Written by Elizabeth Cairns, Mobilize Recovery Special Projects and Michael Masiowski, MD, reviewed by Code Recover Clinician Advisors, August 2026

Dr. Lindsey Jennings talks about how to treat precipitated withdrawal.

Dr. Nasir Naqvi talks about myths surrounding buprenorphine and how to avoid precipitated withdrawal in patients.

Opioid withdrawal is a state of profound physical and psychological distress that should be treated as a clinical emergency. Patients in opiate withdrawal are often experiencing discomfort at levels that may drive them to leave against medical advice (AMA). (source) Early identification in triage is essential; clinicians must look for the characteristic constellation of symptoms: tachycardia, diaphoresis, restlessness, dilated pupils, and "gooseflesh" skin (piloerection).

To standardize care, the Clinical Opiate Withdrawal Scale (COWS) is the gold-standard 11-item objective assessment tool. Scores are categorized as Mild (5–12), Moderate (13–24), Moderately Severe (25–36), and Severe (over 36). (source) A score of 8 or higher — indicating objective withdrawal sufficient for safe induction — should trigger the initiation of buprenorphine, which is the standard of care. (source)

Clinicians must remain vigilant for precipitated withdrawal — an abrupt worsening of symptoms following buprenorphine or naloxone. (source) Mild cases are often brief and self-resolving with observation and supportive care. When precipitated withdrawal is severe or persistent, however, observation alone is insufficient. One published approach is the 90-Minute Treatment Bundle for Precipitated Withdrawal, a site example from Highland General Hospital, which uses high-dose buprenorphine (16mg SL) with adjunctive lorazepam (2mg PO) to overcome the receptor blockade, reassessing at 30 minutes and repeating the buprenorphine dose if symptoms have not improved. 

Effective triage requires a "low-barrier" model where nursing staff are empowered to initiate COWS assessments and comfort measures immediately upon intake. (source) These early moments in the patient encounter are also a critical diagnostic window; clinicians must rule out mimicking conditions such as sepsis, diabetic ketoacidosis (DKA), and alcohol withdrawal, which can present with similar autonomic instability.

Finally, as soon as a peer is available, they should be introduced to the patient. While the clinical team manages withdrawal and physical stabilization, the peer provides social stabilization and support. The peer can help the patient understand the care plan and encourage the trust needed for the patient to accept care.