The Clinical Institute Withdrawal Assessment for Alcohol Scale, Revised (CIWA-Ar) is the most widely used alcohol withdrawal symptom scale. Although it is primarily used in inpatient settings, it’s also useful for outpatient detox since it reminds both clinicians and patients of the types and severity of symptoms seen in alcohol withdrawal.

Rates of opioid use disorder (OUD) and overdose deaths during pregnancy have skyrocketed in recent years. Untreated OUD is associated with many adverse outcomes, including overdose death, that can be mitigated by proper medication for opioid use disorder (MOUD) treatment. Methadone and buprenorphine have a robust evidence base, while injectable naltrexone lacks enough data to recommend during pregnancy and is not recommended.

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.

Opioid use disorder (OUD) is highly comorbid with medical illness and other psychiatric conditions. Most of your patients on medications for OUD (MOUD) will also be taking other medications (Du CX et al, Fam Pract 2022;39(2): 234–240). MOUDs generally play well with other medications, but there are some important interactions to be aware of. Here is a summary of some important med-med interactions to be wary of when prescribing MOUDs.

Rates of opioid use disorder (OUD) and overdose deaths during pregnancy have skyrocketed in recent years. Untreated OUD is associated with many adverse outcomes, including overdose death, that can be mitigated by proper medication for opioid use disorder (MOUD) treatment. Methadone and buprenorphine have a robust evidence base, while injectable naltrexone lacks enough data to recommend during pregnancy and is not recommended.

Getting patients with opioid use disorder (OUD) completely off opioids, so-called “detox,” is generally not advisable. Very few patients with OUD are able to completely stop opioids and remain abstinent for any length of time without further treatment. Moreover, taking patients off opioids completely can lower tolerance and paradoxically increase risk of overdose in the long run. The only situation in which medically supervised withdrawal is a sensible approach is if the patient plans to receive intramuscular naltrexone immediately afterwards, but even this approach can be tough outside of controlled inpatient settings.