Toxicology & Substance Use · Topic 16 of 17

Opioid Use Disorder & Withdrawal in the Hospital

Addiction · opioid use disorder

Opioid Use Disorder & Withdrawal in the Hospital

Use the admission to start buprenorphine or methadone, treat pain on top of it, and send the patient home with naloxone.

Key numbers

Start buprenorphine at COWS ≥ 8COWS ≥ 8

Low-dose initiation: overlap full agonist 3–10 daysstart 0.25–1 mg SL

01 · GiveStart buprenorphine at COWS ≥ 8

Standard buprenorphine start: wait for objective withdrawal (COWS ≥ 8 with an objective sign), usually 6–12 hours after short-acting opioids or 24–72 hours after methadone; give 2–4 mg SL and titrate to 8–24 mg/day.

02 · The ruleMaintenance MOUD, not detox alone

For OUD, starting maintenance buprenorphine or methadone is the standard of care; withdrawal management alone (or with only adjuvant drugs) leads to relapse and a high risk of fatal overdose.

03 · DoNaloxone kit at every discharge

Offer every patient with OUD a naloxone kit at discharge and teach the patient and family how to give it.

What it is

Core idea

Buprenorphine: partial agonist with a ceilingBuprenorphine is a high-affinity partial mu agonist: the ceiling effect limits respiratory depression, its tight binding blocks other opioids, and it displaces full agonists — the cause of precipitated withdrawal.

Presentation

What you'll see

Mydriasis, piloerection, yawning, rhinorrhea mean withdrawal must knowSigns specific to opioid withdrawal: mydriasis, piloerection, lacrimation or rhinorrhea, and yawning, with diaphoresis, cramps, diarrhea and tachycardia. It is not life-threatening — fever, seizures or delirium point to another cause.

Diagnosis & monitoring

Work-up

Methadone prolongs QTc — obtain ECGsMethadone prolongs the QTc and can cause torsades de pointes — obtain an ECG before and during initiation and dose titration.

Do right now

In this order

First moves

Mydriasis, piloerection, yawning, rhinorrhea mean withdrawal

→

Start buprenorphine at COWS ≥ 8COWS ≥ 8

→

Naloxone kit at every discharge

Why each step

Mydriasis, piloerection, yawning, rhinorrhea mean withdrawalSigns specific to opioid withdrawal: mydriasis, piloerection, lacrimation or rhinorrhea, and yawning, with diaphoresis, cramps, diarrhea and tachycardia. It is not life-threatening — fever, seizures or delirium point to another cause.

Start buprenorphine at COWS ≥ 8Standard buprenorphine start: wait for objective withdrawal (COWS ≥ 8 with an objective sign), usually 6–12 hours after short-acting opioids or 24–72 hours after methadone; give 2–4 mg SL and titrate to 8–24 mg/day.

Naloxone kit at every dischargeOffer every patient with OUD a naloxone kit at discharge and teach the patient and family how to give it.

Management

Orders

Low-dose initiation: overlap full agonist 3–10 daysLow-dose (micro) initiation avoids precipitated withdrawal: start buprenorphine 0.25–1 mg SL and up-titrate over 3–10 days while continuing the full agonist — suits inpatients, patients with pain and methadone-to-buprenorphine transitions.

High-dose initiation: 16–32 mg SL in withdrawalHigh-dose (macro) initiation: once in at least mild withdrawal (COWS ≥ 8), give 16–32 mg SL in 1 or 2 doses; in an ED fentanyl cohort, precipitated withdrawal occurred in < 1% after ≥ 8 mg.

Precipitated withdrawal: give more buprenorphinePrecipitated withdrawal after a buprenorphine dose is treated with more buprenorphine — often to at least 24–32 mg SL on day 1 — plus alpha-2 agonists and symptom-targeted drugs.

Methadone: start 10–30 mg, titrate slowlyStart methadone at 10–30 mg with 5–10 mg extra doses for withdrawal; raise slowly (ASAM ≤ 10 mg about every 5 days), letting it reach steady state; usual maintenance is 60–120 mg/day.

Pain on buprenorphine: continue, split doseAcute pain on buprenorphine: continue it — raise the daily dose 20–25% and split it into 3–4 doses; in supervised settings add short-acting full agonists. Discontinuation before surgery is not required.

Pain on methadone: continue dose, add analgesicsAcute pain on methadone: continue the usual daily maintenance dose and add short-acting full agonists, expecting higher doses than an opioid-naive patient needs.

Naltrexone needs 7 opioid-free daysExtended-release naltrexone (monthly IM) requires at least 7 days without full agonists to avoid precipitated withdrawal; treatment retention is lower than with buprenorphine or methadone.

The rules

Know these

No X-waiver: a standard DEA registration suffices must knowThe X-waiver ended Dec 29, 2022 (Consolidated Appropriations Act 2023, MAT Act): any clinician with a standard DEA registration may prescribe buprenorphine for OUD, with no patient cap; state law still applies.

Hospitals may give methadone during unrelated admissionsA hospital may give methadone to maintain or detoxify a patient admitted for another medical or surgical condition; otherwise, a clinician outside an opioid treatment program may dispense at most a 3-day supply while arranging referral.

Buprenorphine or methadone?

Commonly confused

Pharmacology	Partial mu agonist, ceiling on respiratory depression
Who can prescribe for OUD	Any clinician with a standard DEA registration
Starting	In withdrawal (COWS ≥ 8), or low-dose overlap
Usual maintenance dose	8–24 mg/day SL
Key safety issue	Precipitated withdrawal at initiation

More detail

Reference

Show 6 reference facts

Adjuncts for withdrawal symptoms: clonidine 0.1–0.2 mg PO every 4–6 hours (hypotension, rebound if stopped abruptly), loperamide, ondansetron, acetaminophen or ibuprofen — combined with, not instead of, MOUD.

Buprenorphine–naloxone: the naloxone is inactive sublingually but precipitates withdrawal if injected, deterring misuse; long-acting injectable buprenorphine can follow sublingual stabilization.

With heavy fentanyl exposure, buprenorphine 24–32 mg/day SL or extended-release injectable 300 mg gives the highest plasma levels and may help stabilization.

Heroin withdrawal can start 4 hours after the last dose, peaks within 48–72 hours and subsides in about a week; methadone withdrawal starts later and lasts longer.

Peer recovery coaches during hospitalization improve post-discharge engagement in OUD care and reduce patient-directed discharges.

In pregnancy, methadone or buprenorphine maintenance is standard of care; buprenorphine is associated with less neonatal abstinence syndrome, methadone with better retention.

Pearl

Withdrawal is miserable but rarely dangerous; leaving the hospital without MOUD is what raises the risk of fatal overdose.

Sources · Merck Manual Professional — Opioid Use Disorder · Merck Manual Professional — Opioid Toxicity and Withdrawal · The ASAM National Practice Guideline for the Treatment of Opioid Use Disorder: 2020 Focused Update. J Addict Med 2020;14(2S Suppl 1):1–91 · Weimer MB et al. ASAM Clinical Considerations: Buprenorphine Treatment of Opioid Use Disorder for Individuals Using High-potency Synthetic Opioids. J Addict Med 2023;17(6):632–639 · DEA Diversion Control Division — Dear Registrant letter on elimination of the DATA-Waiver (Jan 12, 2023) · 21 CFR 1306.07 — Administering or dispensing of narcotic drugs (eCFR) · 42 CFR 8.12 — Federal opioid treatment standards (Cornell LII) · DEA Diversion Control Division — Dear Registrant letter on the MATE Act one-time 8-hour training requirement (2023) · Starter sheet built from the verified AGACNP fact map (facts reviewed 2026-10-15).