Admission Checklist

• ABC's: While opioid withdrawal is rarely life-threatening itself, it causes severe discomfort and complications can be serious. Rule out concomitant opioid intoxication (check for respiratory depression, miosis, AMS). Assess for severe volume depletion from vomiting/diarrhea and risk of aspiration.
• Triage: Quantify withdrawal severity using the Clinical Opiate Withdrawal Scale (COWS). This objective score guides treatment initiation and titration.
  • COWS 5-12: Mild withdrawal
  • COWS 13-24: Moderate withdrawal
  • COWS 25-36: Moderately severe withdrawal
  • COWS >36: Severe withdrawal
• Chart Check:
  • Hx of Opioid Use Disorder (OUD), prior treatments (methadone, buprenorphine), prior withdrawal episodes and what worked.
  • Comorbidities: HIV, HCV, psychiatric conditions (esp. anxiety, PTSD, depression), other substance use disorders (alcohol, benzodiazepines).
  • Infectious complications of use: endocarditis, osteomyelitis, bacteremia, skin/soft tissue infections (SSTI).
  • Baseline EKG for QTc interval if considering methadone.
• Can’t Miss:
  • Sepsis (from endocarditis, epidural abscess, SSTI).
  • Concurrent withdrawal from alcohol or benzodiazepines.
  • Influenza or other viral illness.
  • Gastroenteritis.
• Admission Orders:
  • Labs: UDS (note fentanyl and buprenorphine may require specific assays), beta-hCG, HIV Ab, Hep C Ab, RPR, LFTs. Consider BCx, ESR/CRP if infection suspected.
  • EKG: Obtain baseline EKG to assess QTc interval prior to initiating methadone.
  • Nursing: COWS assessment q2-4h and prior to any MOUD/adjunctive medication administration.
• Initial Treatment to Consider:
  • Initiate MOUD (Medications for Opioid Use Disorder): This is first-line and standard of care. Offer to all patients.
    • Buprenorphine: Partial agonist. Must be in moderate withdrawal (COWS >8-12) to avoid precipitated withdrawal.
    • Methadone: Full agonist. Can be started immediately without waiting for withdrawal symptoms.
  • Symptomatic Management:
    • Autonomic sx: Clonidine
    • Nausea/Vomiting: Ondansetron
    • Diarrhea: Loperamide
    • Myalgias/Arthralgias: NSAIDs, Acetaminophen
    • Anxiety/Insomnia: Hydroxyzine, Trazodone
  • Supportive Care: IV fluids for dehydration if unable to tolerate PO.

HPI Intake

• Opioid Use: type (heroin, fentanyl, pills), amount, frequency, route (IV, IN, smoke); most recent use (date/time is critical for buprenorphine initiation).
• Withdrawal Symptoms: onset, duration, characterization (N/V/D, chills, myalgias, anxiety, restlessness, yawning, lacrimation, rhinorrhea).
• Prior MOUD: ever on methadone or buprenorphine; dose, duration, why stopped?
• Other Substances: alcohol, benzodiazepines, stimulants, xylazine ("tranq"); last use of each, signs of withdrawal from these?
• Complications: h/o abscesses, endocarditis, osteomyelitis, HIV, HCV; fevers, focal pain (esp. back pain).
• Psychiatric Hx: anxiety, depression, PTSD, prior suicide attempts or current SI.
• Social Hx: housing status, support system, employment, legal involvement.
• Patient Goals: interest in starting long-term MOUD vs. short-term detox; harm reduction goals.

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High-Yield Question Flow

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1. Onset & Current Symptoms (The Immediate Problem)

1.1  “When was the last time you used any opioids?”

1.2  “When did these withdrawal symptoms begin?”

1.3  “On a scale of 0-10, how severe is your withdrawal right now?”

1.4  “Which symptoms are bothering you the most—body aches, anxiety, nausea, stomach cramps?” (This helps build rapport and guides symptomatic treatment).

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2. Opioid Use History (Characterizing Dependence)

2.1  “What specific opioids have you been using most recently?”

• → If “heroin” or “pills”: “Do you suspect it contains fentanyl? Have you had any unexpected overdoses recently?” (Crucial for anticipating withdrawal severity and duration).

2.2  “How much do you typically use in a day?” (e.g., number of bags, pills, monetary amount).

2.3  “How do you primarily use it—injecting, smoking, or snorting?” (Informs risk for infectious complications).

2.4  “For how long have you been using at this frequency?”

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3. Assessment for Opioid Use Disorder (OUD) (Using DSM-5 Concepts)

3.1  “Have you ever tried to cut down or stop but found you couldn’t?”

3.2  “Do you find yourself spending a lot of time getting, using, or recovering from opioids?”

3.3  “Has your use caused any problems with your health, relationships, or work/school?”

3.4  “Do you have strong cravings or urges to use?”

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4. Patient Goals & Shared Decision-Making

4.1  “What are your goals for today? Are you just looking for relief from withdrawal, or are you thinking about longer-term treatment?”

4.2  “What are your thoughts about medications like buprenorphine (Suboxone) or methadone to help with withdrawal and cravings?”

• → If hesitant: “What have you heard about them? Any concerns I can address?”
• → If interested: “Which, if any, have you considered or would you prefer?”

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5. Past Treatment Experiences

5.1  “Have you ever been in treatment for opioid use before?”

5.2  “Have you ever taken buprenorphine (Suboxone) in the past?”

• → If yes: “What was that experience like? Did it ever make you feel sick right after taking it?” (Screens for prior precipitated withdrawal).

5.3  “Have you ever been on methadone?”

• → If yes: “Which clinic? What was your last dose and the date you last took it?” (Important for safety if restarting).

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6. Screening for Life-Threatening Co-Withdrawals & Polysubstance Use

6.1  “Besides opioids, what other substances do you use regularly?”

6.2  “Specifically, how much alcohol do you drink daily? When was your last drink?”

6.3  “Do you use benzodiazepines like Xanax, Klonopin, or Valium regularly? When was your last dose?”

• → If yes to 6.2 or 6.3: "Have you ever had seizures or DTs when stopping them?"

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7. Harm Reduction & Safety Assessment

7.1  “Do you have a naloxone (Narcan) kit? Do you know how to use it?”

7.2  “Do you have access to new needles and supplies for each use?”

7.3  “Do you typically use alone or with others?”

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8. Relevant Medical & Psychiatric History

8.1  “Are you pregnant or is there any chance you could be?”

8.2  “Do you have any known heart conditions, liver problems (like hepatitis), or HIV?” (Especially important for methadone and medication metabolism).

8.3  “How has your mood been? Have you had any thoughts of hurting yourself?” (Suicide risk is elevated).

8.4  “Are you currently taking any psychiatric medications?”

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9. Social Context & Disposition Planning

9.1  “Where are you staying right now? Is it a stable place?”

9.2  “Do you have a phone and a way to get to follow-up appointments?”

9.3  “Is there anyone—family or friends—who is supportive of you getting treatment?”

To Note on Exam

• General: Anxious, restless, uncomfortable, yawning frequently.
• Vitals: Tachycardia, hypertension, tachypnea, low-grade fever.
• HEENT: Mydriasis (dilated pupils), lacrimation (tearing), rhinorrhea (runny nose).
• Cardiac: Assess for new or changing murmurs (endocarditis).
• Abdominal: Hyperactive bowel sounds.
• Skin: Diaphoresis (sweating), piloerection ("gooseflesh"), track marks, skin abscesses, cellulitis, necrotic ulcers (consider xylazine).
• Neuro: Tremor, hyperreflexia. Mental status should be normal; AMS is not a feature of opioid withdrawal and suggests another process.

Etiology/Differential

• Withdrawal Syndromes: Opioid withdrawal, alcohol withdrawal, benzodiazepine withdrawal, xylazine withdrawal
• Infectious: Sepsis (e.g., endocarditis, spinal epidural abscess), influenza, gastroenteritis, meningitis/encephalitis
• Other: Sympathomimetic toxidrome, anxiety disorder/panic attack

If You Remember Nothing Else

Opioid withdrawal, while intensely uncomfortable, is an opportunity to engage patients in life-saving care. Untreated withdrawal is a primary driver for patients leaving the hospital Against Medical Advice (AMA), often with untreated severe infections like endocarditis. The standard of care is to treat withdrawal aggressively with opioid agonist therapy.

The two first-line options are buprenorphine and methadone. Buprenorphine, a partial agonist, can only be started once a patient is in moderate withdrawal (use the COWS scale) to avoid precipitating a more severe withdrawal. This can be challenging with illicit fentanyl due to its long and unpredictable half-life. Methadone, a full agonist, can be started immediately regardless of withdrawal severity but requires QTc monitoring and has a higher overdose risk.

Withdrawal management alone ("detox") is not considered adequate treatment for OUD. It leads to loss of opioid tolerance, placing patients at extremely high risk for fatal overdose upon relapse. Every patient should be offered a seamless transition to long-term maintenance MOUD. This requires proactive discharge planning by social work and case management to secure an outpatient appointment before the patient leaves the hospital. Always prescribe naloxone at discharge.

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