Approach to the critical patient
›First 5 minutes workflow
›Airway and breathing
›If hypoventilation or hypoxia, treat as opioid toxicity pathway
›Naloxone titration if opioid intoxication present
›Circulation
›IV access if dehydration or severe symptoms
›Isotonic fluids if orthostasis or poor intake
›Monitoring
›Continuous pulse oximetry if sedating co ingestion suspected
›Cardiac monitoring if severe autonomic instability
›Initiation criteria
›Objective withdrawal present
›Moderate withdrawal severity
›Sufficient time since last short acting opioid use
›Standard induction example adult
›Buprenorphine naloxone SL 4 mg
›Reassess in 45 to 60 minutes
›Additional 4 mg if symptoms persist
›Typical day 1 total 8 to 16 mg
›Precipitated withdrawal risk
›Higher risk with fentanyl exposure
›Higher risk with long acting opioids
›Alternative initiation strategies
›Micro induction local protocol dependent
›Specialist consultation when high precipitated withdrawal risk
›Fluids and electrolytes
›Oral rehydration if tolerated
›IV normal saline bolus 500 to 1000 mL if dehydration
›Autonomic symptoms
›Clonidine dosing per blood pressure
›Avoid if hypotension or bradycardia
›Nausea and vomiting
›Ondansetron dosing
›Metoclopramide alternative if appropriate
›Diarrhea and cramping
›Loperamide within recommended maximum
›Avoid high dose misuse
›Pain and myalgias
›NSAIDs if renal safe
›Acetaminophen if hepatic safe
›Time based reassessment
›Recheck symptoms at 30 to 60 minutes after therapy
›Repeat vital signs every 30 to 60 minutes until stable
›Response targets
›Improved oral intake
›Reduced autonomic instability
›Safe ambulation
›Addiction medicine and outpatient linkage
›Rapid access opioid agonist therapy clinic referral
›Harm reduction services linkage