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

Handout

Pdf Summary

This document summarizes inpatient management of opioid withdrawal in the fentanyl era. It emphasizes that fentanyl is far more potent than heroin, that stigma is common, and that patients with substance use disorders (SUD) are at high risk for patient-directed discharge. Starting medication for opioid use disorder (MOUD) in the hospital can reduce this risk.<br /><br />A key point is careful assessment: clinicians should partner with patients around shared goals and evaluate use of opioids plus other substances such as stimulants, nicotine, and alcohol. The Clinical Opiate Withdrawal Scale (COWS) is still useful, but it does not capture cravings, which may be one of the most distressing symptoms and can drive in-hospital substance use or early discharge. Clinicians should also consider newer adulterants like xylazine, which may cause refractory agitation, anxiety, and ulcerated wounds.<br /><br />Withdrawal may be underestimated in fentanyl users because fentanyl is lipophilic and accumulates in adipose tissue, creating a depot effect and making withdrawal behave more like that from a long-acting opioid. Very high COWS scores may also reflect benzodiazepine/alcohol withdrawal or acute illness such as sepsis. It is important to assess for medical illness, concurrent withdrawal, and self-treatment through in-hospital substance use.<br /><br />Treatment options include non-opioid adjuncts, methadone, buprenorphine, and short-acting opioids. Non-opioid adjuncts alone are usually insufficient. Methadone is commonly started at 20–30 mg daily with additional 5–10 mg doses as needed, while monitoring for dose stacking. Buprenorphine is often best started with microinduction/cross-titration because traditional induction may precipitate withdrawal in fentanyl users. Short-acting opioids like hydromorphone or oxycodone can rapidly relieve withdrawal and pain in the hospital, especially in highly tolerant patients. Xylazine withdrawal may respond to clonidine, tizanidine, or dexmedetomidine.

Keywords

opioid withdrawal

fentanyl era

hospital management

MOUD

COWS scale

methadone

buprenorphine microinduction

patient-directed discharge

xylazine withdrawal

substance use disorder