On-Shift

1. Look for at least two clear objective signs not attributable to something else: large pupils, yawning, runny nose & tearing, sweating, vomiting, diarrhea, gooseflesh/piloerection, tachycardia.
2. Confirm with the patient that they feel ‘bad’ withdrawal and they feel ready to start bup. If they feel their withdrawal is mild, it is likely too soon.
3. As needed, consider using the COWS (clinical opioid withdrawal scale). Start if COWS ≥ 8 with ≥ 2 objective signs.
4. Withdrawal sufficient to start bup typically occurs 24-36 hrs after decreased/stopped use, but can vary from 6-72 hrs. Methadone withdrawal commonly takes longer.

1. Respect patient preference. Shared decision-making, flexibility, and collaboration are essential. 
2. Heavy dependence/tolerance (e.g., fentanyl) may need higher doses of bup. 
3. Low dependence/tolerance may do well with lower doses of bup.
4. Starting bup may be delayed or modified if there complicating factors:
   
   
   • Altered mental status, delirium, intoxication
   • Severe acute pain, trauma, or planned surgery
   • Severe medical illness
   • Long-term methadone maintenance

• Wait for severe withdrawal then start with 8-24+ mg SL. 
• Rx per “Discharge” instructions below.

OR

• If appropriate consider self-directed starts: Bup Self-Start

• Worsening withdrawal (common): Occurs with lower starting doses and heavy tolerance; improves with more bup (additional 8-16 mg SL). 
• Other substance intoxication or withdrawal: Continue bup and manage additional syndromes. 
• Bup side-effects: e.g., nausea or headache. Continue bup and treat side-effects with supportive medications. 
• Medical illness: Continue bup and manage underlying condition. 
• If sudden & significant worsening, consider precipitated withdrawal (rare): See box below.

(Sudden, significant worsening of withdrawal soon after bup administration)

1. Administer 16 mg bup SL and 2 mg lorazepam PO.
2. Reassess after 30 min, if symptoms improve, observe and plan for discharge.
3. If symptoms have not improved, administer an additional 16 mg bup SL.
4. Reassess after 30min; if severe withdrawal continues:
   
   Escalate level of care to manage potential moderate to deep sedation including cardiac, pulse oximetry, and end tidal CO2 monitoring:
   1. Ketamine (0.3 mg/kg IV slow push q 15 minutes and/or infusion).
   2. Fentanyl 200 mcg IV q10 minutes. Total dose of > 2000 mcg has been reported.
5. After clinical resolution, observe and discharge with bup Rx and/ or XR-bup.

Adjuvants: OK but should not delay or replace bup. Use sparingly with appropriate caution:

• Benzodiazepines: 
  • Lorazepam 2 mg PO/IV
• Antipsychotics: 
  • Olanzapine 5 mg PO/IM 
• Alpha-agonists: 
  • Clonidine 0.1-0.3 mg PO 
• D2/D3 agonists: 
  • Pramipexole 0.25 mg PO 
• Gabapentinoids: 
  • Pregabalin 150 mg PO

• Prescribe at least a 2 week supply of 16-32 mg SL bup per day.  
• Example 2 week order: buprenorphine/ naloxone 8/2 mg film 1 film SL TID #42,1 refill. Notes to pharmacy: OK to substitute tablets or monoproduct. Bill Medicaid FFS, ICD 10 F11.20. 
• Dispense/distribute naloxone in-hand from the ED.

• The X-waiver program has ended. Only a DEA license is needed to prescribe (schedule III). 
• Either bup or bup/nx SL films or tab are OK. 
• Bup monoproduct or bup/nx OK in pregnancy.
• For pregnancy: Bup in Pregnancy 
• For post-overdose: Bup Opioid Overdose
• For minors: Caring for Youth