Question 1

A 32-year-old man with severe opioid use disorder presents to the ED requesting buprenorphine initiation. He last used intravenous heroin 6 hours ago. He is uncomfortable but his COWS score is 4. He reports mild anxiety and yawning but no other withdrawal symptoms. Pupils are 4 mm bilaterally. He is asking for buprenorphine "right now" because he "can't handle withdrawal." What is the most appropriate next step?

Accepted Answer

Buprenorphine is a high-affinity partial mu-opioid agonist. If administered while full agonists still occupy the receptors (as indicated by a low COWS score), buprenorphine will displace the full agonist and precipitate withdrawal that is more severe and acute than natural withdrawal. This patient is only 6 hours from his last heroin use with a COWS of 4, far too early for safe induction. The standard protocol requires a COWS of 8-12 or higher, generally 12-24 hours after short-acting opioids. In the interim, symptomatic management with clonidine (for autonomic symptoms), ondansetron (nausea), loperamide (diarrhea), and NSAIDs (myalgias) provides comfort. Administering naloxone to force withdrawal is dangerous and not standard practice. Discharging without supervised first dose risks precipitated withdrawal at home.

Question 2

EMS is called to a park where a 24-year-old woman is found unresponsive. She is cyanotic with a respiratory rate of 3 breaths per minute, pinpoint pupils, and agonal respirations. There is drug paraphernalia nearby. EMS administers naloxone 4 mg intranasally. Within 2 minutes she is awake, agitated, and vomiting. Her respiratory rate increases to 16. She refuses further care and wants to leave. What are the critical management considerations?

Accepted Answer

The key concept is the mismatch between naloxone's short duration of action (30-90 minutes) and the longer duration of most opioids, especially fentanyl and methadone. After the initial reversal, the opioid outlasts the naloxone, and the patient can re-sedate and stop breathing again. Monitoring for at least 2-4 hours after the last naloxone dose is essential, longer if a long-acting opioid is suspected. A second naloxone dose is indicated if re-sedation occurs, not preemptively in a patient who has already responded. Buprenorphine induction during naloxone-induced withdrawal is not appropriate since the withdrawal is artificially induced and will resolve when naloxone clears. This encounter is also a critical touchpoint for offering MOUD, naloxone for home, and connecting the patient with harm reduction and treatment services. Every overdose reversal is a clinical opportunity.

Question 3

A 29-year-old woman at 16 weeks gestation presents for prenatal care. She has severe opioid use disorder and is currently using intravenous fentanyl daily. She wants to stop using and is willing to accept treatment. She asks about her options. Which of the following is the most appropriate treatment recommendation?

Accepted Answer

The standard of care for OUD in pregnancy is medication treatment with methadone or buprenorphine, not detoxification and not naltrexone. Medically supervised withdrawal during pregnancy is associated with high relapse rates (often exceeding 80%), and repeated cycles of intoxication and withdrawal pose greater risk to the fetus than stable medication treatment. Naltrexone is contraindicated in pregnancy due to insufficient safety data and the blockade of endogenous opioid activity. Neonatal opioid withdrawal syndrome (NOWS) may occur with medication treatment but is treatable, time-limited, and far preferable to the consequences of untreated OUD. Every major guideline organization, including ACOG, SAMHSA, and the WHO, recommends MOUD as first-line treatment for OUD in pregnancy.

Opioid Use Disorder

Red Flags & Key Clinical Considerations

Respiratory Depression and Overdose

Precipitated Withdrawal from Premature Buprenorphine Induction

Polysubstance Use with Benzodiazepines

Suicidality

Pregnancy

Related Medications

References & Further Reading