What's Your Diagnosis? Opioid Use Disorder in the ED

Welcome to this month’s What’s Your Diagnosis Challenge!

But before we begin, check to see if you got the previous case on Current Concepts in Ketamine Therapy in the Emergency Department correct.

Case Presentation: Managing Emergency Department Patients With Opioid Use Disorder

A 55-year-old man presents to the ED complaining of opioid withdrawal and is requesting methadone…

The patient starts to raise his voice asking for the medication. His vital signs are normal.
As you assess the patient for opioid withdrawal, he is pacing the room and reports experiencing chills, body aches, and abdominal cramping. The patient states that he feels very anxious.
Physical examination reveals normal-sized pupils, rhinorrhea, and piloerection. You calculate a Clinical Opiate Withdrawal Scale (COWS) score of 12 and think to yourself: Can this patient be safely started on medication for opioid use disorder, and if so, should I give methadone or offer another medication?

Case Conclusion

The patient was counseled on the risks and benefits of starting buprenorphine versus methadone, and he agreed to try buprenorphine. Given that he had a COWS score of 12, he was given 4 mg of sublingual buprenorphine and observed for 45 minutes. When he did not experience worsening withdrawal, he was then given an additional 4 mg of sublingual buprenorphine. A social worker was able to schedule a follow-up appointment in 7 days at a MOUD clinic, and the patient left the ED with a prescription for 7 days of buprenorphine/naloxone.