Suspected Substance Withdrawal in Adolescents — Management of Withdrawal Symptoms for Opioids — Clinical Pathway: Inpatient

Suspected Substance Withdrawal in Adolescents Clinical Pathway — Inpatient

Management of Withdrawal Symptoms for Opioids

  • Clinical Opiate Withdrawal Scale (COWS)  
  • Scale with 11-item scale administered by a clinician
  • Can be used in both inpatient and outpatient settings to reproducibly assess presence and severity of common signs/symptoms of opiate withdrawal and monitor these symptoms over time

Signs and Symptoms of Opioid Withdrawal Syndrome

General Signs, Symptoms of Withdrawal

Peak Period 1-3 days
Duration 5-7 days
Signs
  • Mydriasis, piloerection, diaphoresis
  • Rhinorrhea, lacrimation, diarrhea, insomnia
  • Elevated blood pressure and pulse (mild)
Symptoms
  • Intense desire for drugs, anxiety, restlessness
  • Nausea, vomiting, malaise, myalgia, arthralgia
Precipitated Withdrawal Sudden and severe onset of withdrawal symptoms as a result of medication

Pharmacologic Management: Buprenorphine

  • Both buprenorphine and methadone can be used for adult adolescents with opioid withdrawal
  • Only buprenorphine can be prescribed to adolescent in CHOP’s catchment area
  • Buprenorphine is a partial opioid agonist with high affinity for the mu receptor and long duration of action
  • There are 2 methods to begin treatment for withdrawal symptoms:
    • Standard vs. low-dose/micro-induction
      • Standard induction for initial COWS ≥ 12
      • Low-dose/micro-induction for initial COWS < 12
    • Once started on an induction pathway, adolescent stays on the same pathway regardless of a change in COWS score
  • If concern for overdose during induction, call Code and utilize nasal naloxone in code cart

Assess Contraindications for Buprenorphine-Naloxone

Contraindications
  • Receiving methadone maintenance
  • Lethargy or somnolence
  • GI obstruction or ileus
  • Allergy to buprenorphine or naloxone
Pregnancy Use buprenorphine without naloxone

Low-Dose/Micro-Induction with Buprenorphine and Buprenorphine-Naloxone; COWS < 12

  • General Principles
    • May be started without any period of abstinence
    • Withdrawal risk is determined by amount of opioid used and reported severity of withdrawal symptoms
    • Induction occurs without withdrawal symptoms as opioid dose given until therapeutic buprenorphine
      levels reached
      • Conversion easier if using prescription-grade opioids vs. street opioids
      • Before induction, establish an opioid regimen, oxycodone most commonly used
      • It is not necessary to wean off long-acting/short-acting opioids once
        buprenorphine therapeutic
    • Uses buprenorphine (0.3 mg) buccal film then buprenorphine (2 mg) + naloxone (0.5 mg) sublingual film
    • For breakthrough pain, consider short-acting opioid in addition to the buprenorphine
    • Home medication management is possible if a provider is identified and the home environment is stable
    • Obtain pulse oximetry with vital signs if sleeping, if patient prescribed benzodiazepines/opioid, and/or they appear sedated
Buprenorphine
Buprenorphine-naloxone		 Oxycodone
Day 0 None
  • CHOP clinicians, call CHOP Poison Control Center at 4-2100 to convert street substance or prescription grade to initiate oxycodone (immediate release)
    • Typical starting dose: 20 mg every 4 hrs
    • Anticipate titrating up by 10 mg every 4 hrs (based on elevated COWS > 6) to treat ongoing acute withdrawal/untreated pain
    • Following up-titration, typical doses may range from 40-60 mg every 4 hrs
Day 1
Induction
  • Buprenorphine buccal films
  • 0.3 mg (300 mcg) every 6 hrs;
  • Max 1.2 mg/day (1,200 mcg/day)
  • Continue oxycodone at same dose
  • Notify provider if COWS > 12
  • Increase opioid as indicated
Day 2
  • Buprenorphine buccal films
  • 0.6 mg (600 mcg) every 6 hrs;
  • Max 2.4 mg/day (2,400 mcg/day)
Day 3
  • Switch to buprenorphine-naloxone sublingual films
  • 2 mg every 6 hrs; Max 8 mg/day
Day 4 Buprenorphine-naloxone sublingual films
4 mg every 6 hrs; Max 16 mg/day		 Discontinue oxycodone
Day 5
Post-induction
  • Switch to daily dose
  • If adolescent still symptomatic at 16 mg, discuss with consultants

Standard Induction with Buprenorphine with Naloxone; COWS ≥ 12

Confirm Time Since Last Specific Opioid Use to Determine Time to Begin Standard Induction (COWS > 12)

Fentanyl > 18 hrs
Short-acting Oral Opioids
Morphine IR, Oxycodone IR		 > 12 hrs
Extended-release Opioids
Morphine ER, Oxycodone ER		 > 24 hrs
Methadone > 72 hrs
Standard Induction Additional Notes
Day 1
First 24 hrs
  • 2 mg every 2 hrs as needed
  • Max: buprenorphine 8 mg/24 hrs
  • Document Baseline COWS
  • Document COWS:
    • Before each dose of buprenorphine-naloxone
    • 1 hr after dose
    • Every 2 hrs while awake
    • Do not wake adolescent to
      complete scoring
  • Contact ordering provider if COWS is the same or increasing despite medication
Day 2
  • Cumulative dose from day 1 + 2 mg
  • Then give 2 mg every 4 hrs PRN for COWS ≥ 12
  • Max: buprenorphine 16 mg/24 hrs
  • COWS every 4 hrs while awake
  • Increase frequency as clinically indicated
  • Contact ordering provider if COWS is the same or increasing despite medication
Day 3
  • Cumulative dose from day 2 + 2 mg
  • Then give 2 mg every 8 hrs PRN for COWS ≥ 12
  • Max: buprenorphine 24 mg/24 hrs
  • COWS every 8 hrs while awake
  • Contact ordering provider if COWS is the same or increasing despite medication
  • If > 16 mg required, discuss with consultants
  • Most reach maintenance by Day 3
Day 4
Post-induction
  • Can switch to daily dose if not
    done already
  • Continue current dose of buprenorphine-naloxone sublingual films
 If > 16 mg required, discuss with consultants