1. Opioids are often taken in larger amounts or over a longer period than intended.
2. There is a persistent desire or unsuccessful efforts to cut down or control opioid use.
3. A great deal of time is spent in activities necessary to obtain the opioid, use the opioid, or recover from its effects.
4. Opioid cravings are experienced.
5. Recurrent opioid use results in failure to fulfill major obligations at work, school, or home.
6. Continued opioid use occurs despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of opioids.
7. Important social, occupational, or recreational activities are given up or reduced because of opioid use.
8. Recurrent opioid use occurs in situations in which it is physically hazardous.
9. Continued opioid use occurs despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.
10. Exhibits tolerance.
11. Exhibits withdrawal.

Step 2: Assess Readiness to Quit

What are the patient’s goals? Are they ready and willing to start treatment in hopes of stopping their opioid use? Use the Readiness Ruler to assess the stage of change (example question: “On a scale of 1 to 10, how ready are you to make a change today?”).¹⁰ Obtain informed consent before starting buprenorphine-naloxone in the emergency department. If the patient is not ready to start the medication, share your concerns about their ongoing opioid use, the risk of overdose and medical complications, and harm-reduction techniques (eg, a naloxone kit, clean needles, etc.).

Step 3: Assess the Severity of Opioid Withdrawal Using COWS

Use the validated assessment tool Clinical Opiate Withdrawal Scale (COWS) to determine the withdrawal severity.¹¹ This scale is similar to the Clinical Institute Withdrawal Assessment scale used for alcohol withdrawal and is easily administered by ED staff. Points are assigned for the signs and symptoms of withdrawal (eg, tachycardia, sweating, restlessness, enlarged pupils, bone/joint aches, runny nose/tearing, upset gastrointestinal, tremor, yawning, anxiety/irritability, and gooseflesh). A score of 5–12 = mild, 13–24 = moderate, 25–36 = moderately severe, and greater than 36 = severe.

Patients must score at least in the moderate range to be eligible for buprenorphine-naloxone therapy.

Step 4: Buprenorphine-Naloxone and Withdrawal Symptom Treatment

Relative contraindications to buprenorphine-naloxone initiation include allergy to either buprenorphine or naloxone, hepatic dysfunction, current respiratory distress, decreased level of awareness currently, concurrent active alcohol use disorder, and concurrent benzodiazepine use.

Suboxone is buprenorphine and naloxone in a sublingual tablet. Naloxone is not active unless injected; it is a taper-resistance medication. Buprenorphine is a partial agonist that acts on the opioid mu receptor. It has a high binding affinity but only partial intrinsic activity on the receptor. This means it is effective for pain and withdrawal but features less risk of respiratory depression and side effects than pure opioids.