Provider Orders
(Provider must sign all orders-check and/or fill in appropriate blanks)
Date__________Time___________________
VPH Opiate Withdrawal Protocol orders
Last modified: 2007-09-13 09:28:57.0
Treatment Protocol (pregnant patients should not be withdrawn from opiates)
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NURSING: op01) initiate the opiate withdrawal protocol if pt. meets criteria based on pt's report
&/or documentation of opiate dependency (i.e., + hx, + uds, long term use)
NURSING: op02) if the pt. requires detoxification from multiple CNS depressants &/or alcohol,
do not use this protocol until the detoxification from these substances is completed
NURSING: op03) obtain vital signs prior to each dose of Clonidine &/or Buprenorphine; then q
shift after stabilization of acute detoxification
NURSING: op04) each time vital signs are obtained, assess the pt. using the Clinical Opiate
Withdrawal Scale (COWS)
NURSING: op05) document the COWS scores on the "Clinical Opiate Withdrawal Scale" form and
on the "Opiate Withdrawal Flowsheet"
NURSING: op06) if COWS score is 5 or greater, administer Clonidine 0.1 mg po q1h, up to 0.4 mg
within an 8 hr period, while awake
NURSING: op07) after pt. has received a total of 0.4 mg of Clonidine in 8 hrs or less or has scored
15 or > prior to reaching 0.4 mg of Clonidine, call MD for orders to start Buprenorphine
NURSING: op08) continue Clonidine orders even after Buprenorphine injections have started
according to parameters of protocol
NURSING: op09) if score 15 or above after dose 3 of 0.3 mg Buprenorphine, call MD for order to
increase Buprenorphine to 0.6 mg IM for doses 4-6 - Decrease doses 7, 8 & 9 to 0.3 mg IM to
prevent subsequent withdrawal from Buprenorphine
NURSING: op10) If the patient is symptomatic after 9 doses of buprenorphine, physician
assessment for drug seeking behavior is recommended; administering more than 9 doses per
detox admission is not advised
VPH Opiate Withdrawal Protocol orders continued on 2nd page
Date/ Time ___________________
Provider Signature _________________________ Print Name_____________________Beeper#_______
Provider Orders
(Provider must sign all orders-check and/or fill in appropriate blanks)
Date__________Time___________________
VPH Opiate Withdrawal Protocol orders continued
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NURSING: op11) inform pt. that the buprenorphine will not be restarted once it has been
stopped
NURSING: op12) 24 hours of observation is recommended following the last dose of
Buprenorphine prior to discharge
NURSING: op13) encourage pt. not to take any more Buprenorphine than absolutely necessary,
particularly if the COWS score is 0 prior to the 9th dose
NURSING: op14) observe pt. for signs of cns depression and, if present, notify md
Protocol Medication
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2. CLONIDINE (PHV PROTOCOL) (ters: if baseline bp =/< 100/70, hold for bp =/< 80/50, if
baseline bp > 100/70, hold for bp < 90/600.1mg q1h prn up to 0.4 mg within an 8 hr period,
while awake, for COWS score of 5 or greater; hold for following parame)
Additional Protocol Medication (if protocol criteria met)
NOTE: If patient is symptomatic after 9 doses of buprenorphine, physician assessment for drug
seeking behavior is recommended
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3. BUPRENORPHINE INJ: BUPRENEX 0.3 mg im q8hx9 doses (for pain management; on day 1,
may alter dose spacing to not < q6h to adjust to the 6a-2p-10p dosing schedule)
Administering more than 9 doses is not advised
Alternate order for Buprenorphine if initial order has been discontinued
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4. BUPRENORPHINE INJ: BUPRENEX 0.6 mg im q8hx3 doses (for doses 4-6 if pt. continues to
score 15 or > after dose 3 of 0.3 mg for pain management)
BUPRENORPHINE INJ: BUPRENEX 0.3 mg im q8hx3 doses (for doses 7, 8 & 9 for pain
management (after pt. has received 0.6 mg for doses 4-6))
Date/ Time ___________________
Provider Signature _________________________ Print Name_____________________Beeper#_______