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

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The document is a teaching presentation on treating opioid withdrawal in the fentanyl era, aimed at hospitalized patients and clinicians. It emphasizes that fentanyl use has changed withdrawal management because withdrawal can be prolonged, unpredictable, and severe, with high risk of patient-directed discharge, in-hospital substance use, and poor outcomes. The speakers stress using non-stigmatizing, person-first language and building rapport through permission-based, transparent, and open-ended communication.<br /><br />The presentation outlines how to assess withdrawal using history, cravings, and the Clinical Opiate Withdrawal Scale (COWS), noting that patients may appear quietly uncomfortable and self-medicate if untreated. It reviews three main treatment strategies: non-opioid adjuncts (such as clonidine, hydroxyzine, NSAIDs, ondansetron, and loperamide), opioid agonist treatment with methadone, and buprenorphine, including low-dose (“microdose”) and higher-dose approaches. It also highlights a fourth practical inpatient strategy: short-acting full agonist opioids (for example, oxycodone or hydromorphone) to rapidly relieve withdrawal and pain, especially for patients with very high fentanyl tolerance or those not ready for MOUD.<br /><br />The talk explains that in-hospital treatment of withdrawal is legal and can support completion of medical care, reduce suffering, maintain tolerance, and serve as a bridge to long-term medications for opioid use disorder when desired. It also discusses managing concurrent in-hospital substance use, recommending a non-punitive, supportive approach rather than involving law enforcement unless there is a clear safety issue.<br /><br />A brief section addresses xylazine (“tranq”), including its overdose and withdrawal features. The presentation concludes with key takeaways: recognize fentanyl withdrawal, partner with patients using respectful language, treat withdrawal effectively with opioids when needed, start methadone or buprenorphine if desired, and educate learners.

Keywords

opioid withdrawal

fentanyl

hospitalized patients

methadone

buprenorphine

COWS

harm reduction

person-first language

xylazine

withdrawal management