Author: Daniel Carlat
Last Updated: 4/19/20
1. Ensure patient is in early withdrawal
- Patient should be in mild withdrawal, with a COWS score of greater than 10.
- If you are not using the COWS scale, ask patient whether he/she is feeling “sick”, and assess pupil size. If moderately dilated, patient is likely in withdrawal.
- Timing depends on what opioid patient has been using.
- Short acting opioids (eg, oxycodone)—6-12 hours after last dose
- Longer acting (eg methadone)—up to 36 hours after last dose
2. Start with a 4 mg dose of Suboxone
- Most withdrawal symptoms will disappear within 5 minutes
3. Reassess and repeat dosing if needed
- Reassess hourly with COWS scale or by pupil exam and patient’s subjective report
- If score goes higher than 10, give another 4 mg dose of Suboxone
- Most patients require 8-12 mg of Suboxone
4. The following day, start regular Suboxone dosing
- Give entire dose once a day in the morning
- This will generally be the patient’s maintenance dose
- Give clonidine (0.1-0.2 mg BID) as needed for mild breakthrough withdrawal symptoms
5. On discharge, give prescriptions to last until outpatient appointment
- Typically you will write for one week of suboxone with no refills, eg:
- Suboxone 8mg/2 mg, 2 SL qd, #14, 0 refills
- In addition, write for Naloxone, eg:
- Naloxone 4mg/0.1mL intranasal, prn opioid overdose. Spray 0.1 mL into one nostril, call 911, if no response in 2-3 minutes repeat with second device in additional nostril. #1 pack of 2, 3 refills.