenorphine]]
*[[Special:MyLanguage/Naloxone|Naloxone]]
*[[Special:MyLanguage/Methadone|Methadone]]
*[[Special:MyLanguage/Naltrexone|Naltrexone]]
*[[Special:MyLanguage/Endocarditis|Endocarditis]]
*[[Special:MyLanguage/Toxidromes|Toxidromes]]

==External Links==

*[https://medicine.yale.edu/edbup/ Yale ED-Initiated Buprenorphine Resource Center]
*[https://www.acep.org/by-medical-focus/mental-health-and-substanc-use-disorders/opioids/opioid-case-management ACEP Opioid Use Disorder Resources]
*[https://www.mdcalc.com/cows-score-opiate-withdrawal COWS Score Calculator (MDCalc)]
*[https://www.samhsa.gov/medications-substance-use-disorders SAMHSA Medications for Substance Use Disorders]

==References==
{{Reflist|2}}
[[Category:Pharmacology]]
</translate>

← Older revision		Revision as of 09:13, 22 March 2026
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	*Opioid use disorder (OUD) is a chronic, relapsing medical condition defined as a problematic pattern of opioid use leading to clinically significant impairment or distress<ref name="DSM5">American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Washington, DC: APA; 2013.</ref>		*Opioid use disorder (OUD) is a chronic, relapsing medical condition defined as a problematic pattern of opioid use leading to clinically significant impairment or distress<ref name="DSM5">American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Washington, DC: APA; 2013.</ref>
	*~87,000 opioid-related overdose deaths in the US annually (2023-2024 data); fentanyl is now the dominant illicit opioid<ref name="CDC2024">CDC. Overdose Prevention: Drug Overdose Deaths. https://www.cdc.gov/overdose-prevention/</ref>		*~87,000 opioid-related overdose deaths in the US annually (2023-2024 data); fentanyl is now the dominant illicit opioid<ref name="CDC2024">CDC. Overdose Prevention: Drug Overdose Deaths. https://www.cdc.gov/overdose-prevention/</ref>
	*Medications for opioid use disorder (MOUD) — [[Special:MyLanguage/buprenorphine\|buprenorphine]], [[Special:MyLanguage/methadone\|methadone]], and [[Special:MyLanguage/naltrexone\|naltrexone]] — reduce all-cause mortality by ~~'''~~50-80%~~'''~~<ref name="Sordo2017">Sordo L, Barrio G, Bravo MJ, et al. Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies. BMJ. 2017;357:j1550.</ref>		*Medications for opioid use disorder (MOUD) — [[Special:MyLanguage/buprenorphine\|buprenorphine]], [[Special:MyLanguage/methadone\|methadone]], and [[Special:MyLanguage/naltrexone\|naltrexone]] — reduce all-cause mortality by 50-80%<ref name="Sordo2017">Sordo L, Barrio G, Bravo MJ, et al. Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies. BMJ. 2017;357:j1550.</ref>
	*ED-initiated buprenorphine '''increases 30-day treatment engagement ~5-fold''' compared to referral alone (D'Onofrio 2015 landmark RCT)<ref name="DOnofrio2015">D'Onofrio G, O'Connor PG, Pantalon MV, et al. Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial. JAMA. 2015;313(16):1636-1644.</ref>		*ED-initiated buprenorphine '''increases 30-day treatment engagement ~5-fold''' compared to referral alone (D'Onofrio 2015 landmark RCT)<ref name="DOnofrio2015">D'Onofrio G, O'Connor PG, Pantalon MV, et al. Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial. JAMA. 2015;313(16):1636-1644.</ref>
	*No X-waiver or special certification is required to prescribe buprenorphine (eliminated January 2023 by the Consolidated Appropriations Act)<ref name="CAA2023">Consolidated Appropriations Act, 2023, Pub. L. No. 117-328, § 1262.</ref>		*No X-waiver or special certification is required to prescribe buprenorphine (eliminated January 2023 by the Consolidated Appropriations Act)<ref name="CAA2023">Consolidated Appropriations Act, 2023, Pub. L. No. 117-328, § 1262.</ref>
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	*Onset varies by substance: heroin 6-12 hrs, prescription opioids 8-24 hrs, fentanyl variable (lipophilic depot may delay onset), methadone 24-72 hrs		*Onset varies by substance: heroin 6-12 hrs, prescription opioids 8-24 hrs, fentanyl variable (lipophilic depot may delay onset), methadone 24-72 hrs
	*Pupils: ~~'''~~mydriasis~~'''~~ (opposite of intoxication)		*Pupils: mydriasis (opposite of intoxication)
	*GI: nausea, vomiting, diarrhea, abdominal cramping		*GI: nausea, vomiting, diarrhea, abdominal cramping
	*Musculoskeletal: myalgias, arthralgias		*Musculoskeletal: myalgias, arthralgias
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	*DSM-5 criteria: ≥2 of 11 criteria within a 12-month period (see below)<ref name="DSM5"/>		*DSM-5 criteria: ≥2 of 11 criteria within a 12-month period (see below)<ref name="DSM5"/>
	**Mild: 2-3 criteria; Moderate: 4-5 criteria; Severe: ≥6 criteria		**Mild: 2-3 criteria; Moderate: 4-5 criteria; Severe: ≥6 criteria
	*In the ED, a formal 11-criterion assessment is not necessary — ~~'''~~a clinical diagnosis based on history is sufficient to initiate treatment~~'''~~<ref name="ACEP2021"/>		*In the ED, a formal 11-criterion assessment is not necessary — a clinical diagnosis based on history is sufficient to initiate treatment<ref name="ACEP2021"/>
	*Key ED diagnostic clues: recurrent overdoses, needle marks, withdrawal symptoms, requests for OUD treatment, opioid-positive UDS in clinical context		*Key ED diagnostic clues: recurrent overdoses, needle marks, withdrawal symptoms, requests for OUD treatment, opioid-positive UDS in clinical context
	*[https://www.mdcalc.com/cows-score-opiate-withdrawal ~~'''~~Clinical Opioid Withdrawal Scale (COWS)~~'''~~] — 11-item scoring tool to quantify withdrawal severity and guide induction timing:		*[https://www.mdcalc.com/cows-score-opiate-withdrawal Clinical Opioid Withdrawal Scale (COWS)] — 11-item scoring tool to quantify withdrawal severity and guide induction timing:
	**0-4: No withdrawal		**0-4: No withdrawal
	**5-12: Mild withdrawal		**5-12: Mild withdrawal
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	*See {{Suboxone protocol}} for induction strategies		*See {{Suboxone protocol}} for induction strategies

	~~'''~~Adjunctive symptom management (if buprenorphine not initiated or as supplemental therapy):~~'''~~		Adjunctive symptom management (if buprenorphine not initiated or as supplemental therapy):
	*[[Special:MyLanguage/Clonidine\|Clonidine]] 0.1-0.2 mg PO/SL q4-6h for autonomic symptoms (max 0.8 mg/day; monitor for [[Special:MyLanguage/hypotension\|hypotension]])		*[[Special:MyLanguage/Clonidine\|Clonidine]] 0.1-0.2 mg PO/SL q4-6h for autonomic symptoms (max 0.8 mg/day; monitor for [[Special:MyLanguage/hypotension\|hypotension]])
	*[[Special:MyLanguage/Ondansetron\|Ondansetron]] 4 mg IV/PO for nausea/vomiting		*[[Special:MyLanguage/Ondansetron\|Ondansetron]] 4 mg IV/PO for nausea/vomiting
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	===ED-Initiated Buprenorphine for OUD===		===ED-Initiated Buprenorphine for OUD===

	~~'''~~This is the cornerstone of ED OUD management.~~'''~~<ref name="DOnofrio2015"/><ref name="ACEP2021"/><ref name="Hughes2024"/>		This is the cornerstone of ED OUD management.<ref name="DOnofrio2015"/><ref name="ACEP2021"/><ref name="Hughes2024"/>

	*Three induction strategies exist depending on withdrawal status — standard, high-dose (macro), and low-dose (micro)		*Three induction strategies exist depending on withdrawal status — standard, high-dose (macro), and low-dose (micro)
	*See [[Special:MyLanguage/Buprenorphine\|Buprenorphine]] page and {{Suboxone protocol}} for detailed induction protocols		*See [[Special:MyLanguage/Buprenorphine\|Buprenorphine]] page and {{Suboxone protocol}} for detailed induction protocols

	~~'''~~Key principles:~~'''~~		Key principles:
	*Any patient with OUD who is willing to accept treatment should be offered buprenorphine		*Any patient with OUD who is willing to accept treatment should be offered buprenorphine
	*'''Do not delay initiation for lab results, urine drug screen, or social work evaluation'''		*'''Do not delay initiation for lab results, urine drug screen, or social work evaluation'''
	*COWS ≥8 is traditional threshold; post-overdose patients can be inducted earlier while naloxone is still active		*COWS ≥8 is traditional threshold; post-overdose patients can be inducted earlier while naloxone is still active
	*Precipitated withdrawal is managed with ~~'''~~more buprenorphine~~'''~~ (not less), plus adjunctive medications<ref name="Hughes2024"/>		*Precipitated withdrawal is managed with more buprenorphine (not less), plus adjunctive medications<ref name="Hughes2024"/>
	*Discharge with buprenorphine/naloxone prescription (16 mg/day × 7-14 day bridge supply)		*Discharge with buprenorphine/naloxone prescription (16 mg/day × 7-14 day bridge supply)
	*No X-waiver required<ref name="CAA2023"/>		*No X-waiver required<ref name="CAA2023"/>
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	*Full mu-opioid agonist; available for OUD only through registered opioid treatment programs (OTPs)		*Full mu-opioid agonist; available for OUD only through registered opioid treatment programs (OTPs)
	*ED physicians may administer (not prescribe) methadone for up to 72 hours for acute withdrawal under the ~~'''~~72-hour rule~~'''~~ (21 CFR §1306.07(b)) while arranging referral to an OTP<ref name="72hour">21 CFR §1306.07(b). Administering or dispensing of narcotic drugs.</ref>		*ED physicians may administer (not prescribe) methadone for up to 72 hours for acute withdrawal under the 72-hour rule (21 CFR §1306.07(b)) while arranging referral to an OTP<ref name="72hour">21 CFR §1306.07(b). Administering or dispensing of narcotic drugs.</ref>
	*Starting dose: 20-30 mg PO; may give additional 5-10 mg after 2-4 hours if withdrawal persists (max 40 mg day 1)		*Starting dose: 20-30 mg PO; may give additional 5-10 mg after 2-4 hours if withdrawal persists (max 40 mg day 1)
	*Caution: QTc prolongation risk, full agonist (no ceiling effect for respiratory depression), unpredictable half-life (8-59 hours)		*Caution: QTc prolongation risk, full agonist (no ceiling effect for respiratory depression), unpredictable half-life (8-59 hours)
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	*Long-acting mu-opioid antagonist; blocks opioid effects		*Long-acting mu-opioid antagonist; blocks opioid effects
	*Must be opioid-free for ~~'''~~7-10 days~~'''~~ before initiation (risk of precipitated withdrawal)		*Must be opioid-free for 7-10 days before initiation (risk of precipitated withdrawal)
	*Not practical for ED initiation but may be referenced in follow-up planning		*Not practical for ED initiation but may be referenced in follow-up planning
	*Available as oral (50 mg daily) or IM depot (Vivitrol 380 mg monthly)		*Available as oral (50 mg daily) or IM depot (Vivitrol 380 mg monthly)
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	===Post-Overdose Observation===		===Post-Overdose Observation===

	*Patients reversed with naloxone should be observed for ~~'''~~at least 1 hour~~'''~~ after last naloxone dose (longer if sustained-release opioid or fentanyl suspected, where re-sedation risk is higher)<ref name="ACEP2021"/>		*Patients reversed with naloxone should be observed for at least 1 hour after last naloxone dose (longer if sustained-release opioid or fentanyl suspected, where re-sedation risk is higher)<ref name="ACEP2021"/>
	*Use the observation period to engage patient in OUD treatment discussion and buprenorphine initiation		*Use the observation period to engage patient in OUD treatment discussion and buprenorphine initiation