The Clinical Institute Withdrawal Assessment for Alcohol Scale, Revised (CIWA-Ar) is the most widely used alcohol withdrawal symptom scale. Although it is primarily used in inpatient settings, it’s also useful for outpatient detox since it reminds both clinicians and patients of the types and severity of symptoms seen in alcohol withdrawal.

Rates of opioid use disorder (OUD) and overdose deaths during pregnancy have skyrocketed in recent years. Untreated OUD is associated with many adverse outcomes, including overdose death, that can be mitigated by proper medication for opioid use disorder (MOUD) treatment. Methadone and buprenorphine have a robust evidence base, while injectable naltrexone lacks enough data to recommend during pregnancy and is not recommended.

Methadone is a long-acting opioid agonist that is one of the mainstays of opioid use disorder (OUD) treatment, along with buprenorphine. Compared to patients not in treatment, those receiving methadone have lower all-cause mortality, rates of transmissible diseases, criminal convictions, suicide, and even cancer. Methadone for OUD must come from a federally regulated opioid treatment program (OTP), or “methadone clinic.” Patients start out by going to the clinic daily, which can be an inconvenience. Disadvantages include the potential for diversion and the possible accumulation of doses due to its long half-life.

Induction refers to the process of starting a patient on buprenorphine (with or without naloxone; the combination product is most often preferred). It can be done either inpatient or outpatient and typically takes two to three days, depending on the ultimate dose. See also the “Buprenorphine Microinduction” fact sheet for an alternative approach.

The Clinical Opiate Withdrawal Scale (COWS) is an 11-item scale designed to be administered by a clinician. This tool can be used in both inpatient and outpatient settings to reproducibly rate common signs and symptoms of opiate withdrawal and monitor these symptoms over time. The summed score for the complete scale can be used to help clinicians determine the severity of opiate withdrawal.

Unless you work in a federally funded methadone clinic, known as an opioid treatment program (OTP), you won’t be managing methadone long term or making dose adjustments on your own. Treating OUD patients with methadone for more than a few days requires collaboration with an OTP, so if you have a patient who needs methadone, don’t hesitate to reach out to one nearby, if one is available. You will also see patients on methadone for other psychiatric needs, so you need to know some details about how OTPs operate and how methadone can interact with other medications. For those initiating methadone in an inpatient setting and referring to OTP for follow-up, see “Managing Opioid Withdrawal in the Inpatient Setting” fact sheet.

Sublocade and Brixadi are long-acting forms of injectable buprenorphine given once every four or eight weeks for Sublocade and weekly or monthly for Brixadi. The ease of use and flexible dosing of these extended-release formulations make them real game-changers, particularly for patients with adherence challenges. Both products are expensive, though Medicare and many Medicaid programs cover the cost. See “Buprenorphine Extended-Release Injection Monotherapy” fact sheet for additional information.

This medication is used to help manage moderate to severe opioid use disorder. It is also used to provide relief from moderate to severe pain.

The illicit opioid supply has become increasingly unpredictable. Over the last 10 years, fentanyl and its derivatives have found their way into this supply and have become key contributors to the continued increase in overdose deaths. One of the most concerning and persistent additives is xylazine, known on the street as “tranq.” Here, we will cover the basic pharmacology of xylazine, why it’s so concerning, what to look out for if you suspect it, and how to counsel your patients.

Drug overdose deaths, the vast majority of which involve opioids, continue to rise in the US. Health care providers should be able to identify patients at particularly high risk for overdose, know how to mitigate risk using harm reduction strategies, and educate patients to recognize and quickly treat overdose. (See “Opioid Overdose Overview Fact Sheet for Patients.”)