Initial Questions As with any psychiatric interview, start by building an alliance and showing interest in your patient in a general way. The first few questions, although not explicitly related to psychiatric issues, will typically naturally transition to the patient’s reason for their visit. ⦁ “Where are you from?” ⦁ “What do you do for work and fun?”

The Clinical Opiate Withdrawal Scale (COWS) is an 11-item scale used for rating the degree of opioid withdrawal. See our accompanying fact sheet that reproduces the entire scale for your use. While the COWS may appear straightforward, it can be confusing when using it to assess patients undergoing withdrawal in the real world. In this fact sheet, we offer some hard-won tips and pitfalls to avoid so that you can more accurately rate your patient’s withdrawal symptoms.

Like all substance use disorders, opioid use disorder (OUD), defined by the DSM-5, includes 11 criteria. While most experienced clinicians can diagnose OUD without going through a formal checklist of symptoms, we suggest you try using this sheet during interviews. You are likely to find it helpful in at least two ways.

Rationale for Microinduction The standard method of starting a patient on buprenorphine (see “How to Discuss and Initiate Buprenorphine” fact sheet) involves having the patient stop all opioids hours to days before the induction. This period is needed because buprenorphine can trigger opioid withdrawal if given when the patient still has most of their opioid receptors occupied by agonists. T

The global supply of illicit opioids is rapidly shifting and unstable. Fentanyl went from being an occasional contaminant to nearly completely taking over street opioids in the span of just a few years. More often than not, patients obtain different opioid drugs from a variety of sources. Depending on what is available at a given time, the same person may be sniffing, smoking, injecting, or swallowing different varieties of opioids, some illegal (such as heroin), some legal but illicitly obtained (such as OxyContin), and some legal drugs that were manufactured illicitly (such as fentanyl). In this fact sheet, we introduce you to the landscape of street opioids in order to help you understand what your patients are using and allow you to speak their language.

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.

Getting patients with opioid use disorder (OUD) completely off opioids, so-called “detox,” is generally not advisable. Very few patients with OUD are able to completely stop opioids and remain abstinent for any length of time without further treatment. Moreover, taking patients off opioids completely can lower tolerance and paradoxically increase risk of overdose in the long run. The only situation in which medically supervised withdrawal is a sensible approach is if the patient plans to receive intramuscular naltrexone immediately afterwards, but even this approach can be tough outside of controlled inpatient settings.

Who Is Likely to Experience Withdrawal Symptoms? ⦁ It’s hard to predict whether a particular person will experience withdrawal or how severe their symptoms will be. Generally speaking, anyone who consistently takes an opioid for two weeks or longer is at risk.

Opioids can cause a bad and potentially fatal reaction (overdose) that makes your breathing slow or even stop, which can be fatal. Opioids include prescriptions such as hydrocodone, oxycodone, morphine, codeine, and hydromorphone. Other opioids are heroin and fentanyl, which can be obtained illicitly or may contaminate street drugs like cocaine, methamphetamine, or counterfeit pills.

Opioid use disorder (OUD) is highly comorbid with medical illness and other psychiatric conditions. Most of your patients on medications for OUD (MOUD) will also be taking other medications (Du CX et al, Fam Pract 2022;39(2): 234–240). MOUDs generally play well with other medications, but there are some important interactions to be aware of. Here is a summary of some important med-med interactions to be wary of when prescribing MOUDs.