DSM-V criteria for opioid use disorder (OUD)
At least two of the following should be observed within a 12-month period:
Source: American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
Assess most recent use of substances
Has the patient used opioids in the last 72 hours?Assess for contraindications
Does the patient have an allergy to buprenorphine/naloxone?Patients with lost opioid tolerance
OUD and no opioid use in past 72 hours
Initiation
- Provide bup/nal 2 mg
- Calculate and administer daily dose as per standard bup/nal treatment guidance
Reassess dose
- Reassess dose every 3-7 days and increase by 2 mg if indicated based on ongoing withdrawal symptoms, cravings, or non-prescribed opioid use.
Assess most recent use of substances
Has the patient used short-acting opioids in the last 12 hours?The Clinical Opiate Withdrawal Scale (COWS)
Source: Wesson DR, Ling W. The Clinical Opiate Withdrawal Scale (COWS). J Psychoactive Drugs. 2003;35(2):253–259.
-
Resting Pulse Rate
Measured after patient is sitting or lying for one minute
Pulse rate 80 or below
0
Pulse rate 81-100
+1
Pulse rate 101-120
+2
Pulse rate greater than 120
+4
-
Sweating
Over past 1/2 hour not accounted for by room temperature or patient activity
No report of chills or flushing
0
Subjective report of chills or flushing
+1
Flushed or observable moistness on face
+2
Beads of sweat on brow or face
+3
Sweat streaming off face
+4
-
Restlessness
Observation during assessment
Able to sit still
0
Reports difficulty sitting still, but is able to do so
+1
Frequent shifting or extraneous movements of legs/arms
+3
Unable to sit still for more than a few seconds
+5
-
Pupil Size
Pupils pinned or normal size for room light
0
Pupils possibly larger than normal for room light
+1
Pupils moderately dilated
+2
Pupils so dilated that only the rim of the iris is visible
+5
-
Bone or Joint Aches
If patient was having pain previously, only the additional component attributed to opiates withdrawal is scored
Not present
0
Mild diffuse discomfort
+1
Patient reports severe diffuse aching of joints/muscles
+2
Patient is rubbing joints or muscles and is unable to sit still because of discomfort
+4
-
Runny Nose or Tearing
Not accounted for by cold sumptoms or allergies
Not present
0
Nasal stuffiness or unusually moist eyes
+1
Nose running or tearing
+2
-
GI Upset
Over last 1/2 hour
No GI symptoms
0
Stomach cramps
+1
Nausea or loose stool
+2
Vomitting or Diarrhea
+3
Multiple episodes of diarrhea or vomitting
+5
-
Tremor
Obersavation of outstretched hands
No tremor
0
Tremor can be felt, but not observed
+1
Slight tremor observable
+2
Gross tremor or muscle twitching
+4
-
Yawning
Observation during assessment
No yawning
0
Yawning once or twice during assessment
+1
Yawning three or more times during assessment
+2
Yawning serveral times/minute
+4
-
Anxiety or Irritability
None
0
Patient reports increasing irritability or anxiousness
+1
Patient obviously irritable anxious
+2
Patient so irritable or anxious that participation in the assessment is difficult
+4
-
Gooseflesh Skin
Skin is smooth
0
Piloerrection of skin can be felt or hairs standing up on arms
+3
Prominent piloerrection
+5
COWS Score: 0
Assess for contraindications
Does the patient have an allergy to buprenorphine/naloxone?Patients in withdrawal
OUD, opioid use in past 72 hours, and COWS 12+
Initiation
- Provide bup/nal 4 mg
- Reassess in 2-12 hours - if ongoing withdrawal based on COWS score, administer an additional 2-4 mg
- Calculate and administer daily dose as per standard bup/nal treatment guidance
Reassess dose
- Reassess dose every 3-7 days and increase by 2-4 mg if indicated based on ongoing withdrawal symptoms, cravings, or non-prescribed opioid use.
Criteria for opioid use disorder not met: Treatment with buprenorphine/naloxone not indicated.
Buprenorphine/naloxone treatment not appropriate in the context of allergy or severe respiratory distress. Consider other treatment options.
Patient may be at risk of precipitated withdrawal with buprenorphine/naloxone initiation. Consider whether buprenorphine/naloxone start is indicated or should be held.
COWS score <12: Consider whether bup/nal initiation is indicated now. If not initiated, reassess COWS score in 12-24 hours.
Dip urine
- Urine dip is recommended but not required for treatment initiation.
Order lab investigations
- Not required to start treatment
- Consider which labs to order based on risk factors, recent testing, patient preference, and anticipated length of time in custody
- CBC, electrolytes, Cr, AST/ALT, Hepatitis A, B, C, HIV
- Copy clinician(s) in the community in case patient is released before results come back
- Obtain informed consent for treatment, including possible treatment side effects (e.g., nausea, sedation, euphoria)
- All patients require a plan to support access to treatment post-release
- Counsel regarding harm reduction in custody and post-release
Precipitated withdrawal (PPWD)
- PPWD can occur with recent opioid use –usually when short-acting opioid consumed within past 12 hours, long-acting opioid (e.g.methadone, slow release oral morphine) within 24 hours. For fentanyl and methadone, at least 24-48 hours should elapse before starting bup/nal and start bup/nal at 1-2 mg on first day
- Presents like opioid withdrawal but occurs suddenly within 1-2 hours after dose
- Severity is dose related so start low if any concerns about most recent opioid intake
This tool was developed in consultation with health care providers working in corrections and people with lived experience of opioid use and incarceration.
Funding support was provided by the Canadian Institutes of Health Research through the Canadian Research Initiative in Substance Misuse (SMN-139150).
If you have any questions or feedback about the tool, please contact the project lead, Dr. Fiona Kouyoumdjian (kouyouf@mcmaster.ca)