Methadone is a long-acting opioid agonist that is one of the mainstays of opioid use disorder (OUD) treatment,
along with buprenorphine. Compared to patients not in treatment, those receiving methadone have lower all-cause
mortality, rates of transmissible diseases, criminal convictions, suicide, and even cancer. Methadone for OUD must
come from a federally regulated opioid treatment program (OTP), or “methadone clinic.” Patients start out by going
to the clinic daily, which can be an inconvenience. Disadvantages include the potential for diversion and the possible
accumulation of doses due to its long half-life.
Induction refers to the process of starting a patient on buprenorphine (with or without naloxone; the combination
product is most often preferred). It can be done either inpatient or outpatient and typically takes two to three days,
depending on the ultimate dose. See also the “Buprenorphine Microinduction” fact sheet for an alternative approach.
The Clinical Opiate Withdrawal Scale (COWS) is an 11-item scale designed to be administered by a clinician. This tool
can be used in both inpatient and outpatient settings to reproducibly rate common signs and symptoms of opiate
withdrawal and monitor these symptoms over time. The summed score for the complete scale can be used to help
clinicians determine the severity of opiate withdrawal.
Unless you work in a federally funded methadone clinic, known as an opioid treatment program (OTP), you won’t be
managing methadone long term or making dose adjustments on your own. Treating OUD patients with methadone
for more than a few days requires collaboration with an OTP, so if you have a patient who needs methadone, don’t
hesitate to reach out to one nearby, if one is available. You will also see patients on methadone for other psychiatric
needs, so you need to know some details about how OTPs operate and how methadone can interact with other
medications. For those initiating methadone in an inpatient setting and referring to OTP for follow-up, see “Managing
Opioid Withdrawal in the Inpatient Setting” fact sheet.
Sublocade and Brixadi are long-acting forms of injectable buprenorphine given once every four or eight weeks
for Sublocade and weekly or monthly for Brixadi. The ease of use and flexible dosing of these extended-release
formulations make them real game-changers, particularly for patients with adherence challenges. Both products are
expensive, though Medicare and many Medicaid programs cover the cost. See “Buprenorphine Extended-Release
Injection Monotherapy” fact sheet for additional information.
The illicit opioid supply has become increasingly unpredictable. Over the last 10 years, fentanyl and its derivatives
have found their way into this supply and have become key contributors to the continued increase in overdose
deaths. One of the most concerning and persistent additives is xylazine, known on the street as “tranq.” Here, we will
cover the basic pharmacology of xylazine, why it’s so concerning, what to look out for if you suspect it, and how to
counsel your patients.
Drug overdose deaths, the vast majority of which involve opioids, continue to rise in the US. Health care providers
should be able to identify patients at particularly high risk for overdose, know how to mitigate risk using harm
reduction strategies, and educate patients to recognize and quickly treat overdose. (See “Opioid Overdose Overview
Fact Sheet for Patients.”)
Initial Questions
As with any psychiatric interview, start by building an alliance and showing interest in your patient in a general way.
The first few questions, although not explicitly related to psychiatric issues, will typically naturally transition to the
patient’s reason for their visit.
⦁ “Where are you from?”
⦁ “What do you do for work and fun?”
The Clinical Opiate Withdrawal Scale (COWS) is an 11-item scale used for rating the degree of opioid withdrawal.
See our accompanying fact sheet that reproduces the entire scale for your use. While the COWS may appear
straightforward, it can be confusing when using it to assess patients undergoing withdrawal in the real world. In
this fact sheet, we offer some hard-won tips and pitfalls to avoid so that you can more accurately rate your patient’s
withdrawal symptoms.