Opioid Withdrawal

Brief HPI:

A 28 year-old female with a history of IV drug use presents to the emergency department with back pain and fever. During evaluation for spinal epidural abscess, she develops vomiting and diarrhea. Examination reveals diaphoresis, mydriasis and hyperactive bowel sounds – she states that her last heroin use was 18-hours ago.

The patient was interested in guidance with cessation of opioid dependence and was evaluated by a recovery support specialist in the emergency department and provided with an appointment for outpatient follow-up. She was treated with buprenorphine-naloxone 8mg sublingual and her symptoms resolved. Her diagnostic evaluation was normal and she was discharged with a prescription for buprenorphine-naloxone 16mg daily until follow-up.

An Algorithm for the Management of Opioid Withdrawal1-4

An Algorithm for the Management of Opioid Withdrawal


  • Mydriasis
  • Piloerection
  • Diaphoresis
  • Hyperactive bowel sounds

COWS Calculator


  • Dysphoria
  • Rhinorrhea
  • Myalgias, arthralgias
  • Nausea, vomiting, diarrhea
  • Abdominal cramps

Buprenorphine Considerations

Buprenorphine is a high-affinity, opioid partial agonist. The administration of buprenorphine may displace lower-affinity opioids.5 When used for the treatment of acute opioid withdrawal, special care must be taken to ensure that sufficient time has elapsed since last use (evidenced by the presence of moderate withdrawal symptoms) as the immediate displacement of existing opioids can precipitate severe withdrawal. In addition to provoking the maximum severity of the symptoms for which treatment was sought, this can generate mistrust in an otherwise effective medication and the healthcare system more broadly. The combination of buprenorphine with naloxone is intended to deter parenteral abuse – oral/sublingual naloxone is poorly bioavailable.

The initiation of medication-assisted treatment for opioid dependence from the emergency department should be dependent on the availability of outpatient follow-up and addiction treatment programs.6

Supportive Care4,6-7

Symptom Agent Dose
Nausea, Vomiting Promethazine 25mg IM
Diarrhea Loperamide 4mg PO
Octreotide 50mcg SQ
Muscle cramps Baclofen 5mg PO
Anxiety, Dysphoria Lorazepam 1-2mg IV
Diazepam 2-10mg PO, IM, IV
Pain, Myalgia Acetaminophen 650mg – 1,000mg PO
Ibuprofen 600mg PO

Unobserved Induction Guide8

The following guide is adapted from the Yale Department of Emergency Medicine ED-Initiated Buprenorphine Program and is available free for use.
Home Induction Guide Preview

This algorithm was developed with Dr. Drew Silver. Drew is an emergency medicine resident at McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth).


  1. Strayer R, Hawk K, Hayes B, Herring A et al. Management of Opiate Misuse Disorder in the Emergency Department: A White Paper Prepared for the American Academy of Emergency Medicine. American Academy of Emergency Medicine.
  2. ED-Initiated Buprenorphine. Retrieved July 17, 2020, from https://medicine.yale.edu/edbup/Algorithm_338052_5_v2.pdf
  3. Su, M., Lopez, J., Crossa, A., Hoffman, R. (2018). Low dose intramuscular methadone for acute mild to moderate opioid withdrawal syndrome The American Journal of Emergency Medicine 36(11), 1951-1956. https://dx.doi.org/10.1016/j.ajem.2018.02.019
  4. Stolbach A, Hoffman R. Opioid withdrawal in the emergency setting. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc.
  5. Boas, R., Villiger, J. (1985). Clinical actions of fentanyl and buprenorphine. The significance of receptor binding. British journal of anaesthesia 57(2), 192-6. https://dx.doi.org/10.1093/bja/57.2.192
  6. D’Onofrio, G., Chawarski, M., O’Connor, P., Pantalon, M., Busch, S., Owens, P., Hawk, K., Bernstein, S., Fiellin, D. (2017). Emergency Department-Initiated Buprenorphine for Opioid Dependence with Continuation in Primary Care: Outcomes During and After Intervention Journal of General Internal Medicine 32(6), 660-666. https://dx.doi.org/10.1007/s11606-017-3993-2
  7. Gowing, L., Farrell, M., Ali, R., White, J. (2016). Alpha2‐adrenergic agonists for the management of opioid withdrawal Cochrane Database of Systematic Reviews https://dx.doi.org/10.1002/14651858.cd002024.pub5
  8. Home Initiated Buprenorphine. Retrieved July 17, 2020, from https://medicine.yale.edu/edbup/quickstart/Home_Buprenorphine_Initiation_338574_42801_v1.pdf
  9. Wesson DR, Ling W. The Clinical Opiate Withdrawal Scale (COWS). J Psychoactive Drugs. 2003;35(2):253-259. doi:10.1080/02791072.2003.10400007

Pediatric Sizes and Doses

Below is a rapid reference for essential information related to the care of pediatric patients including sizing estimates for endotracheal tubes and weight-based dosing for critical/common medications (rapid sequence intubation, pediatric advanced life support, seizure management), compiled by Dr. Kelly Young1.


4 + Age/4 = uncuffed
Subtract 0.5 for cuffed
Gestational age (weeks) / 10 if premature
Depth = ETTx3
Newborn: 0
<2yo: 1
2-8yo: 2
>8yo: 3
Other Tubes
NGT = ETT x 2
Chest tube = ETT x 4

Estimating Weight

Age (years) 1 3 5 7 9
Weight (kg) 10 15 20 25 30

Vital Signs

Blood Pressure

Age Measure
Neonate 60mmHg
<1yo 70mmHg
1-10yo 70 + (Age x2)
>10yo 90mmHg

Heart/Respiratory Rate

Age (yrs) HR RR
0-1 140 40
1-4 120 30
4-12 100 20
>12 80 15


Name Dose
RSI (Paralysis)
Succinylcholine 1mg/kg (x2 infant, x3 neonate)
Rocuronium 1-1.2mg/kg
RSI (Sedation)
Etomidate 0.3mg/kg
Ketamine 2mg/kg
Midazolam 0.1mg/kg
Fentantyl 1mcg/kg
Defibrillation 2, 4, 10J/kg
Cardioversion 0.5, 1J/kg
Epinephrine 0.01mg/kg (0.1mL/kg of 1:10,000)
Atropine 0.02mg/kg (minimum dose 0.1mg, maximum 0.5mg)
Adenosine 0.1mg/kg (max 6mg), 0.2 mg/kg (max 12mg)
Amiodarone 5mg/kg
Calcium gluconate (10%) 1mL/kg
Calcium chloride (10%) 0.2mL/kg
Magnesium sulfate 25mg/kg
Sodium bicarbonate 1mEq/kg
3% saline 5cc/kg
Mannitol 1g/kg
Normal saline (0.9%) 20cc/kg
PRBC 10cc/kg
Maintenance 4cc/kg (first 10kg), 2cc/kg (second 10kg), 1cc/kg thereafter
<1yo D10, 5cc/kg
1-10yo D25, 2cc/kg
>10yo D50, 1cc/kg
Lorazepam, Midazolam 0.1mg/kg x3
Fosphenytoin 20 PE/kg
Keppra 20-40mg/kg
Valproate 20mg/kg
Phenobarbital 20mg/kg
Midazolam infusion 0.1mg/kg/h
Midazolam IN 0.2mg/kg (max 10mg)
Ceftriaxone 50mg/kg
Amoxicillin 90mg/kg divided BID
Azithromycin 10mg/kg day 1, 5mg/kg days 2-5
Common Medications
Acetaminophen 15mg/kg
Ibuprofen 10mg/kg
Diphenhydramine 1.25mg/kg
Ondansetron 0.15mg/kg
Intranasal Medications
Fentanyl 1.5mcg/kg (max 100mcg)
Midazolam 0.5mg/kg (max 10mg)


  1. Young, K. D. (2016, April 18). Pediatric Doses and Sizes. Lecture presented at Harbor-UCLA Medical Center in CA, Torrance.