Opiate Intoxication and Withdrawal

Management of Severe Opiate Intoxication

Defined as:

Altered LOC
- GCS < 10
Bradycardia
Bradypnea
- RR < 10
- Hypercarbia
Hypotension not requiring vasopressors
Requiring IV naloxone therapy

Key Management Points:

Always get urine drug screen - do not assume opiate intoxication just because patient has history of OUD
IV naloxone therapy can precipitate withdrawal - start low, go slow. Titrate to respiratory rate and LOC.
Assess for co-ingestions
Never abruptly stop OAT
Always offer opiate agonist therapy for patients in opiate withdrawal
Referral to RAAM as an outpatient

Medication Management

Opiate Intoxication

Naloxone

Bolus dosing: 0.4mg - 2mg IV/SC/IM x 1 (IV administration preferred)
Infusion rate: 2/3 of what patient required to normalize respirations
- Adjust to maintenance of respiratory rate not withdrawal symptoms

Opiate Withdrawal

For symptom management:

Clonidine 0.1mg PO TID
Gabapentin 300mg PO TID
Naproxen 500mg PO BID
Acetaminophen 500-1000mg PO QID

Opiate Agonist Therapy

Patients often will have preference between OATs and/or prefer not to start OAT at this time. Patient-centered decision making and informed consent are required for initiation of OAT.

Buprenorphine

Monitor COWS score
- When >/= 12, then give Suboxone 2mg/0.5mg PO x 1
- Monitor symptoms - if ongoing withdrawal - can give another 2mg q1h prn up to a total day 1 dose of 8mg
Patient must be in clinically-apparant opiate withdrawal to administer buprenorphine. Otherwise, administration will precipitate withdrawal.
Side Effects: Precipitated withdrawal

Methadone

Confirm last dose and home dosage
New starts of methadone should be done with an addiction's medicine specialist
Missed dose guidelines:
- 1-2 days - Continue home dose
- 3 - 4 days
  - Home dose 30mg - continue home dose
  - Home dose 31-60mg - continue at 30mg
  - Home dose >60mg - continue at 50% home dose
- 5 days or more
  - Restart at 5 - 30 mg (depending on tolerance)
Side Effects: Prolonged QTc

Last Updated: October 2021

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