Clinical Opiate Withdrawal Scale Research Articles

Implementation of a clinical pathway to screen and treat medical inpatients for opioid withdrawal.

Background:Opioid-related inpatient hospital stays are increasing at alarming rates. Unidentified and poorly treated opioid withdrawal may be associated with inpatients leaving against medical advice and increased health care utilization. To address these concerns, we developed and implemented a clinical pathway to screen and treat medical service inpatients for opioid withdrawal.Methods:The pathway process included a two-item universal screening instrument to identify opioid withdrawal risk (Opioid Withdrawal Risk Assessment [OWRA]), use of the validated Clinical Opiate Withdrawal Scale (COWS) to monitor opioid withdrawal symptoms and severity, and a 72-h buprenorphine/naloxone-based treatment protocol. Implementation outcomes including adoption, fidelity, and sustainability of this new pathway model were measured. To assess if there were changes in nursing staff acceptability, appropriateness, and adoption of the new pathway process, a cross-sectional survey was administered to pilot four hospital medical units before and after pathway implementation.Results:Between 2016 and 2018, 72.4% (77,483/107,071) of admitted patients received the OWRA screening tool. Of those, 3.0% (2,347/77,483) were identified at risk for opioid withdrawal. Of those 2,347 patients, 2,178 (92.8%) were assessed with the COWS and 29.6% (645/2,178) were found to be in active withdrawal. A total of 49.5% (319/645) patients were treated with buprenorphine/naloxone. Fifty-seven percent (83/145) of nurses completed both the pre- and post-pathway implementation surveys. Analysis of the pre/post survey data revealed that nurse respondents were more confident in their ability to determine which patients were at risk for withdrawal (p = .01) and identify patients currently experiencing withdrawal (p < .01). However, they cited difficulty working with the patient population and coordinating care with physicians.Conclusions:Our study demonstrates a process for successfully implementing and sustaining a clinical pathway to screen and treat medical service inpatients for opioid withdrawal. Standardizing care delivery for patients in opioid withdrawal can also improve nursing confidence when working with this complex population.

Management of smack addiction through adjuvant Ayurvedic treatment

The smack addiction is very much spreading nowadays among the youth, which is injurious for a healthy society. Opiates are highly addictive. Long-term use of opiates causes dependence, leading to tolerance. Overdose incidents occur due to chronic intake or addiction that can lead to life-threatening complications. In the present case, a 21-year-old male with a history of smack addiction for the last three years presented to the outpatient department with withdrawal symptoms including tremors, running nose, watering eyes, body ache, sleeplessness, sweating, nausea, irritability, and diarrhea. The assessment of withdrawal symptoms was based on Clinical Opiate Withdrawal Scale (COWS). The multimodal treatment including Shirodhara (~oil dripping on the forehead) with Ashwagandha taila and Tila taila, Sarvanga abhyanga (~synchronized whole body massage with medicated oil) with Dashmoola taila, Svedana (~sudation) using Dashmoola kwatha, and Nasya (~medications through nasal route) with Jatamansi taila along with internal medications of Vishatinduka vati and Sameeragaja kesari rasa showed promising results. Within one month of the treatment, the withdrawal symptoms of smack addiction were reduced considerably. The COWS score decreased to 3 from 22 after three weeks of treatment, inferring that multimodal Ayurvedic treatment can be an effective and safe solution in case of smack addictions.

Abstract- Poster

Pages: 2Word count: 250 ()Acknowledgement: NoneIntroduction-Abuse of antihistamines alone or in combination with other substances have been known for decades. Antihistamine containing cough syrups, cough suppressants, pheniramine maleate (Avil) tablets and injections are available easily as over-the-counter (OTC) medications. Psychological tolerance to the sedation and physical withdrawal symptoms following pheniramine abuse have been documented but surveying literature on pheniramine dependence yielded limited case reports on the same. Hereby, we present a unique case of pheniramine dependence, which is first of its kind ever reported of such mega doses of pheniramine abuse.Case report-A 29 years old Indian male presented to the psychiatry outpatient with history of abuse of heavy doses of pheniramine with opioids parenterally subsequently developing dependence, and injecting pheniramine up to 1700 mg daily. To obtain such high doses he purchased pheniramine meant for veterinary use (Panavil). He was started on tapentadol 300 mg, pregabalin 150 mg and quetiapine 50 mg. Tapentadol was down-tapered. Clinical opiate withdrawal scale (COWS) decreased from 13 on the day of admission to 4 on discharge. The patient was started on relapse prevention therapy and was discharged on tapentadol 50 mg, pregabalin 75 mg and quetiapine 25 mg with plan to continue psychotherapy sessions on follow up.Conclusion-Our case concludes that pheniramine has a dependence potential. OTC medication abuse seem to be under-reported and could be an emerging medical concern in the ensuing years. We enunciate the need of formulation of specific rules and regulations to supervise the availability of both human and veterinary drugs.

Methadone initiation in a bridge clinic for opioid withdrawal and opioid treatment program linkage: a case report applying the 72-hour rule

BackgroundIn the United States, methadone for opioid use disorder (OUD) is limited to highly regulated opioid treatment programs (OTPs), rendering it inaccessible to many patients. The “72-hour rule” allows non-OTP providers to administer methadone for emergency opioid withdrawal management while arranging ongoing care. Low-barrier substance use disorder (SUD) bridge clinics provide rapid access to buprenorphine but offer an opportunity to treat acute opioid withdrawal while facilitating OTP linkage. We describe the case of a patient with OUD who received methadone for opioid withdrawal in a bridge clinic and linked to an OTP within 72 h.Case presentationA 54-year-old woman with severe OUD was seen in a SUD bridge clinic requesting OTP linkage and assessed with a clinical opiate withdrawal scale (COWS) score of 12. She reported daily nasal use of 1 g heroin/fentanyl. Prior OUD treatment included buprenorphine-naloxone, which was only partially effective. Her acute opioid withdrawal was treated with a single observed oral dose of methadone 20 mg. She returned the following day with persistent opioid withdrawal (COWS score 11) and was treated with methadone 40 mg. On day 3, the patient was successfully admitted to a local OTP, where she remained engaged 3 months later.ConclusionsWhile patients continue to face substantial access barriers, bridge clinics can play an important role in treating opioid withdrawal, building partnerships with OTPs to initiate methadone on demand, and preventing life-threatening delays to methadone treatment. Federal policy reform is urgently needed to make methadone more accessible to people with OUD.

Emergency department-initiated buprenorphine protocols: A national evaluation.

ObjectiveEmergency department‐initiated buprenorphine (BUP) for opioid use disorder is an evidence‐based practice, but limited data exist on BUP initiation practices in real‐world settings. We sought to characterize protocols for BUP initiation among a geographically diverse sample of emergency departments (EDs).MethodsIn December 2020, we reviewed prestudy clinical BUP initiation protocols from all EDs participating in CTN0099 Emergency Department‐INitiated bupreNOrphine VAlidaTION (ED‐INNOVATION). We abstracted information on processes for identification of treatment‐eligible patients, BUP administration, and discharge care.ResultsAll participating ED‐INNOVATION sites across 22 states submitted protocols; 31 protocols were analyzed. Identification of treatment‐eligible patients: Most EDs 22 (71%) relied on clinician judgment to determine appropriateness of BUP treatment with only 7 (23%) requiring decision support tools or diagnosis checklists. Before BUP initiation, 27 (87%) protocols required a documented Clinical Opiate Withdrawal Scale (COWS) score; 4 (13%) required a clinical diagnosis of withdrawal with optional COWS score. Twenty‐seven (87%) recommended a minimum COWS score of 8 for ED‐initiated BUP. BUP administration: Initial BUP dose ranged from 2–16 mg (mode = 4). For continued withdrawal symptoms, 27 (87%) protocols recommended an interval of 30–60 minutes between first and second BUP dose. Total BUP dose in the ED ranged from 8 to 32 mg. Discharge care: Twenty‐eight (90%) protocols recommended a BUP prescription (mode 16 mg daily) at discharge. Naloxone prescription and/or provision was suggested in 23 (74%) protocols.ConclusionsIn this geographically diverse sample of EDs, protocols for ED‐initiated BUP differed between sites. Future work should evaluate the association between this variation and patient outcomes.

Decreasing Length of Stay in Opioid Withdrawal.

In 2017, more than 1,200 opioid-related deaths were reported in Virginia, with slightly fewer in 2018, at 1,193 deaths. The current opioid crisis has placed a strain on an already limited number of mental health (MH) inpatient beds. The industry standard for assessment and treatment of opioid withdrawal symptoms, in the inpatient setting, is the Clinical Opiate Withdrawal Scale (COWS), and yet some units continue to utilize the Clinical Institute Withdrawal Assessment for Alcohol-Revised (CIWA-Ar) for this population. The purpose of this nurse-led performance improvement project was to implement COWS in the inpatient MH setting and improve length of stay (LOS) by 1 day. In 2018, in a large federal teaching facility in the mid-Atlantic region, the COWS was implemented to replace the CIWA-Ar for opioid withdrawal, with the focus on decreasing LOS. Prior to implementation of COWS, LOS on the inpatient MH unit for opioid withdrawal was 8.6 days, which was higher than the ~6- to 7-day LOS for surrounding private sector hospitals. Individual electronic medical records were reviewed for LOS and completion of COWS and pertinent details were discussed daily with nursing staff and monthly with the interdisciplinary team. Baseline data were collected from April 2017 to March 2018, with data collection continuing through the project implementation, April to September 2018. Completion of COWS on 100% of patients admitted with opioid withdrawal and a decrease in LOS from 8.6 to 4.7 days was found, a 45% reduction. The nurse-driven performance improvement project affected business acumen, through decreased LOS, as well as quality of care, through better symptom management.

Delivering Transcutaneous Auricular Neurostimulation (Tan) to Improve Symptoms Associated with Opioid Withdrawal: Results from a Randomized, Controlled Trial

Background: The development of practical strategies for treatment of addiction is a major priority for government agencies and health plans given the substantial impact on health, social, and economic welfare. Recently, neurostimulation approaches have demonstrated efficacy managing opioid withdrawal symptoms (OWS). This investigation determined whether transcutaneous auricular neurostimulation (tAN) is safe and effective in management of OWS. Methods: Participants were followed during residential detox treatment (Austin, Texas) at a single center in the US in this randomized, participant and assessor-blinded, parallel group trial. Adult (18–65) participants with a history of opioid withdrawal were randomized 1:1 with sealed opaque envelopes, using permuted blocks of four to active tAN or delayed tAN. tAN was delivered up to 23 hours per day for five days at the following settings: 5 Hz, 250 μs, 1·0 mA at cymba concha and 100 Hz, 250 μs, 1·4 mA adjacently anterior to tragus. The hypothesis-driven primary outcome was change in opioid withdrawal symptoms, measured by the Clinical Opiate Withdrawal Scale (COWS), from baseline to 60 minutes after start of tAN therapy in the intention-to-treat (ITT) population. This study is registered with ClinicalTrials.gov (NCT04075214). Outcomes: Thirty-five (35) participants were enrolled between December 2019 and December 2020 and 31 of those were assigned equally to treatment. The primary endpoint analysis included all randomized participants. Mean (SD) COWS scores were significantly reduced by 7·0 (4·7) points at 60 minutes after start of tAN (95% CI, −4·2 to 9·7; p<0·0001; Cohen’s d=2·0), meaning the observed percent reduction in COWS score for the primary endpoint was both significant and clinically meaningful at 45·9%. Two participants (7·7%) experienced a device-related adverse event which resolved without intervention. Interpretation: Results provide relevant and statistical evidence of safe and effective use of tAN in reducing OWS and supported FDA clearance. Trial Registration: This study is registered with ClinicalTrials.gov (NCT04075214). Funding: Trial was funded by the Sponsor, Spark Biomedical. Declaration of Interest: NK, SW, DP, CB, HV and AC are employees of Spark Biomedical. CT has private equity (stock options or other ownership interest) in and is a paid consultant of Spark Biomedical. Ethical Approval: This trial was conducted in accordance with ICH Good Clinical Practices Guidelines (E6) and FDA regulations and followed the Consolidated Standards of Reporting Trials (CONSORT) reporting guidelines. Institutional Review Board (IRB) approval from Western Copernicus Group (20191239; Puyallup, WA) was obtained prior to study conduct

199 Extended-Release Injectable Buprenorphine for Emergency Department Patients with Opioid Use Disorder in Minimal Withdrawal

To assess the safety of a 7-day extended-release injectable buprenorphine formulation (XR-BUP, CAM2038) in emergency department (ED) patients with opioid use disorder (OUD) presenting in minimal to no withdrawal defined as Clinical Opioid Withdrawal Scale (COWS) scores < 8.

High-dose buprenorphine in the ED could be safe for some patients

Doses of buprenorphine well above the established standards (>12 mg) administered in the emergency department are safe and well-tolerated in individuals experiencing opioid withdrawal symptoms, says a new case series published by Herring and colleagues in the July 2021 issue of JAMA. The authors’ findings suggest that a relatively high buprenorphine induction dose, in certain patient populations that do not respond to current recommended induction regimens, may allow for a paradigm shift in common opioid use disorder (OUD) treatment modalities. The clinical algorithm presented in the study’s design allows for a more rapid response to withdrawal symptoms while also removing barriers to short-term medication access. The authors hope that by rapidly achieving therapeutic levels of buprenorphine and extending buprenorphine’s duration of action, it will potentially improve patient engagement in longer-term addiction treatment programs. Herring and colleagues conducted a retrospective review of patient electronic health record data from Highland Hospital Emergency Department in Oakland, CA in 2018. The authors identified specific OUD patients who did not have their withdrawal symptoms relieved by current guideline-recommended buprenorphine induction therapy as outlined by the Substance Abuse and Mental Health Services Administration (SAMHSA). Patients who had a COWS score (Clinical Opioid Withdrawal Scale) of 8 or more after receiving 8 mg to 12 mg of buprenorphine in the ED could be escalated to what the authors refer to as the “high-dose induction pathway,” in which the patient could receive up to 32 mg of buprenorphine, provided they showed no clinical signs of sedation, respiratory depression, or other complicating factors. Additionally, the participating providers could discharge the patient with a prescription for 16 mg of buprenorphine daily until follow-up at an addiction treatment clinic. Of the 579 opioid withdrawal ED visits during the study’s timeframe, 366—or 63.2%—were escalated to the high-dose induction pathway. Additionally, of all the buprenorphine dose totals, nearly one-fourth of them were equal to 28 mg or more. The high-dose intervention appears to have been very well-tolerated, with only one case experiencing precipitated withdrawal symptoms after receiving 24 mg of buprenorphine. In fact, of the 5 total cases of precipitated withdrawal recorded, 4 of them occurred after 8 mg of buprenorphine, but resolved after their doses were escalated to 28 mg total. Overall, there were no serious adverse effects related to buprenorphine recorded during the study, including sedation, hypoxia, or naloxone rescue in the ED 24 hours after discharge. It has been well-established that allowing withdrawal treatment through EDs improves patient engagement in addiction treatment programs. However, according to buprenorphine (specifically SUBUTEX) drug label information from 2017, “in some studies, gradual induction over several days led to a high rate of drop-out of buprenorphine patients during the induction period.” The drug labeling recommends that an adequate treatment dose, titrated to clinical effectiveness, should be achieved as rapidly as possible. Currently, the 2021 Treatment Improvement Protocols—the official guidance document by SAMHSA—recommends buprenorphine 2 mg to 4 mg, followed by a second dose of 2 mg to 4 mg after approximately 2 hours, with a maximum of 8 mg to 12 mg on day 1 and 16 mg on day 2 via a referred addiction clinic. However, this guidance may be too uniform and not adequate for patients who require a higher dosing strategy. The authors imply that the current standard often prolongs the time for maximum saturation of μ-opioid receptors and reduction in cravings. Furthermore, they state that it assumes the patient has adequate access to a buprenorphine prescription for the second day, which is often not the case. The treatment algorithm presented by Herring and colleagues is a good step forward for redefining current recommendations with regard to opioid addiction treatment in the ED. While the study may be a retrospective case series at a single site, it represents a practical application (with a well-represented patient population) for adopting a relatively safe high-dose treatment algorithm into routine practice. This new treatment technique could help prevent the inadvertent prolongation of withdrawal symptoms that current guidance may yield and improve patient follow-up and retention with addiction centers.

Safety of induction at standard doses of buprenorphine for inpatients with opioid use disorder

Introduction: Patients with opioid use disorder (OUD) are commonly admitted to various inpatient services where treatment can be started. The typical initiation of buprenorphine involves delay of treatment until withdrawal symptoms occur, however, those symptoms may interfere with other medical therapy. The purpose of this study was to evaluate the safety and efficacy of initiation of buprenorphine for inpatients with OUD. Methods: We reviewed the charts of 99 patients for whom the inpatient addiction medicine consult service was contacted over a 15-month period from January 2020 to identify those patients started on buprenorphine. We abstracted data on toxicology results, prior use of buprenorphine, and Clinical Opioid Withdrawal Scale (COWS) and pain scores before and after the administration of buprenorphine. Results: There was no significant difference in COWS classification post treatment based on ancillary or non use of full agonist therapy. There was no significant change in COWS scores based on prior buprenorphine or methadone use. 5% of patients developed moderate withdrawal (COWS score 12–24) after the initiation of buprenorphine. Twenty of the study patients (20%) developed a 2-point increase in pain scores after the initiation of buprenorphine. Summary: The initiation of buprenorphine for inpatients rarely results in a significant increase in withdrawal symptoms. A larger percent of patients may have an increase in pain scores which would need to be managed. Further prospective work on this subject is warranted.

Assessment of craving in opioid use disorder: Psychometric evaluation and predictive validity of the opioid craving VAS

BackgroundThis work evaluated the psychometric properties of the single-item Opioid Craving Visual Analog Scale (OC-VAS) for opioid use disorder (OUD). MethodsPsychometric evaluation of the OC-VAS (range: 0–100 mm) was supported by Subjective Opiate Withdrawal Scale (SOWS) item 16 and total score, Clinical Opiate Withdrawal Scale (COWS) scores, and the 36-Item Short-Form Health Survey, using data from phase 3 study (NCT02357901; N = 487) participants who received randomized treatment and completed the OC-VAS at screening. Descriptive properties, test-retest reliability, construct validity, known-groups validity, and responsiveness were assessed. Interpretation of meaningful change and predictive validity were also explored. ResultsDescriptive properties for the OC-VAS at screening did not provide evidence of problematic floor/ceiling effects or missingness. The test-retest reliability was established by weekly intraclass correlations >0.70. At the screening and end of the study, the strong positive correlations between OC-VAS and SOWS Total/Item 16 score and the significant OC-VAS differences among COWS severity groups supported construct validity and known-groups (discriminating ability) validity, respectively. The associations between the changes in OC-VAS and in supporting measures/opioid use from screening to the end of the study demonstrated responsiveness and the ability to detect change in clinical status. During the induction and randomization treatment periods, significant relationships were identified between OC-VAS score and subsequent opioid use. ConclusionsThis psychometric evaluation of the OC-VAS performed on a large OUD patient population provides evidence to support its use to measure the severity of opioid craving and its ability to predict opioid use.

Percutaneous electrical nerve field stimulation to reduce clincial opiate withdrawal: a case series

ABSTRACT Background Medication-assisted treatment can reduce mortality and withdrawal symptoms, yet treatments can have side effects and are cost ineffective. Research has supported alternative approaches to withdrawal symptoms, specifically percutaneous nerve field stimulator (PNFS); yet, to date, there is a lack of understanding of the initial acceptability within treatment programs. Methods A retrospective case series evaluated PNFS to reduce opioid withdrawal symptoms for five adult patients participating in an in-home withdrawal management program. The device was worn for five consecutive days, in which a licensed practical nurses monitored their care. Evaluation included the clinical opiate withdrawal scale (COWS) and clinical reviews based on self-report and clinician interview. Results Significant reductions were noted for all five participants, with the average COWS score for Day 1 at 19.1 reducing to 2.6 at Day 5. In addition, 2-day post-COWS scores demonstrated a continual reduction to 1.4. Qualitative feedback from the patients was recorded, and generalized themes were recorded and addressed. Conclusions Future controlled, prospective studies should investigate the possibility that PNFS can significantly reduce negative symptoms of opiate withdrawal symptoms, along with providing alternatives to medication-assisted treatments for those who are suffering from opiate use disorder.

Loperamide and P‐glycoprotein modulator in opioid detoxification

Opioids contribute to 70% of the negative health impact associated with drug use disorders. A new opioid withdrawal protocol using over‐the‐counter medications loperamide and P‐glycoprotein inhibitor (omeprazole) was described by Dr Al Garhy previously. In this article the successful use of this protocol, evidenced by the Clinical Opiate Withdrawal Scale, is discussed in a case series.

The effects of Berberis vulgaris L. root extract on the opiate withdrawal syndrome and psychological factors: a randomized double-blind clinical trial.

In this clinical trial, the effect of aqueous extract of Berberis vulgaris L. was investigated on opiate withdrawal syndrome, depression, anxiety, stress, and sleep quality in opioid addicts which were under methadone maintenance therapy. For this purpose, 52 opiate addicts were randomly selected of whom 28 received 500mg capsules of B.vulgaris extract (treatment) and the rest received 500mg of starch capsules (placebo), twice daily for 4weeks. Signs and symptoms of opiate withdrawal syndrome, depression, anxiety, stress, and sleep quality were assessed through Clinical Opiate Withdrawal Scale (COWS), Pittsburgh Sleep Quality Inventory (PSQI) and Depression Anxiety Stress Scales-21 (DASS-21) questionnaires at baseline and after 7, 14, and 28days of receiving intervention. Signs and symptoms of opiate withdrawal syndrome were significantly improved in those who received the extract for 1month compared to the placebo group. However, there were no significant differences in depression, anxiety, stress, and sleep quality scores in the treatment group compared to those in the placebo group. The extract of B.vulgaris root as a traditional herbal product in combination with methadone could improve the symptoms and signs of opiate withdrawal.

Interobserver agreement between emergency clinicians and nurses for Clinical Opiate Withdrawal Scale.

ObjectivesThe Clinical Opiate Withdrawal Scale (COWS) is a validated, commonly used tool to objectively quantify withdrawal symptoms, often in anticipation of treatment with buprenorphine. Our primary aim was to determine the agreement between emergency department (ED) nurses compared with emergency physicians in determining this score in ED patients who presented for opioid withdrawal treatment. Secondarily, we wanted to investigate the safety of buprenorphine induction in the ED setting.MethodsScoring for opioid withdrawal using the COWS was performed by ED clinicians and ED nurses independently on 120 patients. In addition to overall concordance, agreement (weighted kappa) was calculated between the 2 scores by various cutoffs: overall severity, COWS ≥ 5, and the 11 different individual measures. Patient documents also were reviewed for complications that could be possibly linked to buprenorphine induction.ResultsOur study sample of 120 subjects was 77% Hispanic and 78.3% male. The clinicians assigned a median interquartile range overall COWS score of 6 (2–12), which categorizes as mild withdrawal. Seventy‐eight (65%) subjects met the criteria of withdrawal (≥ 5 COWS) and 69 (58%) received an induction dose of buprenorphine (range 2 mg–24 mg) during the ED visit. No adverse effects or worsening withdrawal were reported. The overall observed concordance, based on severity withdrawal categorization, for all clinician pairs, was 67.5% (81/120) (95% confidence interval [CI], 58.7–75.2%). The weighted kappa for that concordance was 0.55 (95% CI, 0.43–0.67), giving a moderate strength of agreement. When data are dichotomized by COWS score ≥5, concordance was 82.5% (99/120) (95% CI, 74.7%–88.3%) and the weighted kappa was 0.65 (95% CI, 0.51–0.78), indicating substantial agreement. The breakdown by the 11 factors that constitute COWS showed only substantial agreement for pulse measurement.ConclusionThe agreement between ED clinicians and nurses for the overall COWS scoring in patients presenting for opioid withdrawal treatment was substantial. COWS scoring by ED nurses may help expedite treatment with buprenorphine on presentation.

Use of clonidine in the management of opiate withdrawal in community patients

AimsClonidine has been used to alleviate symptoms of opiate withdrawal. No validated prescribing schedules exist for the use of Clonidine in opiate detoxification in community patients. We have devised a Clonidine prescribing schedule for adult outpatients seeking opiate detoxification.BackgroundOpiate cessation following prolonged use produces a central noradrenergic (NA) response in the locus coeruleus (LC), causing symptoms that can result in reinstatement of use. Pharmacotherapies for withdrawal are thought to work through decreased NA release in the LC by agonising pre-synaptic alpha-2 adrenoceptors. Clonidine has been used since the 1970s. However, it is off-license in the UK, and superseded by Lofexidine. Though both cause hypotension, this is less marked with Lofexidine, which may be anxiolytic and considered better tolerated. Lofexidine is no longer available in the UK. Specialists may need to resort to Clonidine for those seeking opiate detoxification.MethodWe performed a feasibility study with the primary outcome being tolerability of an outpatient clonidine schedule. Patients (n = 7) were aged between 18 and 65 years (mean 32). Six were prescribed buprenorphine as opiate substitution (OST), and one methadone.Exclusion criteria were in keeping with BNF contraindications.An ECG was obtained for each patient before treatment. A urine drug screen and Clinical Opiate Withdrawal Scale were taken to confirm opiate dependence and withdrawal. Patients self-monitored withdrawal using the Subjective Opiate Withdrawal Scale and daily blood pressure measurements. Standard adjuvants for withdrawal were prescribed.A test dose of 100mcg Clonidine was given to assess for hypotension. If tolerant they received 100mcg QDS, reducing over eight days.Patients were contacted by their recovery worker twice during the period.ResultFive of the seven completed the course, two dropped out due to hypotension. No other adverse effects warranting discontinuation were encountered. Patients reported fatigue and light-headedness as their most troublesome side-effects. Of 3 patients who returned SOWS scores, 2 reported decline by 21/64 and 14/64 respectively. One reported an increase of 49/64 over 8 days. 3 of the 5 subjects who completed the course were not abstinent at completion, citing opiate withdrawal symptoms as causative.ConclusionThere is scope for the safe use of clonidine in the community for motivated individuals. Adequate monitoring of heart rate and blood pressure is required. Starting doses at 100mcg QDS appear well tolerated. Prescribers may wish to reduce this over a longer period to encourage completion and improve tolerability. Further research is needed.

Case Study: Three Day Suboxone Taper for Opiate Withdrawal

Drug addiction has reached epic proportions throughout the United States. Providers and researchers are working to develop treatment options to help individuals who wish to overcome addiction. Suboxone tapers are now frequently utilized to manage opiate withdrawal. However, the use of a three-day taper is not well discussed in literature. This case study gives an overview of how a three-day taper may be utilized for some clients experiencing negative withdrawal symptoms. After initiating the suboxone taper, the client reported mild symptoms of withdrawal per the clinical opiate withdrawal scale (COWS) ratings. This individual was able to complete the detox program and move onto residential living. These results suggest that a three-day suboxone taper may help aid in the recovery of individuals with substance use disorder (SUD), but due the limited size of a single case study, more research is needed including long-term evaluation.

877 Inpatient buprenorphine induction for opioid use disorder in pregnancy

Buprenorphine is used for opioid use disorder but there is limited data to guide induction protocols in pregnancy. A protocol for inpatient buprenorphine induction with titration based on Clinical Opiate Withdrawal Scale (COWS) scores was initiated at our institution in 2015. The purpose of this study is to assess the inpatient buprenorphine induction patterns, treatment retention, and pregnancy outcomes among obstetric patients with opioid use disorder seeking treatment. Obstetric patients with opioid use disorder admitted for inpatient buprenorphine induction between May 2015 to 2020 were studied retrospectively. A descriptive analysis of the cohort, induction patterns, and retention after discharge evaluated. Among patients delivered at our institution obstetric and neonatal outcomes were assessed. 60 patients were admitted for inpatient buprenorphine induction at a median gestational age of 16.7 weeks. The median COWS on presentation was 9. Most patients were initiated on 8 mg buprenorphine (30), while 24 were started at 4 mg. 22 patients had no additional withdrawal symptoms day one while 21 patients required a supplemental 2 mg dose. The median duration of hospitalization was 3 days (range 2-12). The median buprenorphine dose upon discharge was 10 mg (range 4-20). Of the 12 patients with birth outcomes, 3 were on a different dose at delivery; 2 decreased dose and 1 switched to methadone. Only 13 of the 35 patients (37%) who desired prenatal care at our institution returned. Of the 12 (20%) patients who delivered at our institution, 9 were live births (75%). Among the live births, the median gestational age at delivery was 37.4 weeks, birthweight 3085 grams, and only 1 developed neonatal abstinence syndrome. The Clinical Opiate Withdrawal Scale can be used to guide inpatient buprenorphine titration for pregnant patients with opioid use disorder which takes approximately three days to establish a satisfactory maintenance dose of 10 mg. The majority of patients who followed up after hospital discharge did not need dose adjustments and had good outcomes.

An Open-label Randomized Control Trial Comparing Clonidine and Buprenorphine for Medically-Assisted Opium Withdrawal of Adolescents

Background: There is an increasing trend in treatment demand for opioid dependence among adolescents in Iran. However, evidence regarding effective treatment in this population is very limited. Objectives: This study aimed to compare the efficacy of clonidine and buprenorphine for inpatient medically-assisted withdrawal of adolescents with opioid dependence aged 12 and 16 years. Materials and Methods: The study is an open-label, randomized controlled trial with convenience sampling. In total, 36 adolescents took part in this study who were randomly assigned to buprenorphine or clonidine groups. The Clinical Opiate Withdrawal Scale was used to monitor the withdrawal severity on days one, two, three, seven, and 14. Results: The findings showed both treatments were effective. However, withdrawal symptoms in the buprenorphine group showed a greater reduction in the first seven days of withdrawal treatment. There was no significant difference in the length of hospitalization between the two groups. Patients with a longer duration of opioid use showed higher levels of withdrawal symptoms in the buprenorphine group on days one and three. Conclusions: Buprenorphine treatment was found to be more effective than clonidine in controlling opioid withdrawal during the initial days of treatment. However, it lost its superiority towards the end of the follow-up. It seems that clonidine could be a good alternative to buprenorphine in the medically-assisted withdrawal of adolescents with opioid dependence.

A Pilot Study of Automated Pupillometry in the Treatment of Opioid Use Disorder.

Introduction/Background:A rough, visual estimate of pupil size is used in grading the severity of opioid withdrawal. Few studies have examined the clinical utility of more precise automated pupillometry measurements.Methods:This prospective cohort study enrolled 27 patients receiving opioid agonist therapy (OAT) to treat cravings or withdrawal during an acute hospitalization. Six sets of automated pupillometry measurements were obtained at regular intervals before and after administration of OAT. Clinical Opiate Withdrawal Scale measurements were performed pre and post OAT. Primary outcomes included pupil size in dark and bright illumination (mm). Latency of the pupillary light response (s), constriction and dilation velocity (mm/s), and percent constriction (%) were secondary outcomes.Results:The mean predosing pupil size in dark and bright illumination was 4.33 ± 1.40 mm and 2.96 ± 0.79 mm, respectively. A significantly decreased mean pupil size was first detected at 15 minutes postdosing (4.01 ± 1.34 mm, P = 0.0115 for dark illumination; 2.71 ± 0.72 mm, P = 0.0003 for bright illumination) and this reduction in pupil size persisted at later postdosing timepoints. Those with Clinical Opiate Withdrawal Scale <5 after dosing had a greater decrease in dark pupil size (10.6% ± 13.2 vs 3.2% ± 3.2, P = 0.043). There was no significant change in the remaining pupil reactivity parameters.Conclusions:Automated pupillometry demonstrated a small but significant change in mean pupil size that occurred within 15 minutes of OAT dosing and was associated with low withdrawal scores. This pilot may inform future work to incorporate pupillometry measurement into OAT dosing assessments.