Opioid Use Disorder (OUD)

Background

Standard of care is opioid stabilization with buprenorphine or methadone (in OUD) or other full agonist opioids (in chronic opioid therapy)
Methadone and buprenorphine can be ordered by any physician for inpatients; buprenorphine can also now be prescribed at discharge by any physician, though methadone for OUD must be dispensed directly from a federally regulated Opioid Treatment Program (“methadone clinic”)
Maintenance agonist therapy should be offered to every patient, with preference for an “optout” approach (even for uninsured patients through state grant funding)

Restlessness/psychomotor activation, anxiety, irritability, nausea, abdominal cramping, loose stool, diffuse musculoskeletal pain, chills, insomnia, yawning
Pupillary dilation, piloerection, tearing, nasal congestion, diaphoresis, restless legs

Due to the partial agonist mu-opioid effect of buprenorphine and high binding affinity, premature induction of buprenorphine in patients previously using full-agonist opioids rapidly induces a withdrawal state (precipitated withdrawal)
Clinical Opioid Withdrawal Scale (COWS): quantifies severity of opioid withdrawal and allows for safer buprenorphine inductions
- Approximates the mu opioid receptor availability to avoid premature induction and precipitated withdrawal in the setting of buprenorphine induction while also allowing for adequate treatment of withdrawal symptoms
Asking about opioid exposure: “You’re uncomfortable. I work with a lot of people in the hospital, and some come with regular exposure to opioids from a lot of different places (their doctors, friends), should we be treating any withdrawal for you?”