2025 Southeastern Residency Conference

Title: Implementation of an Opiate Withdrawal Protocol


Authors: Evan Hardbeck, Jeremy Ray


Objective: To assess the impact of standardizing care for patients presenting with opioid withdrawal.


Self Assessment Question: Which medication when paired with frequent patient assessment significantly decreases risk of opiate overdose?


Background: Opioid dependent patients who are experiencing withdrawal symptoms are in a high-risk period due to the risk of opioid overdose as patients attempt to resolve symptoms and cravings. This is an important consideration for patients presenting to the emergency department with withdrawal symptoms as initiating appropriate management has resulted in fewer relapses for patients as well as lower mortality for such patients. Developing standardized treatment options for withdrawal patients also falls in line with the Centers for Disease Control and Prevention calling for increased involvement from emergency departments in managing opioid use disorder.


Methods: This single-center, IRC approved, pre-post implementation study evaluated all patients with confirmed or suspected opioid withdrawal admitted to a large community hospital between November 2023 and August 2024. Data was collected from the electronic medical record (EHR). Data analysis was performed using descriptive statistics, unpaired t-test, or chi-square test as appropriate. Outcomes assessed included duration (days) of detoxification pre- and post- implementation, hospital length of stay (LOS), readmission rate for opiate use disorder, clinical opiate withdrawal scale scores, adjunctive medications utilized, and adverse events. Post intervention data will utilize the same metrics for comparisons. 


Results: A total of 55 patients were included with 54 in the pre-implementation group and 1 in the post-implementation group. The most common detoxification medication in the pre-implementation group was buprenorphine/naloxone (n=45, 83%) with a mean buprenorphine dose of 7.6 ± 4 mg. Additionally, COWS assessments were performed infrequently (n=7, 12.9%) with a mean score of 8 ± 2 in those assessed. The post-implementation patient received routine COWS assessments (n=1, 100%) with a mean score of 5 ± 3 and was determined to not require any detoxification with buprenorphine/naloxone. No safety events occurred in either group.


Conclusion: A larger sample size is needed to fully assess the safety and efficacy of implementing the opiate withdrawal protocol as the one post implementation patient did not require use of buprenorphine/naloxone. However, the scheduling of COWS assessments in the post-implementation patient led to frequent monitoring that was not present in the pre-implementation group which prevented potentially unnecessary use of buprenorphine/naloxone.