1. Treating Opioid Withdrawal with Buprenorphine/Naloxone
META:PHI in the Emergency Department: Implementing Best Practices for Addictions
Treating Opioid Withdrawal with Buprenorphine/Naloxone

2. What is META:PHI?
Mentoring, Education, and Clinical Tools for Addiction: Primary Care–Hospital Integration
Collaborative project to implement integrated care pathways for addiction throughout Ontario
Partnership between hospitals, withdrawal management services, FHTs, CHCs, and community agencies
Goals:
Improve care for patients with addictions
Improve care provider experience
Improve population health
Reduce service use
Provide sustainable care

3. How it works
Patients presenting with addiction-related concerns receive evidence-based interventions and are referred to rapid access addiction medicine (RAAM) clinics for treatment
RAAM clinics offer substance use disorder treatment on walk-in basis; no formal referral/appointment needed
Patients stabilized at RAAM clinic referred back to primary care for long-term addiction treatment (with ongoing support from RAAM clinic as required)
Key components:
Integration of care at hospital, RAAM clinic, primary care
Training, support, and mentorship from addictions specialists
Capacity-building

4. Role of the ED With support from META:PHI team:
Follow best practices for treating urgent alcohol-/opioid-related presentations (e.g., CIWA-Ar protocol for alcohol withdrawal, buprenorphine for opioid withdrawal)
Diagnose underlying substance use disorder causing urgent presentations
Refer patients to treatment at RAAM clinic

5. Opioid withdrawal management goals
Dispense buprenorphine to relieve withdrawal
Provide outpatient buprenorphine prescription
Give harm-reduction advice and take-home naloxone
Provide referral to RAAM clinic for long term medication-assisted treatment
Naloxone HCL

6. Clinical features of opioid withdrawal
Symptoms start six hours after last use of short-acting opioid, peak at 2–3 days, and begin to resolve by 5–7 days
Physical symptoms: myalgias, chills, sweating, nausea and vomiting, abdominal cramps, diarrhea, rhinorrhea, lacrimation, piloerection
Psychological symptoms: insomnia, anxiety/irritability, restlessness, dysphoria, craving
Signs: Sweating, yawning, watery eyes and nose, restlessness

7. Risks of untreated withdrawal
Suicide, if patient cannot access opioids
Relapse, with heightened risk of overdose
Tolerance to opioids markedly declines within a few days of abstinence
Illicit opioids are often laced with fentanyl
Patients should never be discharged without a plan for withdrawal management

8. Buprenorphine Partial opioid agonist with ceiling effect
Slow onset and long duration of action
Binds tightly to receptors, displacing other opioids and triggering withdrawal
Patient must be abstinent from opioids for at least 12 hours and be in mild/moderate withdrawal before the first dose

9. Advantages of bup treatment
Treats withdrawal more effectively than clonidine or opioids
Long-term treatment with buprenorphine is much more effective than abstinence-based treatment, and is of comparable effectiveness to methadone treatment
Long-term buprenorphine treatment reduces addiction rates, overdose rates, and repeat ED visits
Buprenorphine is far safer than methadone or any other opioid so can safely be prescribed by ED and family physicians

10. Indications for buprenorphine
Any patient who presents with a possible complication of opioid use disorder:
Overdose
Withdrawal
Drug-seeking
Infection: Sepsis, endocarditis, cellulitis, abscess
Depression and suicidal ideation
Trauma

11. Clinical Opioid Withdrawal Scale (COWS)
Resting heart rate
(≤ 80) 1
(81–100) 2
(101–120) 4
(121+)
Sweating 3
Restlessness 5
Pupil size
Bone/joint aches
Runny nose/tearing
GI upset
Tremor
Yawning
Anxiety/irritability
Gooseflesh skin
TOTAL
5–12
13–24
Mild
Moderate
25–36
37+
Moderately severe
Severe

12. Buprenorphine protocol (1)
For patients currently in withdrawal:
Assess patient using COWS: a score of 12+ indicates it is safe to administer buprenorphine/naloxone
Initial dose: 4 mg SL
Reassess with COWS in 1–2 hours
If withdrawal substantially improved, give 2–4 mg to take home, plus outpatient script
If still in significant withdrawal, give another 4 mg SL in ED and reassess again in 1–2 hours
Treatment complete when 4–12 mg have been dispensed and withdrawal symptoms are minimal

13. Buprenorphine protocol (2)
For patients not yet in withdrawal:
Give an outpatient prescription for 2 mg x 18 tablets
Give patient clear instructions:
Wait at least 12–16 hours since your last opioid use
Make sure your COWS score is at least 12 (give scale)
Put 2 tablets under your tongue and let them dissolve
Wait 2 hours and measure your COWS score again
If still in withdrawal, take another 2 tablets
Do not take more than 6 tablets (12 mg) in first 24 hours
Next day: Take total first-day amount as single dose
Tell patient to follow up with the RAAM clinic within 3 days for ongoing prescription

14. Common concerns “Buprenorphine will increase length of stay”
No need to hold patient until in withdrawal
If not in withdrawal, give script for patient to start at home
“I don’t know how to prescribe buprenorphine”
To prescribe methadone, MDs require special training and certification from CPSO because methadone has higher overdose rate than other opioids
But buprenorphine has lower OD rate than other opioids
CPSO has no oversight over buprenorphine prescribing
ED physicians aren’t providing long-term addiction treatment; they are treating acute withdrawal and giving bridging prescription until patient starts treatment at RAAM clinic

15. ED discharge Always refer patient to RAAM clinic
Prescribe total amount of buprenorphine given in ED as single dose
Dispensed daily under observation, or give take-home doses for a few days if patient is reluctant to attend daily
Prescription should last until next RAAM clinic
Refer patient to WMS if has transient housing, lack of social supports, and/or at high risk for relapse
Fax prescription to WMS’s regular pharmacy
Write note to WMS informing them of prescription and advising them that patient should attend next RAAM clinic
Give harm reduction advice and take-home naloxone

16. Harm reduction advice To reduce the risk of overdose: Do not inject
Take a much smaller opioid dose than usual
Start with a test dose
Don’t mix opioids with alcohol/benzodiazepines
Never use alone - always have a friend with you while you’re using
Always carry naloxone
If your friend appears drowsy, has slurred speech, or is nodding off after taking opioids:
Shake/talk to them to keep them awake
Call 911 and start chest compressions
Administer naloxone

17. Wrap-up
Treating addicted patients is our responsibility as health care providers
Addiction is the same as any other chronic illness: patients need specialist referrals, medication, treatment of co-occurring conditions, and regular follow-up
The ED is an opportune setting to intervene, as many patients are motivated to get help for their disorder
Effective addiction treatments are available
Purpose of META:PHI project is to facilitate adoption of best practices and support clinicians

18. Resources META:PHI website: www.metaphi.ca
META:PHI mailing list for clinical questions and discussion ( to join)
META:PHI contacts: Medical lead: Dr. Meldon Kahan Manager: Kate Hardy Knowledge broker: Sarah Clarke