Rapid Clinical Updates: Inpatient Management of Opioid Withdrawal in the Fentanyl Era-Handout

Handout

Pdf Summary

This document addresses the challenges and approaches to treating opioid withdrawal in hospitalized patients, specifically in the era of fentanyl, a synthetic opioid approximately 50 times stronger than heroin. Patients with substance use disorder (SUD) face significant stigma and are much more likely to leave the hospital against medical advice; however, inpatient medication for opioid use disorder (OUD) reduces this risk.<br /><br />Key points include the importance of collaborating with patients on shared goals, thoroughly assessing substance use history—including stimulants, nicotine, and alcohol—and recognizing limitations of the Clinical Opioid Withdrawal Scale (COWS), which does not measure cravings, a critical and often distressing symptom driving in-hospital substance use or self-discharge. Emerging concerns include xylazine, an alpha-2 agonist adulterant linked to refractory agitation, anxiety, and ulcerated wounds.<br /><br />Fentanyl’s lipophilic nature causes accumulation in fat tissue, producing withdrawal symptoms akin to long-acting opioids like methadone, complicating treatment and necessitating caution in starting buprenorphine. Withdrawal may also overlap with medical illness or withdrawal from other substances.<br /><br />Treatment modalities combine non-opioid adjuncts (e.g., clonidine, hydroxyzine, ondansetron), although opioids remain necessary for symptom relief unless refused by the patient. Methadone initiation starts at 20-30 mg daily with add-ons for cravings, but dose titration is slow due to delayed steady state. Buprenorphine microinduction, involving gradual titration alongside full agonists, offers an option but requires careful management. Short-acting opioids may rapidly alleviate symptoms and pain inpatient but are not suitable for outpatient OUD treatment.<br /><br />Xylazine withdrawal requires management with clonidine, tizanidine, or dexmedetomidine. Overall, rapid methadone titration and low-dose buprenorphine microdosing under hospital supervision enhance patient comfort and outcomes. The references range from 2019 to 2023 addiction medicine studies and guidelines.

Keywords

opioid withdrawal

fentanyl

substance use disorder

inpatient medication

Clinical Opioid Withdrawal Scale

xylazine

buprenorphine microinduction

methadone titration

non-opioid adjuncts

hospitalized patients