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Clinical protocols for patients with opioid use disorder in a hospital or emergency department setting.

Buprenorphine Initiation

COWS ≥ 4

Considerations

Higher doses of buprenorphine have been found to be very safe in the adult population.

Risk of precipitated withdrawal is low with high dose protocol.

Providers should engage in shared decision making with the patient prior to initiating treatment.

Potential complicating actors include: 

  • Allergy or sensitivity
  • Severe respiratory compromise 
  • Chronic use of long acting opioids (e.g., methadone or oxycontin) 

Consider expert consultation, but prioritize treating symptoms.

Consider screening for HIV, HCV, STIs, and mental health comorbidities.

flow-chart

If your patient is under 18, review the Adolescent Buprenorphine Initiation protocol.

Treat withdrawal symptoms with Adjunct Medications.

If your patient’s COWS score has increased by 5 or more, review the Precipitated Withdrawal protocol.

Nursing Considerations

Because it is a partial agonist, if the first dose of buprenorphine is administered too soon after recent full agonist opioid use in a patient with opioid dependence, there is a risk of precipitated withdrawal. If this happens, additional doses of buprenorphine and medications for alleviating withdrawal symptoms should be administered immediately as ordered. 

Educate the patient on the correct administration of the medication. Ensure the patient understands that buprenorphine is taken under the tongue and is not absorbed in the stomach; it can take 5 to 10 minutes for the medication to fully absorb, and that the patient should avoid eating, drinking, smoking, or talking while taking buprenorphine. 

Prior to discharge, educate patients about the risk of overdose and death when using buprenorphine with other sedatives, such as alcohol or benzodiazepines. Provide a work note if needed.  They should not drive or operate heavy machinery until they are used to the medicine. Ensure patient is discharged with naloxone and overdose prevention education. 

Help the patient schedule a follow-up appointment. The Washington Recovery Helpline MOUD Locator (online or at 1-866-789-1511) is a good resource for finding OUD treatment in Washington. Ensure the patient is provided with a buprenorphine prescription to last until their scheduled outpatient MOUD appointment. If there is not an appointment scheduled, provide at least 7-14 days to allow time for the patient to secure an appointment. 

Opioid use disorder is a treatable health condition. It often takes multiple treatment attempts for patients to recover. Stopping substance use is extremely challenging. Patients should be supported regardless of how many times they ask for help. Even the most severe cases do recover. 

Patients with OUD or other substance use disorders experience a great deal of stigma and often have high levels of anxiety related to previous negative healthcare experiences. Research shows that stigma, bias, and even perceived judgment worsens symptoms and prolongs recovery. It’s vital to treat patients in a caring and supportive manner.

Discharge Instructions

Information about buprenorphine

  • Buprenorphine is a long-acting medication used to treat opioid use disorder. Long-acting means the medication acts slower in the body for a longer time. It is a partial opioid agonist, which means that it partially activates the opioid receptors in the body.
  • When taken as directed, buprenorphine helps people with opioid use disorder get out of the cycle of use and withdrawal, feel more stable, and have a chance to focus on other aspects of their lives so they can recover.
  • When used as prescribed, buprenorphine significantly reduces the risk of opioid overdose if you take other opioids.
  • Buprenorphine-naloxone contains naloxone in addition to the buprenorphine. The naloxone is not absorbed when the medication is taken as directed (under the tongue). If the medication is injected, the naloxone will be absorbed and can cause severe opioid withdrawal.
  • Buprenorphine is safe and there is no limit to how long a person can take the medication. It is recommended that most people be on the medication long-term.
  • Side effects may occur and are typically mild and improve over time. They can include constipation, sweating, headache, dizziness, trouble sleeping, nausea, and sleepiness. If these occur notify your healthcare provider, nurse, or pharmacist.
  • Over time, your body will get used to the medicine. If you stop taking it suddenly, you will feel withdrawal symptoms within a few days.

How to take the medication

  • You will receive the medication in either film or tablet form.
  • Do not swallow the medicine; it will not work if it is swallowed.
  • Place medication under your tongue and allow it to completely dissolve; this can take 5-15 minutes. Drinking water before taking the medication can help it dissolve faster. Do not drink water while the medication is under the tongue.
  • Do not eat, drink, talk, or smoke while the medication is dissolving.
  • Do not smoke, eat or drink anything for at least 15 minutes after it has dissolved.
  • To prevent tooth decay, rinse your mouth with water 30 minutes after you take the medication.

CAUTION

  • Continue to take your regular buprenorphine dose, even after you feel better. Stopping buprenorphine may cause withdrawal and cravings to use other opioids, and your risk of opioid overdose will be much higher if you do use opioids without being on this medication.
  • Don’t take other sedatives, like benzodiazepines or alcohol. The combination could make you so sleepy that you stop breathing. Talk to your healthcare provider, nurse, and pharmacist about what other medications and substances you are taking.
  • Do not drive while you are starting buprenorphine because it may slow your reaction time. Wait until you know how this medication affects you.
  • Remember that changes in use patterns can alter tolerance and increase your risk of opioid overdose. If you use other opioids, take steps to reduce the risk associated with overdose, like having naloxone, not using alone or calling the Never Use Alone lifeline (877-696-1996), and starting low and going slow.
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Buprenorphine Home Initiation

COWS < 4

Considerations

Inform patient about the risk of precipitated withdrawal.

Moderate withdrawal in this case means 3 or more symptoms of withdrawal.

Consider screening for HIV, HCV, STIs, and mental health comorbidities

flow-chart

Nursing Considerations

Inform the patient about the risk of precipitated withdrawal and reinforce the need to have 3 or more symptoms of withdrawal before starting buprenorphine at home. 

Ensure the patient has prescriptions to help manage withdrawal symptoms and review these medications with the patient. Educate the patient on the correct administration of the medication. Ensure the patient understands that buprenorphine is taken under the tongue and is not absorbed in the stomach; it can take 5 to 10 minutes for the medication to fully absorb, and that the patient should avoid eating, drinking, smoking, or talking while taking buprenorphine. 

Help the patient schedule a follow-up appointment. The Washington Recovery Helpline MOUD Locator (online or at 1-866-789-1511) is a good resource for finding OUD treatment in Washington. Ensure the patient is provided with a buprenorphine prescription to last until their scheduled outpatient MOUD appointment. If there is not an appointment scheduled, provide at least 7-14 days to allow time for the patient to secure an appointment.

Prior to discharge, educate patients about the risk of overdose and death when using buprenorphine with other sedatives, such as alcohol or benzodiazepines. Provide a work note if needed. They should not drive or operate heavy machinery until they are used to the medicine. Ensure patient is discharged with naloxone and overdose prevention education.

Opioid use disorder is a treatable health condition. It often takes multiple treatment attempts for patients to recover. Stopping substance use is extremely challenging. Patients should be supported regardless of how many times they ask for help. Even the most severe cases do recover.

Patients with OUD or other substance use disorders experience a great deal of stigma and often have high levels of anxiety related to previous negative healthcare experiences. Research shows that stigma, bias, and even perceived judgment worsens symptoms and prolongs recovery. It’s vital to treat patients in a caring and supportive manner.

Discharge Instructions

DAY ONE 

Wait at least 12-24 hours since your last opioid use. Take other prescribed medications to treat symptoms.

When you are in moderate withdrawal (3 or more symptoms) take 2 tablets or films at once (16 mg). Wait 30-60 minutes.

Take an additional 1-2 tablets or films if needed. Do not take more than 4 tablets or films (32 mg total) on day 1.

DAY TWO

Take 1 tablet or film (8 mg) in the morning, afternoon, and evening. Continue taking it three times daily until your next visit.

Click here for more information on how to start buprenorphine at home.

Information about buprenorphine

  • Buprenorphine is a long-acting medication used to treat opioid use disorder. Long-acting means the medication acts slower in the body for a longer time. It is a partial opioid agonist, which means that it partially activates the opioid receptors in the body.
  • When taken as directed, buprenorphine helps people with opioid use disorder get out of the cycle of use and withdrawal, feel more stable, and have a chance to focus on other aspects of their lives so they can recover.
  • When used as prescribed, buprenorphine significantly reduces the risk of opioid overdose if you take other opioids.
  • Buprenorphine-naloxone contains naloxone in addition to the buprenorphine. The naloxone is not absorbed when the medication is taken as directed (under the tongue). If the medication is injected, the naloxone will be absorbed and can cause severe opioid withdrawal.
  • Buprenorphine is safe and there is no limit to how long a person can take the medication. It is recommended that most people be on the medication long-term.
  • Side effects may occur and are typically mild and improve over time. They can include constipation, sweating, headache, dizziness, trouble sleeping, nausea, and sleepiness. If these occur, notify your healthcare provider, nurse, or pharmacist.
  • Over time, your body will get used to the medicine. If you stop taking it suddenly, you will feel withdrawal symptoms within a few days.

How to take the medication

  • You will receive the medication in either film or tablet form.
  • Do not swallow the medicine; it will not work if it is swallowed.
  • Place medication under your tongue and allow it to completely dissolve; this can take 5-15 minutes. Drinking water before taking the medication can help it dissolve faster. Do not drink water while the medication is under the tongue.
  • Do not eat, drink, talk, or smoke while the medication is dissolving.
  • Do not smoke, eat or drink anything for at least 15 minutes after it has dissolved.
  • To prevent tooth decay, rinse your mouth with water 30 minutes after you take the medication.

CAUTION

  • Continue to take your regular buprenorphine dose, even after you feel better. Stopping buprenorphine may cause withdrawal and cravings to use other opioids, and your risk of opioid overdose will be much higher if you do use opioids without being on this medication.
  • Don’t take other sedatives, like benzodiazepines or alcohol. The combination could make you so sleepy that you stop breathing. Talk to your healthcare provider, nurse, and pharmacist about what other medications and substances you are taking.
  • Do not drive while you are starting buprenorphine because it may slow your reaction time. Wait until you know how this medication affects you.
  • Remember that changes in use patterns can alter tolerance and increase your risk of opioid overdose. If you use other opioids, take steps to reduce the risk associated with overdose, like having naloxone, not using alone or calling the Never Use Alone lifeline (877-696-1996), and starting low and going slow.
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Precipitated Withdrawal

Considerations

In the setting of precipitated withdrawal, consider other medical problems such as sepsis, cardiac conditions, DKA, thyroid disorders, co-ingestions, etc.

Use caution when giving the patient multiple different medications that can suppress respiratory drive.

Medications used to sedate an agitated patient or keep them from behavior that poses harm to themselves, or others, may be considered a chemical restraint.

flow-chart

Nursing Considerations

A patient with moderate to high serum opioid levels may experience severe withdrawal symptoms if they are given naloxone (e.g., to reverse an opioid overdose) or buprenorphine, which precipitates withdrawal. 

A rapid increase in COWS score 30 minutes after initial dose of buprenorphine may be precipitated withdrawal. Believe your patients reported withdrawal symptoms. Withdrawal can be excruciating. Listen to your patient and advocate for them. Quickly inform the provider if precipitated withdrawal occurs. 

Withdrawal symptom management medications and medications for opioid use disorder should be made available ASAP to alleviate symptoms and avoid self-discharge/patient leaving AMA. 

Help the patient get comfortable. Offer cool compress for head, emesis basin/bag, turn lights off and provide a quiet environment until medications take effect. Reassess every 1 hour until symptoms are stable. 

Opioid use disorder is a treatable health condition. It often takes multiple treatment attempts for patients to recover. Stopping substance use is extremely challenging. Patients should be supported regardless of how many times they ask for help. Even the most severe cases do recover. 

Patients with OUD or other substance use disorders experience a great deal of stigma and often have high levels of anxiety related to previous negative healthcare experiences. Research shows that stigma, bias, and even perceived judgment worsens symptoms and prolongs recovery. It’s vital to treat patients in a caring and supportive manner.

Discharge Instructions

Continue taking buprenorphine. Buprenorphine only causes severe withdrawal symptoms when you have high levels of opioids in your system. When you are farther out from your last dose of opioids, buprenorphine makes withdrawal and cravings better, not worse. You’ve made it through the hardest part — it gets easier from here.

Other medications were prescribed to help with nausea, agitation, difficulty sleeping, belly cramping, etc. Ask your provider about these medications and continue to treat symptoms that are giving you trouble. You can also take over-the-counter ibuprofen and acetaminophen for pain. 

Remember that changes in use patterns can alter tolerance and increase your risk of opioid overdose. If you use other opioids, take steps to reduce the risk associated with overdose, like having naloxone, not using alone or calling the Never Use Alone lifeline (877-696-1996), and starting low and going slow.

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Methadone Initiation

Methadone dispensation

Patient may be discharged with up to 72 hours worth of methadone while awaiting connection to an OTP per the 72 hour rule per 21 CFR 1306.07(b). Connecting the patient to an OTP is required if dispensing medication.

Considerations

  • Age over 65 
  • Concurrent sedative use
  • COPD with oxygen requirement
  • Underlying heart disease (potential for QT prolongation)

It is vital to determine whether the patient can successfully connect to an OTP. Consider the daily dosing requirement, distance from and transportation to the OTP, and if the OTP is taking new patients. It is best to schedule the OTP appointment before discharge, and the patient must be linked to the OTP within 72 hours. Fully inform patient of OTP process and expectations.

Communicate with the OTP. At a minimum, the OTP needs documentation of what date/time the patient was given their dose and what their dosing regimen is. Call, if possible, and fax and provide the info to the patient to bring to the OTP.

Consider screening for HIV, HCV, STIs, and mental health comorbidities.

Methadone can have significant drug-drug interactions, which should be reviewed prior to initiation.

flow-chart

Treat withdrawal symptoms with Adjunct Medications.

Nursing Considerations

Outside of the hospital, methadone can only be obtained at a specialty clinic known as an opioid treatment program (OTP). Make sure your patient will be able to connect with an OTP for ongoing care. They will need to present to the OTP daily to receive their dose – ensure they are aware of this and have a plan for transportation. If a patient is unable to connect with an OTP for ongoing care, they should not start methadone. Explore buprenorphine as a treatment option instead. 

Connect the patient to care at the OTP: Provide information on where to go and when, sign ROI if needed, and fax referral paperwork that includes the dose received in the ED and what doses they were discharged with. Provide the patient with discharge instructions or a signed note that includes time of last dose, and when to take the next dose. 

Because of the cumulative effects of methadone, which is a long-acting opioid, methadone doses are started low and slowly up-titrated until an adequate dose is achieved over days or weeks. The initial dose of methadone is not usually enough to adequately manage withdrawal, and patients commonly need adjunct medications to control withdrawal symptoms until an adequate dose is achieved. Advocate for prescriptions for appropriate adjunct medications. Symptoms may be better controlled with b.i.d. dosing. Ensure patient understands importance of taking the medication every day at about the same time. 

Federal rules allow for hospitals to provide methadone to treat opioid withdrawal and initiate medications to treat opioid use disorder. Patients can be sent home with up to a 3-day (72 hour) supply of methadone for OUD if they are referred to an OTP for ongoing care. This can bridge the gap between discharge and follow up. 

Opioid use disorder is a treatable health condition. It often takes multiple treatment attempts for patients to recover. Stopping substance use is extremely challenging. Patients should be supported regardless of how many times they ask for help. Even the most severe cases do recover. 

Patients with OUD or other substance use disorders experience a great deal of stigma and often have high levels of anxiety related to previous negative healthcare experiences. Research shows that stigma, bias, and even perceived judgment worsens symptoms and prolongs recovery. It’s vital to treat patients in a caring and supportive manner.

Discharge Instructions

Information about methadone

  • Methadone is a long-acting opioid medication. Long-acting means that the drug acts slower in the body for a longer period of time.
  • Methadone is prescribed to treat opioid use disorder by preventing withdrawal symptoms and reducing cravings. When taken as directed, methadone reduces the need for other opioids and gives individuals a chance to stabilize their lives. Methadone is a safe, effective medication that can be used for long term management of opioid use disorder.
  • Because of the cumulative effects of methadone, doses are started low and slowly up-titrated until an adequate dose is achieved over days or weeks. You may need other medications during this time to help you manage symptoms of withdrawal. Ask your provider about these medications and take them for symptoms that are giving you trouble. You can also take over-the-counter ibuprofen and acetaminophen for pain.
  • Common side effects of methadone include constipation, sweating, dry mouth, changes in sex drive, drowsiness, light-headedness, nausea and vomiting, and weight gain.
  • Over time, your body will get used to the medicine. If you stop taking it suddenly, you will feel withdrawal symptoms within a few days.

Getting methadone

  • Methadone can only be obtained from a specialty clinic, known as an opioid treatment provider (OTP).
  • You may need to go in person to the OTP daily to receive your dose of methadone. Over time, you may be able to receive “take home” doses, but you will still need to go in person regularly.
  • Do not start methadone if you cannot connect with an OTP for ongoing care. Ask your provider about buprenorphine instead.

CAUTION

  • Don’t take other sedatives, like opioids, benzodiazepines, or alcohol. The combination could make you so sleepy that you stop breathing. Talk to your healthcare provider, nurse, and pharmacist about what other medications and substances you are taking.
  • Do not drive while you are starting methadone because it may slow your reaction time. Wait until you know how this medication affects you.
  • Remember that changes in use patterns can alter tolerance and increase your risk of opioid overdose. If you use other opioids, take steps to reduce the risk associated with overdose, like having naloxone, not using alone or calling the Never Use Alone lifeline (877-696-1996), and starting low and going slow.
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Pain Management

Considerations

  • Full agonist opioids can be used in addition to buprenorphine. Full agonists will need to be given at higher doses than normal because the buprenorphine will competitively occupy opioid receptors.
  • Patients with OUD have a higher tolerance to opioids and often need 2-3x the usual dose to adequately control pain. The risk of respiratory depression in this case is very low, especially if the patient is being monitored. If their vitals remain within normal limits, the dose is not too high.

Treating an acute painful condition does not worsen a patient's OUD.

Consider screening for HIV, HCV, STIs, and mental health comorbidities.

flow-chart

If your patient wants to start methadone, review the Methadone Initiation protocol.

If your patient wants to start buprenorphine and is being admitted, review the Buprenorphine with Acute Pain protocol.

If your patient wants to start buprenorphine and is not being admitted, review the Buprenorphine Home Initiation protocol.

If your patient is still in pain, review the Patient-Controlled Analgesia protocol.

Nursing Considerations

Patients taking opioid agonist medications for opioid use disorder (MOUD), like buprenorphine (sublingual or long-acting injectable) or methadone, should continue their regular dose throughout their stay to improve outcomes. 

Patients on MOUD that have severe acute pain (e.g., from amputations, large wounds, fractures, surgeries, etc.) are likely to need additional opioids to manage pain. 

MOUD treats opioid use disorder, it does not adequately manage severe acute pain. Patients with OUD/on MOUD often need higher doses of opioids than other patients with same source of acute pain typically require, often double the dose. This is due to tolerance and pharmacology of MOUD. If the patient's vital signs are within normal limits, the dose is not too high.

Adequately treating pain often requires a multi-modal approach. Additional pharmacological and non-pharmacological pain management techniques should be explored. Adjunct medications (e.g., NSAIDs, acetaminophen, hydroxyzine, clonidine) may also reduce the dose of opioid needed to control pain. 

Many patients will experience anxiety related to under-treated pain. 

If a patient is on sublingual buprenorphine, increased and/or split dosing (e.g., t.i.d.) may help control pain better than a once daily dose. 

If patients are discharged with an additional prescription opioid, ensure they continue to take their MOUD and have a plan to taper off the short-term opioid. Patients may need additional support with medication management during this time. 

Opioid use disorder is a treatable health condition. It often takes multiple treatment attempts for patients to recover. Stopping substance use is extremely challenging. Patients should be supported regardless of how many times they ask for help. Even the most severe cases do recover. 

Patients with OUD or other substance use disorders experience a great deal of stigma and often have high levels of anxiety related to previous negative healthcare experiences. Research shows that stigma, bias, and even perceived judgment worsens symptoms and prolongs recovery. It’s vital to treat patients in a caring and supportive manner.

Discharge Instructions

If you are taking buprenorphine or methadone, continue taking this medication at your usual dose. It is okay to take medications for opioid use disorder along with the medications you were prescribed today. Let your opioid treatment program or buprenorphine provider know that you have a painful condition and tell them what medications you were given today. It is common for people on medications for opioid use disorder to need additional support when they have a painful condition. 

If you are taking buprenorphine at home you may want to try splitting your doses – taking it 2 to 3 times a day instead of once can sometimes help control pain better. 

Use other pain management strategies as well: positions of comfort, heat, cold, and over-the-counter medications like acetaminophen and ibuprofen. 

Remember that changes in use patterns can alter tolerance and increase your risk of opioid overdose. If you use other opioids, take steps to reduce the risk associated with overdose, like having naloxone, not using alone or calling the Never Use Alone lifeline (877-696-1996), and starting low and going slow.

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+/- Calculate COWS

Clinical Opioid Withdrawal Scale

Health care providers may consult with a psychiatrist 24/7 for support initiating MOUD and managing co-occurring disorders in their adult patients. Call the UW Psychiatry Consultation Line (PCL):

1-877-927-7924

Enroll in the program for access to follow up appointment scheduling. Click here to enroll.