inpatient / psychiatry and addiction medicine

Opioid Withdrawal and Opioid Use Disorder (OUD)

PDF coming soon!

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.
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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

Trials and Literature

• You do NOT need to stop buprenorphine when the patient needs increased analgesia - (J Hosp Med, 2019)
• Harm Reduction Review - (J Gen Internal Med, 2021)
• Long-term agonist (methadone) therapy for OUD decreased morbidity and mortality - (BMJ, 2017)
• Microdosing strategy - (CMAJ, 2020); Penn’s Microdosing PDF

Other Resources

• Price of Common Street Drugs
• Curbsiders Podcast - Buprenorphine Master Class, Opioid Use Disorder, 366 OUD in Hospital "The drug supply is highly toxic because it is unpredictable and contaminated. About 73 percent of seized street-supply fentanyl is really fentanyl (DEA National Drug Threat Assessment), but the other 25 percent comprises substances like xylazine, fentanyl analogs, and other high-potency opioids"
• Core IM - 5 Pearls on Stigma in OUD
• MD Calc - MME Calculator
• Video for Safe Injection Practices
• Dr. Joseph D'Orazio Lecture on OUD and Withdrawal Treatment in the ED and Hospital - Video