Opioid Use Disorder

General Overview

  • Screening
    • How many times in the past year have you used an illegal drug, or used a prescription medication for non-medical reasons?
      • If greater than zero for opioids, consider detailed assessment for Opioid Use Disorder (OUD)
    • See Substance Use
  • Prescription Opioids are commonly abused (reasonable estimates of OUD after initial prescription 4.7%) , and a major cause of opioid-related overdose
    • See prescription medication section in Substance Use page
    • Very limited evidence for the use of opioids in chronic non-cancer pain, due to high risks and minimal benefits
      • Common adverse effects: Nausea, vomiting, constipation, drowsiness, dizziness, pruritus
      • Complications: Neuroendocrine (hypogonadism, erectile dysfunction, amenorrhea), worsened sleep apnea, hyperalgesia, overdose/intoxication and respiratory depression (see Poisoning), physiological dependence and withdrawal
    • Optimize nonopioid pharmacotherapy and nonpharmacologic therapy
    • If decision for trial of opioids, consider
      • Titrate to lowest effective dose, restricting to less than 90 morphine milligram equivalent (MME) daily, ideally less than 50 MME daily
      • If ineffective, consider rotation, or tapering and discontinuation
    • Consider assessing for OUD with Prescription Opioid Misuse Index (POMI)

Opioid Withdrawal

💡 Opioid withdrawal causes severe discomfort but is usually NOT life threatening and usually does not cause altered mental status

    • Time to peak and duration of symptoms highly dependent on the half-life of the drug involved (fentanyl < heroin < methadone)
      • Typically starts within hours after use, peaks 36-72h, subsides after 1 week
    • Assess symptoms with clinical and subjective opioid withdrawal scales: COWS and SOWS
      • History: Restlessness, rhinorrhea, lacrimation, myalgias, arthralgias, nausea, vomiting, abdominal pain, diarrhea
      • Physical exam: Mydriasis (dilated pupils), yawning, diaphoresis, piloerection
    • Withdrawal management alone (“detox”) without long-term opioid agonist therapy or comprehensive continuing addiction care is not recommended due to high risk of relapse, HIV infection and overdose death
      • If detoxification is pursued, consider taper > 1 month rather than a rapid <1 week taper to prevent relapse
    • Treatment
      • Discuss past use of treatments, including OAT, psychosocial interventions
      • Discuss community supports
      • Discuss goals
      • OAT (specifically Buprenorphine/naloxone) and adjunctive psychosocial treatment is generally recommended as first-line treatment for OUD


  • Discuss long-term opioid agonist therapy (OAT) with patients for treatment of clearly diagnosed opioid use disorder
    • Buprenorphine/naloxone (Suboxone), generally preferred over methadone due to safety profile
      • Indication: Patient must be in withdrawal (>12-24h for short-acting opioids, >48-72h for long-acting)
      • Contraindications: Allergy, pregnancy, severe liver dysfunction
      • Adverse effects: Headache, insomnia, diaphoresis, nausea, abdo pain
      • Day 1: 4mg/1mg SL (BUP/NLX) once in mild withdrawal, then add 2/0.5mg q2h if withdrawal symptoms (do not exceed 12mg/day)
      • Day 2+: Same dose as sum of previous day, increase by max of 4mg each day until steady state (>16/4mg daily rarely needed, do not exceed 24mg day)
    • Methadone (1mg per 4mg of morphine or typical starting dose of 10-30mg methadone)
      • Can be started immediately
      • Contraindications: Allergy, history or increased risk of prolonged QT
      • Adverse effects: Drowsiness, dizziness, nausea, constipation, diaphoresis, peripheral edema, sexual dysfunction
      • Dose titrated 10mg increments every 3-5d over next several weeks until 80mg/d, then titrate slowly over 1-2w
    • Consider take-home doses (2-7 days) PRN if needed and stable
    • Optimal duration unknown, and may be indefinite
      • If patients wish to discontinue OAT, consider slow taper over months to years
  • Opioid antagonist (Naltrexone)
    • Consider in mild opioid use disorder, safety-sensitive occupations (drivers), criminal justice settings (in prison), opioid free for 7-10 days , who are unable/unwilling to take opioid agonist therapy, or third-line (after failed OAT)
    • Naltrexone 25-50mg blocks all opiate receptors x24h (can be PO daily or long-acting injectable)
  • Consider ECG, bhCG, urine drug testing, LFTs, STI (HIV, Hep B/C, G/C, Syphilis) +/- TB
  • Consider treatment agreements
    • Contingency management: “rewards” for desired behaviour (eg, vouchers or prizes) or loss of privileges for undesired behaviour (eg, loss of medication carries for positive urine drug screening results)
        • Positive effect likely from positive contingencies increases retention in treatment (RR = 1.15, 95% CI 1.09 to 1.21)
  • Offer take-home naloxone (THN) kit to all patients (or their caregivers)
  • Consider other harm reduction services (sterile injection supplies)
  • Adjunctive symptomatic management for withdrawal symptoms (e.g., anxiety, nausea, pain, diarrhea)
  • Psychosocial support should be routinely offered (but not mandatorily required), including standard counseling (15 minutes) is more effective in retention than no or minimal counseling
    • Motivational interviewing, CBT, 12-step program, addiction counseling program, Narcotics Anonymous


  • At each visit discuss
    • Adherence to treatment plan
    • Withdrawal symptoms, cravings
    • Opioid or substance use (especially sedating agents, eg. alcohol, benzodiazepines)
    • General symptoms (sleep, mood)
    • Function (home, social, work)
  • Consider vaccines for Hep A/B if relevant
  • Relapse is common, and should not be seen as failure!
    • Consider switching to another pharmacotherapy (eg. Suboxone to Methadone, or Methadone to Suboxone)
Opioid use PEER-Design-Final.pdf