inpatient / psychiatry and addiction medicine

Opioid Withdrawal and Opioid Use Disorder (OUD)

Last Updated: 1/6/2023

# Opioid Use Disorder
# Opioid Withdrawal

-- Chart Check: previous admissions, patient-initiated discharges, MOUD
-- HPI Intake: substances, how much, last use, needle habits, harm reduction use, infectious history, withdrawal sxs, previous MOUD, goals
-- Can't Miss: other drug use and withdrawal (EtOH, benzos), bacteremia/endocarditis
-- Admission Orders: COWS q4, UDS, infectious workup
-- Initial Treatment to Consider: opioids to address pain and withdrawal, abx if c/f infection

-- Substances:
*** which, route
-- How Much:
*** bag, bundle, $$$
-- Last Use:
-- Needle Habits:
*** re-use, share, lick, injection sites, skin cleaning, water source
-- Harm Reduction:
*** PrEP, naloxone, fentanyl strips
-- Infectious Hx:
*** bacterial infections, HIV, STI
-- Current Withdrawal Sxs:
*** anxiety, n/v, diarrhea, cramps, autonomic
-- Previous MOUD:
*** methadone, buprenorphine, naltrexone
-- Current Goals: 
*** abstinence, safer use, MOUD

-- History: *** current use, route, frequency, last use, gram or $ per day, prev MAT, prev withdrawal, prev OD, prev treatment, social circumstances, current goals, infx history - endocardiits, SSTI, osteo, HIV, HCV, HBV - injection practices, other drug use - benzo, EtOH, cocaine, meth, etc
-- Clinical/Exam: *** tachcyardia, diaphoreis, rigors, restlessness, irritability, yawning, piloerection, mydriasis, rhinorrhea, lacrimation, myalgia, n/v/d, cramping
-- Data: *** UDS, LFTs, HIV, HBV, HCV, TB, syphilis, other infectious workup, EKG (if on or planning to start methadone)

-- f/u UDS
-- if IVDU, consider HIV/HBV/HCV, LFTs
-- EKG

-- MOUD: *** methadone (get psych involved for methadone >40 daily; Day 1 - 10-20mg once with COWS q2h, 5mg if 6-12, 10mg if >12Day 2 - Give Day 1 dose if COWS <6, increase 20% if 6-12If not planning to transition to maintenance, decrease dose by 20% daily); buprenorphine (split up vs continue home dose; New start - "Typical Initiation" - start with 4mg/1mg, repeat in 1 hour if needed, then another 6-12 hours later for max 12mg in 24 hours; max dose for day 2 is 16mg; "Low-dose Inititation" - small dose (450mcg) belbuca buccal q6 hour to start, increase daily and go down on other opioids until bup dose >8mg daily)
-- "Temple Protocol": for patients with very heavy opioid use; oxy ER 30-60mg TID (up by 20mg q8h as needed), with oxy 15-30mg q4 PRN for moderate pain and dialudid 2mg IV breakthrough for severe pain; if this does not work, use PCA - dilaudid 1mg/hr IV (up by 0.5mg/hr every 2 hours) with demand dose of 0.5-1mg/hr with q10 minute boluses; alternative is to use oxy ER with dilaudid PCA demand doses only
-- Pain: *** Tylenol 975mg q6, oxycodone, dilaudid PRN, PCA if need be
-- Withdrawal Symptoms: *** cramps (bentyl 10mg q8 or cyclobenzaprine 10mg q8), nausea (promethazine 25-50mg IM PRN, ondansetron 4mg q6), diarrhea (loperamide 2mg q6), anxiety (hydroxyzine 50mg q6 PRN, trazodone 50-100mg q8 PRN), autonomic dysregulation (clonidine 0.1mg q8 PRN)
-- Opioid-Induced Symptoms: *** constipation (senna, miralax, methylnaltrexone), pruritis (loratadine, cetirizien, diphenhydramine)
-- Discharge Plan: *** insurance, PCP, bup or methadone provider, naloxone; ongoing pain - titrate down one Dilaudid pill per day

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If You Remember Nothing Else

Many patients who use fentanyl do not initially receive enough opioids in the hospital to reach their level of dependence, and they will experience withdrawal symptoms. Though imprecise, a bag of fentanyl in the Philadelphia area is roughly equivalent to ~30-70 MME or 20-50mg of oxycodone. Patients should receive long-acting opioids which are titrated q8 hours with both PO and IV breakthroughs for pain, and a PCA if all else fails. Patients who use IV drugs face a great deal of stigma, and many have had poor experiences with the healthcare system. This can often manifest as patient-initiated discharges when a therapeutic relationship is lost. MOUD options include methadone and buprenorphine which both are associated with improved outcomes, but both have their drawbacks. Most institutions will have different protocols for initiating these medicines in the hospital, and best practices are in constant flux. It's okay if the patient is not interested in initiating MOUD in the hospital, and you should be intent on aligning with their stated goals.

Clinical Pearls

  • OUD is diagnosed based on 2+ criteria; in general, diagnosed when the opioid use has started to interfere with daily life, not just about craving and withdrawal
  • Overdose with opioids is the most common cause of death in adults <50 years old
  • In Philadelphia, 1 bag of heroin/fentanyl is approximately 30-70mg morphine IV; 1 bundle = 14 bags = 420-980mg IV morphine; "Get Well" dose of 2 bags - 60-140mg IV morphine; this wil differ depending on location and over time
  • Asking patients how many bags it takes for them to "get well" may be helpful for understanding the general opioid target you may need to hit to control their withdrawal symptoms
  • "Temple Protocol" is oxy ER 30-60mg TID (up by 20mg q8h as needed), with oxy 15-30mg q4 PRN and dialudid 2mg IV breakthrough; if using PCA - dilaudid 1mg/hr IV (up by 0.5mg/hr every 2 hours) with demand dose of 0.5-1mg/hr with q10 minute boluses
  • Withdrawal starts 6-12 hours after short-acting opioid use, fentanyl tends to last longer, and withdrawal after methadone use starts closer to 24-48 hours
  • Fentanyl is highly lipophilic, the reason it stays in the body for so long - higher risk of precipitated withdrawal with suboxone
  • Harm reduction - clean needles, filters, sterile water, vaccination against Hep A/B, PrEP, naloxone, fentanyl strip testing, supervised consumption
  • Avoid terminology like “positive” vs “negative” for UDS results, and “clean” or “dirty” - utilize “toxicology test was positive for”, “substance-free”, or “in remission” 
  • The street value of drugs - 1 “baggie” of heroin is $5-20; 1 gram = 20 bags so 1 bag = 0.05 grams or 50mg, heroin is about 3 MME’s but these calculations are tricky; more expensive to get prescription opioids buprenorphine dose ~$10
  • MAT is now MOUD - “medications for opioid use disorder” since MAT is a misnomer
  • The addition of psych or behavioral health follow up great, but MOUD alone leads to improved outcomes
  • Buprenorphine is a high-affinity partial agonist (strong binding) with a lower risk of respiratory depression and OD vs. methadone; buprenorphine 16mg/day = oxycodone 120mg/day for analgesia
  • Naloxone not absorbed well sublingually or orally; it is combined with buprenorphine (suboxone) to prevent injection abuse
  • Suboxone can put patients into precipitated withdrawl because even though it is an agonist, it kicks off the other more potent opioids (fentantyl, heroin) - analogy of a car going 120 miles an hour suddenly going to 60 miles per hour - its still going fast, but it feels like you slammed on the breaks (Cubsiders episode #366)
  • Methadone is a long-acting full opioid agonist; QT-prolonging; methadone 30mg/day = oxycodone 175mg/day
  • Normal pupils do not rule out opioid toxicity - low RR and tidal volume is what can kill people
  • Overdose - The goal of naloxone is to improve mental status, get RR >10 - can keep giving more every 2 minutes until you achieve this - goal is NOT to get them to baseline mental status; naloxone effect last 20-40 minutes, will likely need to redose depending on the timing of the OD

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